Sources of clinical distress in young people at ultra high risk of psychosis

A Latent Profile Analysis of Emotion Regulation in Relation to Distress of Symptoms in Youth with Prodromal Psychotic Symptoms

(1) Background: Although abnormal emotion regulation is a key characteristic of youth with prodromal psychotic symptoms and is closely related to the degree of distress caused by these symptoms, research on the internal heterogeneity of emotion regulation within this clinically high-risk population has been insufficient. (2) Methods: The current study analyzed data from 394 college students with prodromal psychotic symptoms, using latent profile analysis (LPA) to identify emotion regulation profiles based on differences in expressive suppression and cognitive reappraisal. One-way ANOVA was employed to examine the relationship between the identified latent profiles and distress of symptoms. (3) Results: Three latent profiles were identified: "high cognitive reappraisal group" (n = 117, 29.70%), "moderate cognitive reappraisal group" (n = 233, 59.14%), and "low cognitive reappraisal group" (n = 44, 11.16%). Significant differences in distress of negative symptoms (F = 9.122, p < 0.05) and perceptual abnormalities (F = 3.103, p < 0.05) were observed across the latent profiles but not in unusual thought content and specific perceptual abnormalities (both p > 0.05). The "low cognitive reappraisal group" exhibited the most severe distress of symptoms, followed by the "moderate cognitive reappraisal group", while the "high cognitive reappraisal group" experienced the least distress. (4) Conclusions: The current study provides evidence for the heterogeneity of emotion regulation among youth with prodromal psychotic symptoms and reveals differences in distress of perceptual abnormalities and negative symptoms between the latent profiles of emotion regulation. These findings support the development of targeted psychological interventions to alleviate the distress of symptoms and improve quality of life.

Response to psychotic experiences: Impact of personality traits on perceived levels of distress

BACKGROUND

This study examined the influence of personality traits on (subclinical) positive symptom distress in patients with a psychotic disorder, their unaffected siblings and healthy controls.

METHODS

Data were obtained from the Genetic Risk and Outcome of Psychosis study (GROUP), a Dutch longitudinal multicenter cohort study. Data from 140 patients, 216 unaffected siblings and 102 healthy controls was available for baseline levels of Five Factor Model personality traits and frequency and distress due to psychotic experiences three years later, assessed with the Community Assessment of Psychic Experience questionnaire. Main effects of all five personality traits on symptom distress were investigated as well as moderating effects of Neuroticism, Extraversion and Openness on positive symptom frequency and positive symptom distress. Age, gender, symptom frequency and IQ were controlled for.

RESULTS

In both patients and siblings, the observed main effects of Neuroticism and Openness on (subclinical) positive symptom distress three years later either lost significance or had a very small effect size when controlling for covariates, mainly due to the correction for the effect of positive symptoms on personality traits at baseline. In both groups, levels of Openness at baseline moderated the association between positive symptom frequency and positive symptom distress three years later, in the direction that higher levels of Openness were associated with weaker associations between positive symptom frequency and - distress, even when covariates were controlled for.

DISCUSSION

The level of Openness to Experiences influences the perceived distress from (subclinical) positive symptoms in both patients and siblings.

Nutraceuticals in Psychiatric Disorders: A Systematic Review

Correct nutrition and diet are directly correlated with mental health, functions of the immune system, and gut microbiota composition. Diets with a high content of some nutrients, such as fibers, phytochemicals, and short-chain fatty acids (omega-3 fatty acids), seem to have an anti-inflammatory and protective action on the nervous system. Among nutraceuticals, supplementation of probiotics and omega-3 fatty acids plays a role in improving symptoms of several mental disorders. In this review, we collect data on the efficacy of nutraceuticals in patients with schizophrenia, autism spectrum disorders, major depression, bipolar disorder, and personality disorders. This narrative review aims to provide an overview of recent evidence obtained on this topic, pointing out the direction for future research.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

AIM

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

METHODS

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

RESULTS

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and modest harmonization for CHR-P criteria. The semi-structured interview, named Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

CONCLUSIONS

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

At-risk mental states and personality traits: A cluster analysis approach on a group of help-seeking young adults

INTRODUCTION

Research on the relationship between personality and psychosis onset is growing, with the goal of preventing or intervening early in patients' vulnerability. The identification of individuals with at-risk mental states has enabled the development of early intervention strategies, such as Programma 2000, a youth mental health service that was implemented in Milan (Italy).

AIMS

Focusing on the 18-25 age range-the time window with the highest incidence of psychotic onset-this study aims to identify the personality traits that may characterize the at-risk mental states and the social functioning of a group of help-seeking young adults.

METHODS

The sample includes 169 people (48.5% males and 51.5% females). Data were collected during an initial assessment that comprised the Social and Occupational Functioning Assessment Scale, the Personality Inventory for DSM-5, the Checklist ERIraos and a clinical session.

RESULTS

Results identified a three-cluster solution based on the Checklist scores: Cluster 1 'Not at psychotic risk'; Cluster 2 'At intermediate risk'; Cluster 3 'With psychotic onset'. The multivariate analysis of the variance of personality traits shows significant differences among the clusters in negative affect, detachment and disinhibition. Higher scores in these traits may distinguish individuals, not at psychotic risk from those at intermediate risk or with psychotic onset. Moreover, social functioning was found to be negatively associated with clusters of psychotic risk.

CONCLUSION

Findings from this study highlighted the need to evaluate personalized interventions targeting such personality traits that could prevent psychotic transition and promote psychological well-being.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

Aim

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

Methods

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

Results

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and partial harmonization for CHR-P criteria. The semi-structured interview, named P ositive SY mptoms and Diagnostic Criteria for the C AARMS H armonized with the S IPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

Conclusion

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Modelling the temporal interplay between stress and affective disturbances in pathways to psychosis: an experience sampling study

BACKGROUND

One putative psychological mechanism through which momentary stress impacts on psychosis in individuals with increased liability to the disorder is via affective disturbance. However, to date, this has not been systematically tested. We aimed to investigate whether (i) cross-sectional and temporal effects of momentary stress on psychotic experiences via affective disturbance, and (ii) the reverse pathway of psychotic experiences on stress via affective disturbance were modified by familial liability to psychosis.

METHODS

The Experience Sampling Method was used in a pooled data set of six studies with three groups of 245 individuals with psychotic disorder, 165 unaffected first-degree relatives, and 244 healthy control individuals to index familial liability. Multilevel moderated mediation models were fitted to investigate indirect effects across groups cross-sectionally and multilevel cross-lagged panel models to investigate temporal effects in the proposed pathways across two measurement occasions.

RESULTS

Evidence on indirect effects from cross-sectional models indicated that, in all three groups, effects of stress on psychotic experiences were mediated by negative affect and, vice versa, effects of psychotic experiences on stress were mediated by negative affect, with all indirect effects being weakest in relatives. Longitudinal modelling of data provided no evidence of temporal priority of stress in exerting its indirect effects on psychotic experiences via affective disturbance or, vice versa.

CONCLUSIONS

Our findings tentatively suggest a rapid vicious cycle of stress impacting psychotic experiences via affective disturbances, which does, however, not seem to be consistently modified by familial liability to psychosis.

Major depressive disorder and attenuated negative symptoms in a child and adolescent sample with psychosis risk syndrome: the CAPRIS study

Some 70-80% of subjects with psychotic risk syndrome (PRS) have lifetime comorbidity, with depressive disorders being the most common. A high proportion of patients with PRS present nonspecific symptoms which can be confounding factors for diagnosis. Depressive and negative symptoms may be difficult to distinguish and it is important to differentiate them. The aim of this study is to assess the presence of depressive disorder in a child and adolescent sample of PRS and to examine the presence of negative symptoms and detect possible confounding characteristics between them and depressive symptoms. This is a naturalistic multi-site study with subjects who met PRS criteria. A sample of 89 PRS adolescent patients was included. Major depressive disorder (MDD) is the most prevalent comorbid disorder (34.83%). The sample was divided into patients who met criteria for MDD (PRS-MDD, n = 31) and those who did not have this disorder (PRS-ND, n = 44). We obtained significant differences in the attenuated negative symptoms (ANS) between PRS-MDD and PRS-ND (68.18 vs. 90.32%, respectively, p = 0.021). Subjects with MDD presented a higher score in ANS and Hamilton Depression Rating Scale (HDRS). Moreover, we obtained a correlation between negative symptomatology and HDRS score with a higher score on HDRS in subjects with higher negative symptom scores (r = 0.533, p < 0.001). More research is needed to fine tune differentiation between depressive and negative symptoms and learn more about the possible impact of MDD on PRS children and adolescents.

Antipsychotics are related to psychometric conversion to psychosis in ultra-high-risk youth

BACKGROUND

The prescription of antipsychotics outside overt psychotic conditions remains controversial, especially in youth where it is relatively widespread. Furthermore, some studies seem to indicate that antipsychotic exposure in individuals at ultra-high-risk (UHR) for psychosis is associated with higher conversion rates. This study was set up to test whether the inter-current prescription of antipsychotics in UHR patients was related to the psychometric threshold for a diagnosis of psychosis.

METHODS

The 24-item Brief Psychiatric Rating Scale (BPRS) was used to quantify treatment response up to 2 years in 125 UHR participants. Standard psychometric criteria were used to quantify conversion to psychosis. Kaplan-Mayer and Cox proportional hazard survival analysis were applied to determine the impact of having or not received the prescription of an antipsychotic drug.

RESULTS

Over the study period 30 (24%) subjects received the prescription of an antipsychotic. In the sample, there were 31 participants (25%) who had reached the psychometric threshold for conversion to psychosis after 2 years of treatment. UHR people who received a prescription of antipsychotics during the first 2 years of treatment were statistically more likely to reach the psychometric threshold for conversion to psychosis on the BPRS: Hazard ratio = 3.03 (95%CI: 1.49-6.16); p = .003.

CONCLUSION

This finding supports the hypothesis that the prescription of antipsychotics within UHR cohorts is to be considered a red flag for higher incipient risk of conversion to psychosis.

Distress Related to Attenuated Psychotic Symptoms: Static and Dynamic Association With Transition to Psychosis, Nonremission, and Transdiagnostic Symptomatology in Clinical High-Risk Patients in an International Intervention Trial

This study examined whether distress in relation to attenuated psychotic symptoms (DAPS) is associated with clinical outcomes in an ultra-high risk (UHR) for psychosis sample. We also investigated whether DAPS is associated with cognitive style (attributional style and cognitive biases) and whether amount of psychosocial treatment provided is associated with reduction in DAPS. The study was a secondary analysis of the "Neurapro" clinical trial of omega-3 fatty acids. Three hundred and four UHR patients were recruited across 10 early intervention services. Data from baseline assessment, regular assessments over 12 months, and medium term follow-up (mean = 3.4 years) were used for analysis. Findings indicated: a positive association between DAPS assessed over time and transition to psychosis; a significant positive association between baseline and longitudinal DAPS and transdiagnostic clinical and functional outcomes; a significant positive association between baseline and longitudinal DAPS and nonremission of UHR status. There was no relationship between severity of DAPS and cognitive style. A greater amount of psychosocial treatment (cognitive-behavioral case management) was associated with an increase in DAPS scores. The study indicates that UHR patients who are more distressed by their attenuated psychotic symptoms are more likely to have a poorer clinical trajectory transdiagnostically. Assessment of DAPS may therefore function as a useful marker of risk for a range of poor outcomes. The findings underline the value of repeated assessment of variables and incorporation of dynamic change into predictive modeling. More research is required into mechanisms driving distress associated with symptoms and the possible bidirectional relationship between symptom severity and associated distress.

Prediction of clinical outcomes beyond psychosis in the ultra-high risk for psychosis population

AIM

Several prediction models have been introduced to identify young people at greatest risk of transitioning to psychosis. To date, none has examined the possibility of developing a clinical prediction model of outcomes other than transition. The aims of this study were to examine the association between baseline clinical predictors and outcomes including, but not limited to, transition to psychosis in young people at risk for psychosis, and to develop a prediction model for these outcomes.

METHODS

Several evidence-based variables previously associated with transition to psychosis and some important clinical comorbidities experienced by ultra-high risk (UHR) individuals were identified in 202 UHR individuals. Secondary analysis of the Neurapro clinical trial were conducted to investigate the associations between these variables and favourable (remission and recovery) or unfavourable (transition to psychosis, no remission, any recurrence and relapse) clinical outcomes. Logistic regression, best subset selection, Akaike Information Criterion and receiver operating characteristic curves were used to seek the best prediction model for clinical outcomes from all combinations of possible predictors.

RESULTS

When considered individually, only higher general psychopathology levels (P = .023) was associated with the unfavourable outcomes. Prediction models suggest that general psychopathology and functioning are predictive of unfavourable outcomes.

CONCLUSION

The predictive performance of the resulting models was modest and further research is needed. Nonetheless, when designing early intervention centres aiming to support individuals in the early phases of a mental disorder, the proper assessment of general psychopathology and functioning should be considered in order to inform interventions and length of care provided.

Annual Research Review: Prevention of psychosis in adolescents - systematic review and meta-analysis of advances in detection, prognosis and intervention

BACKGROUND

The clinical high-risk state for psychosis (CHR-P) paradigm has facilitated the implementation of psychosis prevention into clinical practice; however, advancements in adolescent CHR-P populations are less established.

METHODS

We performed a PRISMA/MOOSE-compliant systematic review of the Web of Science database, from inception until 7 October 2019, to identify original studies conducted in CHR-P children and adolescents (mean age <18 years). Findings were systematically appraised around core themes: detection, prognosis and intervention. We performed meta-analyses (employing Q statistics and I ² test) regarding the proportion of CHR-P subgroups, the prevalence of baseline comorbid mental disorders, the risk of psychosis onset and the type of interventions received at baseline. Quality assessment and publication bias were also analysed.

RESULTS

Eighty-seven articles were included (n = 4,667 CHR-P individuals). Quality of studies ranged from 3.5 to 8 (median 5.5) on a modified Newcastle-Ottawa scale. Detection: Individuals were aged 15.6 ± 1.2 years (51.5% males), mostly (83%) presenting with attenuated positive psychotic symptoms. CHR-P psychometric accuracy improved when caregivers served as additional informants. Comorbid mood (46.4%) and anxiety (31.4%) disorders were highly prevalent. Functioning and cognition were impaired. Neurobiological studies were inconclusive.

PROGNOSIS

Risk for psychosis was 10.4% (95%CI: 5.8%-18.1%) at 6 months, 20% (95%CI: 15%-26%) at 12 months, 23% (95%CI: 18%-29%) at 24 months and 23.3% (95%CI: 17.3%-30.7%) at ≥36 months.

INTERVENTIONS

There was not enough evidence to recommend one specific treatment (including cognitive behavioural therapy) over the others (including control conditions) to prevent the transition to psychosis in this population. Randomised controlled trials suggested that family interventions, cognitive remediation and fish oil supplementation may improve cognition, symptoms and functioning. At baseline, 30% of CHR-P adolescents were prescribed antipsychotics and 60% received psychotherapy.

CONCLUSIONS

It is possible to detect and formulate a group-level prognosis in adolescents at risk for psychosis. Future interventional research is required.

Depression, family interaction and family intervention in adolescents at clinical-high risk for psychosis

AIM

The relationship between family behaviour and depression in adolescents at clinical high risk (CHR) for psychosis remains understudied despite high rates of depression in this population. This study examines the relationship between family problem-solving behaviours and depression in CHR adolescents and the impact of family interventions targeting subthreshold symptoms of psychosis on reducing symptoms of depression over 2-years.

METHODS

Participants were a subset of the North American Prodrome Longitudinal Study who were randomized to 6-months of family focused therapy for individuals at CHR or family psychoeducational treatment. We evaluated the relationship between communication during family conflict discussion and adolescents' symptoms of depression before treatment. At follow-up assessments the family treatment groups were compared on depression. Finally, we compared those in family treatment with matched controls.

RESULTS

Adolescents' constructive communication was associated with less severe symptoms of depression before treatment. Symptoms of depression improved for adolescents in both family treatment groups. However, there were no significant group by treatment interactions. When adolescents who participated in either type of family intervention were compared to CHR adolescent controls, symptoms of depression improved for adolescents in treatment and control groups, but there were no significant time by treatment interactions.

CONCLUSIONS

The communication skills of CHR adolescents are related to both depression and their parents' communication skills pre-treatment. However, reductions in depression over the course of the treatment trial cannot be attributed to family treatment. It is imperative to incorporate interventions that directly target depression into future family treatment studies.

Mental Health Services Research Targeting the Clinical High-Risk State for Psychosis: Lessons, Future Directions and Integration with Patient Perspectives

PURPOSE OF REVIEW

We summarize the history of the clinical high-risk stage of psychosis (CHR), current research on this stage and recent critiques of the field, and evaluate current CHR guidelines and frameworks.

RECENT FINDINGS

Following its identification and characterization, CHR services have successfully been developed in North America, Europe, Australia and elsewhere. As reflected in guidelines, these services and their orientation largely emerged as an outgrowth of the framework pioneered by early intervention services for first-episode psychosis. We critically discuss what is known so far about the subjective experience of the CHR syndrome, the meaning of this "unofficial" diagnosis as well as what is known and unknown about the service-related needs. While a range of outstanding questions remain in the field, there is a particular need for patient-oriented work and to investigate the service-related needs of young people at CHR.

Sleep disturbances and the At Risk Mental State: A systematic review and meta-analysis

AIMS

To synthesise and investigate how sleep disturbances relate to psychotic symptoms, functioning and Quality of Life (QoL) in At Risk Mental State (ARMS) youth.

METHOD

A comprehensive search of six databases (MEDLINE, PsycINFO, Embase, CINAHL, Web of Science and CENTRAL) was conducted. Eligible studies provided data on sleep disturbances or disorders in ARMS patients.

RESULTS

Sixteen studies met the inclusion criteria (n = 1962 ARMS patients) including 7 cross-sectional studies, 2 RCT's and 7 cohort studies. Narrative synthesis revealed that self-reported sleep (e.g., general disturbances, fragmented night time sleep and nightmares) was poorer among ARMS patients compared to healthy controls. In the limited studies (n = 4) including objective measurements of sleep disturbances, ARMS patients experienced higher levels of movement during sleep, more daytime naps and increased sleep latency compared to controls. Furthermore, sleep disturbances were associated with attenuated psychotic symptoms and functional outcomes cross-sectionally and longitudinally. Only one study investigated the relationship between sleep and QoL. The exploratory meta-analysis revealed a significant difference in self-reported sleep disturbances measured by the PSQI (mean difference in score: 3.30 (95% CI 1.87, 4.74), p < 0.00001) and SIPS (mean difference in score: 1.58 (95% CI 0.80, 2.35), p < 0.00001) of ARMS patients compared to control groups.

CONCLUSIONS

ARMS individuals report impaired sleep quality and reduced sleep quantity compared to healthy controls. However, further research is needed to explore the longitudinal relationship between sleep disruptions and QoL in early psychosis. Significant variations in how sleep is measured across studies highlight a need to assess disturbances to sleep using robust and consistent approaches in this patient group.

The Relationship between PID-5 Personality Traits and Mental States. A Study on a Group of Young Adults at Risk of Psychotic Onset

Background and Objectives: The diagnosis of psychosis is a challenge for the scientific community, both in terms of its definition and treatment. Some recent studies have investigated the relationship between personality and psychosis onset to prevent or intervene early. Materials and Methods: Sixty young adults were recruited during their first access in 2019 near the Community Mental Health Service of Niguarda Hospital, Milan, Italy. The assessment included the Social and Occupational Functioning Assessment Scale (SOFAS), the Global Assessment of Functioning (GAF) (clinician scales), the 16-item Version of the Prodromal Questionnaire (PQ-16), the Personality Inventory for DSM-5 (PID-5) (self-report), and a clinical session. Statistical analysis was performed by SPSS. Results: The results show a negative correlation between the Detachment domain and the GAF scores. Correlational analysis also highlights that all PID-5 domains, except for Antagonism, have positive correlations with high scores in the PQ-16. The multivariate analysis of variance showed that patients diagnosed with versus without a psychotic disorder significantly differed on Detachment, Antagonism and Psychoticism PID-5 domains. Conclusions: The involvement of the personality construct in psychopathological development is displayed. In particular, higher levels of Detachment and Psychoticism can distinguish people who are more vulnerable to psychosis or who already have overt psychosis from those who do not have a psychotic predisposition. The study highlights the fundamental role of personality traits, emerging from PID-5, to distinguish young adults at risk of onset.

Community Psychosis Risk Screening: An Instrument Development Investigation

Schizophrenia and other psychotic disorders are serious psychiatric disorders that are associated with substantial societal, family, and individual costs/distress. Evidence suggests that early intervention can improve prognostic outcomes; therefore, it is essential to accurately identify those at risk for psychosis before full psychotic symptoms emerge. The purpose of our study is to develop a brief, valid screening questionnaire to identify individuals at risk for psychosis in non-clinical populations across 3 large, community catchment areas with diverse populations. This is a needed study, as the current screening tools for at-risk psychotic populations in the US have been validated only in clinical and/or treatment seeking samples, which are not likely to generalize beyond these specialized settings. The specific aims are as follows: (1) to determine norms and prevalence rates of attenuated positive psychotic symptoms across 3 diverse, community catchment areas and (2) to develop a screening questionnaire, inclusive of both symptom-based and risk factor-based questions. Our study will develop an essential screening tool that will identify which individuals have the greatest need of follow-up with structured interviews in both research and clinical settings. Our study has the potential for major contributions to the early detection and prevention of psychotic disorders.

Beyond the cognitive insight paradox: Self-reflectivity moderates the relationship between depressive symptoms and general psychological distress in psychosis

BACKGROUND

People with psychosis experience significant emotional burden and distress associated with the symptomatic consequences of their mental disorder, thus difficulting their recovery. Several studies have found self-reflectivity, a dimension of cognitive insight, to be associated with effects which taken together may seem paradoxical, by predicting less psychotic symptom severity but more depression. To elucidate this issue, we examined the influence of psychotic symptoms, depressive symptoms, and self-reflectivity, on psychological distress. Further, we tested whether self-reflectivity moderated the relationship between depressive symptoms and psychological distress.

METHODS

Seventy-six outpatients with psychotic-spectrum disorders were assessed using measures of psychotic symptoms, depressive symptoms, cognitive insight (i.e., self-reflectivity, self-certainty) and psychological distress.

RESULTS

A regression model revealed that depressive, positive symptoms and the interaction between depressive symptoms and self-reflectivity had a significant effect on psychological distress. The moderation analysis showed that higher levels of self-reflectivity were related to less psychological distress associated with depressive mood.

CONCLUSIONS

The role of self-reflectivity on depression and distress may be more complex than a direct effect. Interventions targeted to improve metacognition by enhancing self-reflectivity might be important for lowering the psychological distress associated with depressive symptoms in people with psychosis.

The Prevalence of Negative Symptoms Across the Stages of the Psychosis Continuum

BACKGROUND

Patients in every stage of the psychosis continuum can present with negative symptoms. While no treatment is currently available to address these symptoms, a more refined characterization of their course over the lifetime could help in elaborating interventions. Previous reports have separately investigated the prevalence of negative symptoms within each stage of the psychosis continuum. Our aim in this review is to compare those prevalences across stages, thereby disclosing the course of negative symptoms.

METHODS

We searched several databases for studies reporting prevalences of negative symptoms in each one of our predetermined stages of the psychosis continuum: clinical or ultra-high risk (UHR), first-episode of psychosis (FEP), and younger and older patients who have experienced multiple episodes of psychosis (MEP). We combined results using the definitions of negative symptoms detailed in the Brief Negative Symptom Scale, a recently developed tool. For each negative symptom, we averaged and weighted by the combined sample size the prevalences of each negative symptom at each stage.

RESULTS

We selected 47 studies totaling 1872 UHR, 2947 FEP, 5039 younger MEP, and 669 older MEP patients. For each negative symptom, the prevalences showed a comparable course. Each negative symptom decreased from the UHR to FEP stages and then increased from the FEP to MEP stages.

CONCLUSIONS

Certain psychological, environmental, and treatment-related factors may influence the cumulative impact of negative symptoms, presenting the possibility for early intervention to improve the long-term course.

DSM-5 Attenuated Psychosis Syndrome in Adolescents Hospitalized With Non-psychotic Psychiatric Disorders

Introduction: Although attenuated psychotic symptoms often occur for the first time during adolescence, studies focusing on adolescents are scarce. Attenuated psychotic symptoms form the criteria to identify individuals at increased clinical risk of developing psychosis. The study of individuals with these symptoms has led to the release of the DSM-5 diagnosis of Attenuated Psychosis Syndrome (APS) as a condition for further research. We aimed to characterize and compare hospitalized adolescents with DSM-5-APS diagnosis vs. hospitalized adolescents without a DSM-5-APS diagnosis. Methods: Interviewing help-seeking, hospitalized adolescents (aged 12-18 years) and their caregivers independently with established research instruments, we (1) evaluated the presence of APS among non-psychotic adolescents, (2) characterized and compared APS and non-APS individuals regarding sociodemographic, illness and intervention characteristics, (3) correlated psychopathology with levels of functioning and severity of illness and (4) investigated the influence of individual clinical, functional and comorbidity variables on the likelihood of participants to be diagnosed with APS. Results: Among 248 consecutively recruited adolescents (age=15.4 ± 1.5 years, females = 69.6%) with non-psychotic psychiatric disorders, 65 (26.2%) fulfilled APS criteria and 183 (73.8%) did not fulfill them. Adolescents with APS had higher number of psychiatric disorders than non-APS adolescents (3.5 vs. 2.4, p < 0.001; Cohen's d = 0.77), particularly, disruptive behavior disorders (Cramer's V = 0.16), personality disorder traits (Cramer's V = 0.26), anxiety disorders (Cramer's V = 0.15), and eating disorders (Cramer's V = 0.16). Adolescents with APS scored higher on positive (Cohen's d = 1.5), negative (Cohen's d = 0.55), disorganized (Cohen's d = 0.51), and general symptoms (Cohen's d = 0.84), and were more severely ill (Cohen's d = 1.0) and functionally impaired (Cohen's d = 0.31). Negative symptoms were associated with lower functional levels (Pearson ρ = -0.17 to -0.20; p = 0.014 to 0.031). Global illness severity was associated with higher positive, negative, and general symptoms (Pearson ρ = 0.22 to 0.46; p = 0.04 to p < 0.001). APS status was independently associated with perceptual abnormalities (OR = 2.0; 95% CI = 1.6-2.5, p < 0.001), number of psychiatric diagnoses (OR = 1.5; 95% CI = 1.2-2.0, p = 0.002), and impaired stress tolerance (OR = 1.4; 95% CI = 1.1-1.7, p = 0.002) (r ² = 0.315, p < 0.001). Conclusions: A considerable number of adolescents hospitalized with non-psychotic psychiatric disorders meet DSM-5-APS criteria. These help-seeking adolescents have more comorbid disorders and more severe symptoms, functional impairment, and severity of illness than non-APS adolescents. Thus, they warrant high intensity clinical care.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychosocial characteristics differentiate non-distressing and distressing voices in 10,346 adolescents

Adolescents hearing non-existent voices may be at risk for psychosis, but the prevalence of voice-hearing (VH) in the general population complicates clinical interpretations. Differentiating between VH with and without distress may aid treatment decisions in psychosis services, but understanding the differences between these two phenomena as they present in the normal adolescent population is necessary to validate this differentiation. The present study compared VH with and without distress in 10,346 adolescents in relation to clinical characteristics, known risk factors, predictors and psychosocial moderators of psychosis. A population-based cohort of Norwegian 16-19 years old adolescents completed a comprehensive web-based questionnaire, including two questions from the extended Launay-Slade Hallucinations Scale: (1) I often hear a voice speaking my thoughts aloud and (2) I have been troubled by hearing voices in my head. Adolescents reporting no VH, non-distressing VH or distressing VH were compared on 14 psychosocial and clinical variables. A multinomial regression model showed that non-disturbing voices were predicted by better school grades, social dysfunction, distractibility, affective symptoms and experience of trauma, while the disturbing voices were predicted by the experience of bullying and trauma, perceived negative self-worth and self-efficacy, less family support, dysregulation of activation, distractibility, self-harm and anxiety. Hearing voices without distress versus being distressed by the voices is related to different constellations of psychosocial variables, suggesting that they represent two separate groups of adolescents. The findings validate the emphasis on distress in clinical practice.

The psychosis risk timeline: can we improve our preventive strategies? Part 2: adolescence and adulthood

Current understanding of psychosis development is relevant to patients' clinical outcomes in mental health services as a whole, given that psychotic symptoms can be a feature of many different diagnoses at different stages of life. Understanding the risk factors helps clinicians to contemplate primary, secondary and tertiary preventive strategies that it may be possible to implement. In this second article of a three-part series, the psychosis risk timeline is again considered, here focusing on risk factors more likely to be encountered during later childhood, adolescence and adulthood. These include environmental factors, substance misuse, and social and psychopathological aspects.

LEARNING OBJECTIVES:

After reading this article you will be able to: •

DECLARATION OF INTEREST:

None.

Screening nursing students to identify those at high risk of poor mental health: a cross-sectional survey

OBJECTIVES

This study aimed to identify those at high risk of poor mental health among nursing students and to examine the relationships and consistency among five mental health assessments.

DESIGN

A cross-sectional design with purposive sampling was used. Four mental health screening tools plus previous mental health history/information were conducted during June 2015 to October 2016.

SETTING

A nursing major university in Taiwan.

PARTICIPANTS

A total of 2779 participants aged between 19 and 45 years were recruited.

MAIN OUTCOME MEASURES

Five mental health risks were identified: increased risk for ultra-high risk, putative prepsychosis states, high trait anxiety, high state anxiety with genetic risk and depression.

RESULTS

Out of the 3395 collected questionnaire, 2779 (82%) were found valid and included in the study. 612 (22%) of the participants were identified to be at mental health risk. 12 of them appeared positive in four, 79 in three, 148 in two and 373 in one of the adopted mental health screening tools. 69 participants had the experience of seeking medical help due to mental health issues, and 58% of them were identified to be at risk of mental health during the screening. Trait and state anxiety scored the highest in correlation analysis (r(2620)=0.76, p<0.001). Correlations were observed in the scores on the subscales of Chinese Version of Schizotypal Personality Questionnaire-Brief (CSPQ-B) and those of Brief self-report Questionnaire for Screening Putative Prepsychotic States (BQSPS), and the highest correlation coefficients was (r(2740)=0.70, p<0.001). Although both of the screening tools are used to assess mental illness risk at its prodromal phase, but CSPQ-B in general appeared to have more rigorous screening criteria than BQSPS.

CONCLUSION

For expediting early identification high risk of poor mental health, easy-to-use screening questionnaires can be adopted to assess the mental health state of nursing students whose mental well-being and overall health are of vital importance to the entire healthcare industry.

Anxiety in youth at clinical high risk for psychosis: A case study and conceptual model

Some individuals identified as being at clinical high risk (CHR) for developing psychosis may suffer substantial anxiety due to a fear of transitioning to psychosis. This can be associated with catastrophic misinterpretation of normal mental experiences, such as a momentary lapse in attention, as markers for psychosis, fueled by hypervigilance for mental experiences that may be perceived as signs of impending psychosis. This anxiety may only worsen due to the self-stigma triggered by admission to a psychiatric CHR clinic, independent of whether or not the individual transitions to psychosis. Based on a clinical case study, we propose a cognitive model for this anxiety, an extension of Clark's model of panic. Our model accounts for causal factors of this distress, such as self-stigma and maladaptive core beliefs. It also includes maintaining factors such as hypervigilance for mental experiences and catastrophic misinterpretation of normal mental experiences as anomalous and portending eventual psychosis. We outline assessment and treatment guidelines and offer suggestions for how this model could be empirically validated. We suggest that treatment with this model, under the neural diathesis-stress framework, may have the potential to lower the risk of transition to psychosis and that assessment for such anxiety should be part of standard CHR care.

Suicidal ideation in individuals at ultra-high risk for psychosis and its association with suspiciousness independent of depression

AIM

Psychotic experiences, including delusions and hallucinations, and their attenuated forms have been recently suggested as a significant but under-recognized marker of suicide risk. However, the relationship between attenuated positive symptoms and suicide has not yet been clearly demonstrated in individuals at ultra-high risk (UHR) for psychosis. Here, we investigated the effect of attenuated positive symptoms on suicidal ideation in UHR individuals.

METHODS

Fifty-three healthy controls (HCs) and 74 UHR individuals participated in the present study. All participants were assessed for the intensity of suicidal ideation and depressive symptoms at baseline. The effect of attenuated positive symptoms on suicidal ideation in the UHR group was examined using a multiple linear regression analysis after adjustment for concurrent depressive symptoms.

RESULTS

UHR participants were found to have significantly greater suicidal ideation and more severe depressive symptoms compared to those of HCs. The regression model demonstrated that suspiciousness significantly increased suicidal ideation in UHR participants, independent of the severity of depressive symptoms.

CONCLUSION

The findings of the present study suggest that suspiciousness may serve as a risk indicator for suicide in clinical practice for UHR individuals. It is crucial to focus on the risk of suicide in the UHR population, as they require sufficient clinical attention and proper management for crises related to their unusual and confusing experiences.

Neurocognition as a predictor of transition to psychotic disorder and functional outcomes in ultra-high risk participants: Findings from the NEURAPRO randomized clinical trial

BACKGROUND

Neurocognitive impairments experienced by individuals at ultra-high risk (UHR) for psychosis are potential predictors of outcome within this population, however there is inconsistency regarding the specific neurocognitive domains implicated. This study aimed to examine whether baseline neurocognition predicted transition to psychosis, or functional outcomes, at medium-term (mean = 3.4 years) follow-up, while controlling for other clinical/treatment variables associated with transition to psychosis.

METHOD

Analysis of data collected as part of a multi-centre RCT of omega-3 fatty acids and cognitive-behavioural case management (NEURAPRO) for UHR individuals was conducted on the 294 participants (134 males, 160 females) who completed neurocognitive assessment (Brief Assessment of Cognition for Schizophrenia) at baseline. Transition to psychosis was determined using the Comprehensive Assessment of At-Risk Mental States (CAARMS), and functioning was measured with the Global Functioning: Social and Role Scales.

RESULTS

Mean baseline z-scores indicated that UHR participants performed a quarter to half a standard deviation below normative means in all domains (range mean z = -0.24 to -0.47), except for executive functioning (mean z = 0.16). After adjusting for covariates, poorer Executive (p = .010) and Motor (p = .030) functions were predictive of transition to psychosis. Processing Speed and Verbal Fluency were significant predictors of role functioning at 12 months (p = .004), and social functioning at medium-term follow-up (p = .015), respectively.

CONCLUSIONS

Neurocognitive abilities are independent predictors of both transition to psychosis and functional outcomes within the UHR population. Further research is needed to determine the best combination of risk variables in UHR individuals for prediction of psychosis transition, functioning and other psychopathology outcomes.

Impact of distress related to attenuated psychotic symptoms in individuals at ultra high risk of psychosis: Findings from the Longitudinal Youth at Risk Study

AIM

Recent studies have highlighted that attenuated psychotic symptoms (APS) are an important source of distress in ultra high risk (UHR) individuals and that this distress is related to transition to psychosis (TTP). This study examined distress associated with APS in UHR individuals and investigated its association with TTP.

METHODS

The Comprehensive Assessment of At-Risk Mental State (CAARMS) was used to identify 173 UHR individuals, who were included as participants in the study. Distress related to APS was self-reported. Functioning was assessed on the Social and Occupational Functioning Assessment Scale. Associations between each of the 4 APS subscales in the CAARMS-non-bizarre ideas (NBI), perceptual abnormalities (PA), unusual thought content (UTC) and disorganized speech (DS)-with its distress level were examined.

RESULTS

Of the 173 UHR participants, 154 (89%) reported distress related to one or more APS. NBI was rated to be the most distressing out of the 4 APS by the highest number of participants (32.9%) compared to UTC (12.1%), PA (24.9%) and DS (2.9%). Mean distress scores were significantly associated with CAARMS composite scores (P < .001). However, there was no significant relationship between distress scores and functioning. Both mean distress scores (OR = 1.034, P = .029) and functioning (OR = 0.892, P = .022) were significant predictors of transition to psychosis at 1 year of follow-up.

CONCLUSIONS

This study provides additional evidence to link subjective distress experienced by UHR individuals to APS and to their subsequent clinical outcomes and has significant clinical implications.

Self-Awareness of Psychopathology and Brain Volume in Patients With First Episode Psychosis

Memory impairment, excessive rumination, and increased interpersonal sensitivity are major characteristics of high psychosis risk or first episode psychosis (FEP). Herein, we investigated the relationship between brain volume and self-awareness of psychopathology in patients with FEP. All participants (FEP: 34 and HCs: 34) completed clinical assessments and the following self-reported psychopathology evaluations: prospective and retrospective memory questionnaire (PRMQ), ruminative response scale (RRS), and interpersonal sensitivity measure (IPSM). Structural magnetic resonance imaging was then conducted. The PRMQ, RRS, and IPSM scores were significantly higher in the FEP group than in the healthy controls (HCs). The volumes of the amygdala, hippocampus, and superior temporal gyrus (STG) were significantly lower in the FEP group than in the HCs. There was a significant group-dependent moderation effect between self-awareness of psychopathology (PRMQ, RRS, and IPSM scores) and right STG (rSTG) volume. In the FEP group, self-awareness of psychopathology was positively associated with rSTG volume, while in the HCs, this correlation was negative. Our results indicate that self-awareness of psychopathology impacts rSTG volume in the opposite direction between patients with FEP and HCs. In patients with FEP, awareness of impairment may induce increases in rSTG brain volume. However, HCs showed decreased rSTG volume when they were aware of impairment.

A Mentalization-Informed Staging Approach to Clinical High Risk for Psychosis

The practice of diagnosis is fundamentally designed to orient treatment. In the case of early diagnosis for schizophrenia spectrum disorders (SSP) risk, the empirical base for such a practice is still young, and many clinical questions arise in the everyday clinical application of risk algorithms and ensuing therapeutic options. One of the key questions that we will focus on is the following: in cases of SSP where symptoms are successfully treated, why does residual social functioning impairment remain the most serious obstacle to remission and reinsertion in society? We will present the evidence suggesting that the roots of residual social functioning impairment may, in many cases, come from thwarted or arrested development in the specialization of social cognition during adolescence and early adulthood. We will review the evidence suggesting that both during the premorbid phase and clinical high-risk phase, attenuated psychotic symptoms may impede the maturation of key social cognitive processes, particularly the suite of reflective thinking processes coming under the term of mentalization. From this evidence base, we will adapt the staging model of SSP progression in function of our mentalization-informed model, tailored to provide a coherent framework of care addressing the key clinical needs at every stage of psychosis progression.

Prevalence of non-psychotic disorders in ultra-high risk individuals and transition to psychosis: A systematic review

Despite the growing interest in the prodromes of psychosis, the proper identification of those Ultra High Risk (UHR) subjects who will convert to psychosis remains an unresolved issue. It remains to be fully understood whether the risk of transition to psychosis is incremented by the concomitant presence of non-psychotic symptoms. We performed a systematic review in order to estimate: prevalence rates of non-psychotic disorders in UHR individuals and whether any comorbid disorder impacts on the risk of transition to frank psychosis. The review was conducted using the PRISMA guidelines by searching PubMed until August 2017. The inclusion criteria were: studies with appropriate definition of UHR/ ARMS (At Risk Mental States for psychosis); cross-sectional design (for prevalence rates) or longitudinal design (for transition rates to psychosis); adolescents and/or adults; specified instrument/interview for the diagnosis of mental disorder/symptoms. We included 46 English-language articles. We found that non-psychotic symptoms are a prevalent concern in UHR individuals, and this is true for all comorbid disorders examined. None of the mental disorder examined appear to be a marker for transition to psychosis. Our systematic review found that the great majority of UHR individuals actually has a highly prevalent clearly defined, above-the-threshold mental disorder that should constitute the primary focus of intervention.

Early intervention for everyone? A review of cross-cultural issues and their treatment in ultra-high-risk (UHR) cohorts

AIM

Over the past 20 years, early management of psychosis has become both a research and policy priority. In Western countries, psychotic disorders appear more prevalent in migrant and minority ethnic groups than in native or dominant groups. Moreover, disparities exist in health conditions and access to care among immigrants and minority ethnic groups, compared with native-born and majority groups. Appropriate early detection tools are necessary for the different groups.

METHODS

This systematic review provides a synthesis of the assessment and discussion of transcultural issues in ultra-high-risk (UHR) cohorts. The Medline database was searched via PubMed for peer-reviewed articles published in English from 1995 to 2017. All 79 studies included are prospective UHR cohort studies that used the Comprehensive Assessment of At-Risk Mental States (CAARMS).

RESULTS

In UHR cohort studies that used the CAARMS, transcultural data (native language, ethnicity, place of birth, migration) are rarely collected, and inadequate ability to speak the dominant language is a common exclusion criterion. When they are included, the CAARMS scores differ between some minorities and the native-born majority group.

CONCLUSIONS

This systematic review demonstrates barriers to the access to participation in early intervention research for migrants and ethnic minorities. This selection bias may result in lower validity for the CAARMS among these populations and thus in inadequate intervention programmes. Along with targeted studies, minorities' access to participation in UHR cohorts should be improved through 3 tools: interpreters at recruitment and for administration of CAARMS, a guide to cultural formulation and transcultural data collection.

Expressed emotion as a predictor of the first psychotic episode - Results of the European prediction of psychosis study

OBJECTIVE

To investigate the impact of expressed emotion (EE) on the risk of developing the first psychotic episode (FEP).

METHOD

The European Prediction of Psychosis Study (EPOS) investigated 245 patients who were at clinical high risk (CHR) of psychosis. The predictive value of EE alone and as a part of the multivariate EPOS model was evaluated.

RESULTS

"Perceived irritability", a domain of the Level of Expressed Emotion Scale (LEE), was found to be predictive for the First Psychotic Episode (FEP), even as an individual variable. Furthermore, it was selected in the multivariate EPOS prediction model, thereby replacing two of the original predictor variables. This led to an improved revised version that enabled the identification of three significantly different risk classes with a hazard rate of up to 0.911.

CONCLUSIONS

CHR subjects who perceive the most important person in their individual social environment to be limited in their stress coping skills had a higher risk of conversion to the first psychotic episode. The importance of this risk factor was further demonstrated by an improvement of risk estimation in the original EPOS predictor model. Perceiving a reference person as stress-prone and thus potentially unreliable might amplify self-experienced uncertainty and anxiety, which are often associated with the prodromal phase. Such an enforcement of stress-related processes could promote a conversion to psychosis.

Clinical trajectories in the ultra-high risk for psychosis population

BACKGROUND

Traditionally, research in the ultra-high risk (UHR) for psychosis population has focused on the treatment of existing symptomatology and prevention of transition to psychosis. Recently, there has been an increase in focus on outcomes in individuals who do not transition to psychosis. However, there is a lack of standardised definitions of remission, recovery, recurrence and relapse in UHR, resulting in the inability to generalise and replicate outcomes.

METHOD

The aims of the current study were to develop definitions for remission, recovery, recurrence and relapse, and apply them to a UHR cohort allowing the identification of longitudinal clinical trajectories. Further stratification in broader categories of favourable and unfavourable outcomes was applied. The predictive value of various baseline factors on specific clinical trajectories was also assessed.

RESULTS

17 different trajectories were identified in a cohort of 202 individuals within a 12-month period and classified according to the suggested definitions for recovery (35.7%), remission (7.5%), any recurrence (20%), no remission (17.3%), relapse (4.0%) and transition to psychosis (15.8%). Favourable and unfavourable trajectories represented 43.2% and 57.1% respectively. Long duration of untreated symptoms and high depression scores were associated with unfavourable outcomes.

DISCUSSION

It is possible to apply clear definitions of remission, recovery, recurrence, relapse and transition to psychosis to a UHR cohort to evaluate longitudinal clinical trajectories. Acceptance and use of these definitions will help to facilitate comparisons between trials and to improve clinical clarity across the range of available therapeutic options in UHR individuals.

Clinical high risk for psychosis in children and adolescents: a systematic review

The concept of being at risk for psychosis has been introduced both for adults and children and adolescents, but fewer studies have been conducted in the latter population. The aim of this study is to systematically review the articles associated with clinical description, interventions, outcome and other areas in children and adolescents at risk for psychosis. We searched in MEDLINE/PubMed and PsycINFO databases for articles published up to 30/06/16. Reviewed articles were prospective studies; written in English; original articles with Clinical High Risk (CHR) for psychosis samples; and mean age of samples younger than 18 years. From 103 studies initially selected, 48 met inclusion criteria and were systematically reviewed. Studies show that CHR children and adolescents present several clinical characteristics at baseline, with most attenuated positive-symptom inclusion criteria observed, reporting mostly perceptual abnormalities and suspiciousness, and presenting comorbid conditions such as depressive and anxiety disorders. CHR children and adolescents show lower general intelligence and no structural brain changes compared with controls. Original articles reviewed show rates of conversion to psychosis between 17 and 20% at 1 year follow-up and between 7 and 21% at 2 years. While 36% of patients recovered from their CHR status at 6-year follow-up, 40% still met CHR criteria. Studies in children and adolescents with CHR were conducted with different methodologies, assessments tools and small samples. It is important to conduct studies on psychopharmacological and psychological treatment, as well as replication of the few studies found.

Metacognitive beliefs as psychological predictors of social functioning: An investigation with young people at risk of psychosis

Poor social functioning has been found to be present in those at risk for psychosis. This study aimed to examine metacognitive beliefs as potential predictors of structured activity (measure of social functioning) in those with an At Risk Mental State (ARMS). Regression and correlation analyses were conducted. The sample included 109 young people. Age was found to be positively correlated to structured activity. Metacognitive beliefs concerning uncontrollability and danger of worry were found to negatively predict structured activity. This was after controlling for age, gender, treatment allocation, cognitive schemas, positive symptom severity, social anxiety, and depression. Metacognitive danger items were most important. Age was the only control variable found to be an independent predictor of structured activity in the regression model, despite negative bi-variate relationships with structured activity found across three cognitive schema subscales and social anxiety. This is the first study to find that higher negative metacognitive beliefs about uncontrollability and danger predict lower social functioning in an ARMS sample, and that the perception of thoughts being dangerous was of particular importance. Psychological interventions should consider targeting this metacognitive dimension to increase social functioning. Future longitudinal research is required to strengthen findings in this area.

The effects of cannabidiol on persecutory ideation and anxiety in a high trait paranoid group

BACKGROUND

Previous studies have suggested that cannabidiol has anxiolytic and antipsychotic properties, raising hopes that cannabidiol will translate to the psychiatric clinic. Cannabidiol may be particularly useful for anxiety and paranoia in those at-risk of major mental illness.

METHODS

Immersion in a controlled 3D virtual-reality scenario was used to assay persecutory ideation and anxiety in a sample of non-clinical volunteers ( n=32) pre-selected for high paranoid traits. Participants were randomised to receive oral cannabidiol (600 mg) or placebo 130 min prior to entering virtual-reality. Well-validated rating scales were used to assay persecutory thinking and anxiety. Salivary cortisol concentration, heart rate and blood pressure were measured over the course of the experimental session.

RESULTS

Immersion in the virtual-reality session elicited anxiety as indexed by the Beck's anxiety inventory ( p<0.005), and increased cortisol concentration ( p=0.05), heart rate ( p<0.05) and systolic blood pressure ( p<0.05). However, cannabidiol had no impact upon any of these effects, except for a strong trend to increase anxiety ( p=0.09). Cannabidiol had no effect on persecutory ideation as assayed by the Community Assessment of Psychic Experiences questionnaire or the State Social Paranoia Scale.

CONCLUSIONS

In contrast to previous studies, there was no evidence of any benefits of cannabidiol on anxiety or persecutory ideation in healthy volunteers with high trait paranoia. However, a larger sample will be required for a definitive study.

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

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

Comorbid Mental Disorders and 6-Month Symptomatic and Functioning Outcomes in Chinese University Students at Clinical High Risk for Psychosis

BACKGROUND

High rates of non-psychotic psychopathological symptoms have been observed in clinical population at clinical high risk (CHR) for psychosis. These comorbid disorders affected the baseline functional level of CHR patients. However, little is known about the comorbid mental disorder in CHR individuals in non-clinical adolescent population. This study aimed to investigate the comorbid mental disorder in non-clinical CHR adolescents and the impact on attenuated psychosis symptoms (APS) as well as clinical outcome.

METHODS

The sample consisted of 32 CHR students, who were screened from 2,800 university students. CHR status was evaluated with the Structured Interview of Prodromal Syndromes, comorbid mental disorder diagnoses with the International Neuropsychiatric Interview.

RESULTS

In the CHR sample, 46.9% was found at least one non-psychotic comorbid mental disorder. The CHR participants presenting comorbid mental disorder had significantly more severity of APS than those without comorbid mental disorders, and the remission rate at 6-month follow-up is significantly higher in the individuals without comorbid mental disorders at baseline.

CONCLUSION

In the non-clinical sample of individuals at CHR, non-psychotic comorbid mental disorders are common and anxiety disorder is most frequent. Copresence of anxiety and/or depression is related to higher level of attenuated psychotic symptoms and unfavorable clinical outcome at 6-month follow-up. Assessment and intervention in anxiety and depression for non-clinical CHR adolescents are suggested.

Psychosis risk research versus daily prognosis uncertainties: A qualitative study of French youth psychiatrists' attitudes toward predictive practices

Background

Over the last twenty years, predicting psychosis has become a priority of both research and policies. Those approaches include the use of the At Risk Mental State category (ARMS) and of standardized predictive tools. In comparison to most developed countries, early interventions programs are only little developed in France. However, cases of young patients presenting unclear symptoms that might be a beginning psychosis or might as well reflect some adolescent unease are commonplace in psychiatry. Yet little is known about the routine practices of youth psychiatrists regarding psychosis risk management. Do they anticipate mental disorders?

Method

The Grounded Theory is an agreed-upon qualitative method in social science field that links subjective experiences (individual narratives) to social processes (professional norms and mental health policies). 12 French youth psychiatrists were interviewed about psychosis early management and their daily prognosis practices with teenagers.

Results

If all participants were aware of early intervention programs, most of them did not make use of standardized scales. Psychiatrists’ reluctance toward a psychosis risk standardized assessment was shaped by three difficulties: first the gap between theoretical knowledge and practice; second their impossibility to make reliable prognoses; and third, the many uncertainties surrounding medical judgment, adolescence and the nature of psychosis. Nevertheless, they provided their young patients with multiple months follow up without disclosing any risk category.

Conclusion

Anticipating a psychosis onset remains a highly uncertain task for psychiatrists. In France, psychiatrists’ inconspicuous risk management might be supported by the universal costs coverage that is not conditional on a diagnosis disclosure.

Clinical high risk for psychosis: the association between momentary stress, affective and psychotic symptoms

OBJECTIVE

The aim of this study was to assess associations between momentary stress and both affective and psychotic symptoms in everyday life of individuals at clinical high risk (CHR), compared to chronic psychotic patients and healthy controls, in search for evidence of early stress sensitization. It also assessed whether psychotic experiences were experienced as stressful.

METHOD

The experience sampling method was used to measure affective and psychotic reactivity to everyday stressful activities, events and social situations in 22 CHR patients, 24 patients with a psychotic disorder and 26 healthy controls.

RESULTS

Multilevel models showed significantly larger associations between negative affect (NA) and activity-related stress for CHR patients than for psychotic patients (P = 0.008) and for CHR compared to controls (P < 0.001). Similarly, the association between activity-related stress and psychotic symptoms was larger in CHR than in patients (P = 0.02). Finally, the association between NA and symptoms (P < 0.001) was larger in CHR than in patients.

CONCLUSION

Stress sensitization seems to play a role particularly in the early phase of psychosis development as results suggest that CHR patients are more sensitive to daily life stressors than psychotic patients. In this early phase, psychotic experiences also contributed to the experience of stress.

Clinical presentation of Attenuated Psychosis Syndrome in children and adolescents: Is there an age effect?

There is limited research on clinical features related to age of presentation of the Attenuated Psychosis Syndrome in children and adolescents (CAD). Based on findings in CAD with psychosis, we hypothesized that an older age at presentation of Attenuated Psychosis Syndrome would be associated with less severe symptoms and better psychosocial functioning than presentation in childhood or younger adolescence. Ninety-four CAD (age 9-18) meeting Attenuated Psychosis Syndrome criteria participated in the study. The sample was divided and compared according to the age of presentation of Attenuated Psychosis Syndrome (9-14 vs 15-18 years). The predictive value of age of Attenuated Psychosis Syndrome presentation was investigated using receiver operating characteristic (ROC)-curve calculations. The two Attenuated Psychosis Syndrome groups were homogeneous in terms of gender distribution, IQ scores and comorbid diagnoses. Older Attenuated Psychosis Syndrome patients showed better functioning and lower depressive scores. ROC curves revealed that severity of functional impairment was best predicted using an age of presentation cut-off of 14.9 years for social functioning and 15.9 years for role functioning. This study partially confirmed our hypothesis; older age at presentation of Attenuated Psychosis Syndrome was associated with less functional impairment, but age was not associated with psychotic symptoms.

The role of rumination in illness trajectories in youth: linking trans-diagnostic processes with clinical staging models

Research in developmental psychopathology and clinical staging models has increasingly sought to identify trans-diagnostic biomarkers or neurocognitive deficits that may play a role in the onset and trajectory of mental disorders and could represent modifiable treatment targets. Less attention has been directed at the potential role of cognitive-emotional regulation processes such as ruminative response style. Maladaptive rumination (toxic brooding) is a known mediator of the association between gender and internalizing disorders in adolescents and is increased in individuals with a history of early adversity. Furthermore, rumination shows moderate levels of genetic heritability and is linked to abnormalities in neural networks associated with emotional regulation and executive functioning. This review explores the potential role of rumination in exacerbating the symptoms of alcohol and substance misuse, and bipolar and psychotic disorders during the peak age range for illness onset. Evidence shows that rumination not only amplifies levels of distress and suicidal ideation, but also extends physiological responses to stress, which may partly explain the high prevalence of physical and mental co-morbidity in youth presenting to mental health services. In summary, the normative developmental trajectory of rumination and its role in the evolution of mental disorders and physical illness demonstrates that rumination presents a detectable, modifiable trans-diagnostic risk factor in youth.

Schizotypal traits in adolescents with 22q11.2 deletion syndrome: validity, reliability and risk for psychosis

BACKGROUND

Very little is known about the phenotypic expression of schizotypal traits in individuals with 22q11.2 deletion syndrome (22q11DS). The main purpose was to analyse the factorial structure, internal consistency and temporal stability of schizotypal traits, as well as their associations with prodromal states and clinical psychotic symptoms in adolescents with 22q11DS.

METHOD

The sample comprised 61 adolescents with 22q11DS (mean = 14.95 years, s.d. = 2.13; n = 24 at follow-up). An age-matched comparison group (n = 61, mean = 15.44 years, s.d. = 1.76) was also included. The Schizotypal Personality Questionnaire (SPQ), the Structured Interview for Prodromal Syndromes, the Positive and Negative Syndrome Scale, and the Brief Psychiatric Rating Scale were used.

RESULTS

Adolescents with 22q11DS scored higher than the control group on the interpersonal dimension and suspiciousness subscale of the SPQ. The analysis of the internal structure of the SPQ in the sample of 22q11DS participants yielded a three-component solution (cognitive-perceptual, interpersonal, and disorganized). In addition, internal consistency coefficients ranged between 0.63 and 0.91. The schizotypal traits were highly stable across a 3.6-year interval, and ranged from 0.50 to 0.63. Self-reported schizotypal traits correlated with interview-based ratings of prodromal states and psychotic symptoms.

CONCLUSIONS

These results indicate that the SPQ may be a valid tool to assess schizotypal traits in adolescents with 22q11DS. The identification of a reliable self-report instrument for use in individuals with learning disabilities and at genetic high risk for psychosis could be useful in clinical and research settings. Assessment of schizotypal traits may be used as a distal risk marker and in a close-in strategy in high-risk genetic samples to enhance the possibility of early detection of psychosis.