The factor structure for the Positive and Negative Syndrome Scale (PANSS) in recent-onset psychosis

The mechanisms of persisting disability in schizophrenia: imprecise predictive coding via cortico-striatal-thalamo-cortical loop dysfunction

Persisting symptoms and disability remain a problem for an appreciable proportion of people with schizophrenia despite treatment with antipsychotic medication. Improving outcomes requires an understanding of the nature and mechanisms of the pathological processes underlying persistence. Classical features of schizophrenia, which include disorganization and impoverishment of mental activity, are well recognised early clinical features that predict poor long-term outcome. Substantial evidence indicates that these features reflect imprecise predictive coding. Predictive coding provides an over-arching framework for understanding efficient function of the nervous system. Imprecise predictive coding also has the potential to precipitate acute psychosis characterised by reality distortion (delusions and hallucinations) at times of stress. On the other hand, substantial evidence indicates that persistent reality distortion itself gives rise to poor occupational and social function in the long term. Furthermore, abuse of psychotomimetic drugs, which exacerbate reality distortion, contributes to poor long-term outcome in schizophrenia. Neural circuits involved in modulating volitional acts are well understood to be implicated in addiction. Plastic changes in these circuits may account for the association between psychotomimetic drug abuse and poor outcomes in schizophrenia. We propose a mechanistic model according to which unbalanced inputs to the corpus striatum disturb the precision of sub-cortical modulation of cortical activity supporting volitional action. This model accounts for the evidence that early classical symptoms predict poor outcome, while in some circumstances, persistent reality distortion also predicts poor outcome. This model has implications for the development of novel treatments that address the risk of persisting symptoms and disabilities in schizophrenia.

Rates and correlates of medication non-adherence behaviors and attitudes in adult patients with early psychosis

PURPOSE

Literature on antipsychotic medication adherence in early psychosis primarily assessed adherence behaviors and focused on young patients. There is a paucity of research investigating negative medication attitude and its determinants in the early illness course, particularly in older-aged sample. We aimed to examine prevalence and correlates of medication non-adherence behaviors and negative medication attitudes separately in adult patients with early psychosis.

METHODS

One hundred ninety-nine Chinese early psychosis patients aged 26-55 years who had received three-year treatment for first psychotic episode in Hong Kong were examined. Assessments encompassing socio-demographics, premorbid adjustment, clinical and treatment profiles, self-stigma and therapeutic alliance were conducted. Patients were evaluated with Medication Compliance Questionnaire, which is a modified Chinese-translated version of Medication Adherence Rating Scale and includes items measuring adherence behaviors and attitudes towards medications.

RESULTS

Rates of medication non-adherence and negative attitude towards medications were 38.7% and 50.8%, respectively. Multivariate regression analysis showed that more severe positive symptoms, greater self-stigma and negative medication attitude were independently associated with medication non-adherence. Negative attitude towards medications was significantly associated with younger age, higher educational attainment, diagnosis of other psychotic disorders, poorer insight, greater self-stigma and less satisfaction with communication with healthcare staff, which represented an index reflecting suboptimal therapeutic alliance.

CONCLUSION

Antipsychotic non-adherence and negative medication attitudes are frequently observed in adult early psychosis patients. Our findings indicate that poor insight, elevated self-stigma and suboptimal therapeutic alliance may constitute potential treatment targets for promoting medication adherence and rectifying negative medication attitudes in the early illness stage.

Neuropsychological profiles in first-episodes psychosis and their relationship with clinical, metacognition and social cognition variables

An increasing interest in the assessment of neuropsychological performance variability in people with first-episode psychosis (FEP) has emerged. However, its association with clinical and functional outcomes requires further study. Furthermore, FEP neuropsychological subgroups have not been characterized by clinical insight or metacognition and social cognition domains. The aim of this exploratory study was to identify specific groups of patients with FEP based on neuropsychological variables and to compare their sociodemographic, clinical, metacognition and social cognition profiles. A sample of 149 FEP was recruited from adult mental health services. Neuropsychological performance was assessed by a neuropsychological battery (WAIS-III; TMT; WSCT; Stroop Test; TAVEC). The assessment also included sociodemographic characteristics, clinical, functional, metacognition and social cognition variables. Two distinct neuropsychological profiles emerged: one neuropsychological impaired cluster (N = 56) and one relatively intact cluster (N = 93). Significant differences were found between both profiles in terms of sociodemographic characteristics (age and level of education) (p = 0.001), clinical symptoms (negative, positive, disorganized, excitement and anxiety) (p = 0.041-0.001), clinical insight (p = 0.038-0.017), global functioning (p = 0.014), as well as in social cognition domains (emotional processing and theory of mind) (p = 0.001; p = 0.002). No significant differences were found in metacognitive variables (cognitive insight and 'jumping to conclusions' bias). Relationship between neurocognitive impairment, social cognition and metacognition deficits are discussed. Early identifying of neuropsychological profiles in FEP, characterized by significant differences in clinical and social cognition variables, could provide insight into the prognosis and guide the implementation of tailored early-intervention.

Clinical presentation of first episode psychosis in people with and without HIV in KwaZulu-Natal, South Africa

AIM

Mental disorders and HIV are the main contributors to the increase in years lived with disability rates per person in sub-Saharan Africa. A complex inter-relationship exists between HIV and mental illness, especially in a region with a high HIV prevalence. We examined the duration of untreated psychosis (DUP), and the nature of psychotic and cognitive symptoms in people with first episode psychosis (FEP) living with and without HIV.

METHODS

Adults aged between 18 and 45 years were assessed using a clinical interview, physical examination and several psychiatric tools. These included the Mini International Neuro-psychiatric Interview to confirm psychosis, Positive and Negative Syndrome Scale, International HIV Dementia Scale and other scales to measure symptom variables. HIV ELISA was used for HIV serology testing, with measures being carried out within 6 weeks of the first presentation.

RESULTS

Of the 172 people presenting with FEP, 36 (21%) had comorbid HIV, those with both being older and more likely to be female (p < .001). Clinically, participants with FEP and HIV scored lower on the positive subscale (p = .008). There were no statistically significant differences for DUP or cognitive screening. Of those living with HIV and FEP (n = 36) comorbidity, nine were newly diagnosed with HIV at the time of the study.

CONCLUSION

Individuals presenting with FEP and comorbid HIV were older, female and reported more mood symptoms. The identification of nine new HIV infections also reflects the ongoing need to test for HIV in people presenting with severe mental illness.

Belief Updating, Childhood Maltreatment, and Paranoia in Schizophrenia-Spectrum Disorders

BACKGROUND AND HYPOTHESIS

Exposure to childhood maltreatment-a risk factor for psychosis is associated with paranoia-may impact one's beliefs about the world and how beliefs are updated. We hypothesized that increased exposure to childhood maltreatment is related to volatility-related belief updating, specifically higher expectations of volatility, and that these relationships are strongest for threat-related maltreatment. Additionally, we tested whether belief updating mediates the relationship between maltreatment and paranoia.

STUDY DESIGN

Belief updating was measured in 75 patients with schizophrenia-spectrum disorders and 76 nonpsychiatric controls using a 3-option probabilistic reversal learning (3PRL) task. A Hierarchical Gaussian Filter (HGF) was used to estimate computational parameters of belief updating, including prior expectations of volatility (μ03). The Childhood Trauma Questionnaire (CTQ) was used to assess cumulative maltreatment, threat, and deprivation exposure. Paranoia was measured using the Positive and Negative Syndrome Scale (PANSS) and the revised Green et al. Paranoid Thoughts Scale (R-GPTS).

RESULTS

Greater exposure to childhood maltreatment is associated with higher prior expectations of volatility in the whole sample and in individuals with schizophrenia-spectrum disorders. This was specific to threat-related maltreatment, rather than deprivation, in schizophrenia-spectrum disorders. Paranoia was associated with both exposure to childhood maltreatment and volatility priors, but we did not observe a significant indirect effect of volatility priors on the relationship between maltreatment and paranoia.

CONCLUSIONS

Our study suggests that individuals with schizophrenia-spectrum disorders who were exposed to threatening experiences during childhood expect their environment to be more volatile, potentially facilitating aberrant belief updating and conferring risk for paranoia.

Clinical characteristics of people presenting with first episode psychosis pre- and during the COVID-19 pandemic in KwaZulu-Natal Province, South Africa

BACKGROUND

The COVID-19 pandemic and the lockdown experience may have not only precipitated or exacerbated mental illness but also influenced access to care and the nature and content of the psychotic symptomatology of people with psychosis.

AIM

This study aimed to evaluate the association of the COVID-19 pandemic and lockdown experience on clinical presentation and quality of life of people (QOL) with first episode psychosis (FEP).

METHOD

Two first episode psychosis cohorts from the same epidemiological area collected prior to, and during the COVID-19 pandemic and lockdown were compared in terms of clinical symptomatology, substance use and QOL. All adult in- and outpatients with FEP at five clinical units in KwaZulu-Natal, South Africa, aged between 18 and 45 years, were assessed with the MINI interview for psychosis, Positive and Negative Symptoms Scale, WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the WHO QOL scales.

RESULTS

Eighty-eight FEP participants were recruited between 2019 and 2020 (cohort 1) before the pandemic. Study recruitment was suspended in March 2020 due to the pandemic. On study resumption from November 2020 to November 2022, 95 new participants (cohort 2) were recruited. There were no sociodemographic differences between the two cohorts, except unemployment status (57% vs. 65%) and household income. The cohort presenting post-COVID-19 pandemic onset had significantly more positive psychotic symptoms (21.9 vs. 23.7), lower PANSS domain depressive score, more lifetime use of tobacco, cannabis and alcohol. However, they reported improved QOL (196 vs. 239).

CONCLUSION

Following the pandemic and lockdown experience participants presented with more severe psychotic symptoms and concomitant substance use but improved perceived QOL. This suggests the need to explore individual and social factors that may influence the clinical presentation.

Psychosis superspectrum I: Nosology, etiology, and lifespan development

This review describes the Hierarchical Taxonomy of Psychopathology (HiTOP) model of psychosis-related psychopathology, the psychosis superspectrum. The HiTOP psychosis superspectrum was developed to address shortcomings of traditional diagnoses for psychotic disorders and related conditions including low reliability, arbitrary boundaries between psychopathology and normality, high symptom co-occurrence, and heterogeneity within diagnostic categories. The psychosis superspectrum is a transdiagnostic dimensional model comprising two spectra-psychoticism and detachment-which are in turn broken down into fourteen narrow components, and two auxiliary domains-cognition and functional impairment. The structure of the spectra and their components are shown to parallel the genetic structure of psychosis and related traits. Psychoticism and detachment have distinct patterns of association with urbanicity, migrant and ethnic minority status, childhood adversity, and cannabis use. The superspectrum also provides a useful model for describing the emergence and course of psychosis, as components of the superspectrum are relatively stable over time. Changes in psychoticism predict the onset of psychosis-related psychopathology, whereas changes in detachment and cognition define later course. Implications of the superspectrum for genetic, socio-environmental, and longitudinal research are discussed. A companion review focuses on neurobiology, treatment response, and clinical utility of the superspectrum, and future research directions.

Distinct multimodal biological and functional profiles of symptom-based subgroups in recent-onset psychosis

Symptom heterogeneity characterizes psychotic disorders and hinders the delineation of underlying biomarkers. Here, we identify symptom-based subtypes of recent-onset psychosis (ROP) patients from the multi-center PRONIA (Personalized Prognostic Tools for Early Psychosis Management) database and explore their multimodal biological and functional signatures. We clustered N = 328 ROP patients based on their maximum factor scores in an exploratory factor analysis on the Positive and Negative Syndrome Scale items. We assessed inter-subgroup differences and compared to N = 464 healthy control (HC) individuals regarding gray matter volume (GMV), neurocognition, polygenic risk scores, and longitudinal functioning trajectories. Finally, we evaluated factor stability at 9- and 18-month follow-ups. A 4-factor solution optimally explained symptom heterogeneity, showing moderate longitudinal stability. The ROP-MOTCOG (Motor/Cognition) subgroup was characterized by GMV reductions within salience, control and default mode networks, predominantly throughout cingulate regions, relative to HC individuals, had the most impaired neurocognition and the highest genetic liability for schizophrenia. ROP-SOCWD (Social Withdrawal) patients showed GMV reductions within medial fronto-temporal regions of the control, default mode, and salience networks, and had the lowest social functioning across time points. ROP-POS (Positive) evidenced GMV decreases in salience, limbic and frontal regions of the control and default mode networks. The ROP-AFF (Affective) subgroup showed GMV reductions in the salience, limbic, and posterior default-mode and control networks, thalamus and cerebellum. GMV reductions in fronto-temporal regions of the salience and control networks were shared across subgroups. Our results highlight the existence of behavioral subgroups with distinct neurobiological and functional profiles in early psychosis, emphasizing the need for refined symptom-based diagnosis and prognosis frameworks.

Relapse in schizophrenia: The role of factors other than non-adherence to treatment

AIM

Relapse rates are very high in schizophrenia. However, little is known about the predictors of the time to relapse other than treatment non-adherence. We investigated possible risk factors for the time to relapse in patients with first-episode schizophrenia (n = 107) who received assured treatment by way of long-acting injectable antipsychotic over 24 months and who underwent regular clinical, cognitive, and metabolic assessments.

METHODS

Using Cox regression analyses we assessed selected premorbid and baseline potential predictors of time to relapse. Relapse was defined using operationally defined relapse criteria.

RESULTS

In the primary analysis only neurological soft signs total score retained significance, with higher scores predicting shorter time to relapse (HR = 1.05, 95% CI = 1.01-1.10, p = .029). In a more detailed secondary analysis poorer social relationships predicted shorter time to relapse (HR = 0.85, 95% CI = 0.76-0.95, p = .003).

CONCLUSION

Our predominantly negative findings suggest that many of the previously implicated risk factors for the time to relapse are mediated by non-adherence rather than having a direct effect on relapse-proneness. Neurological soft signs, and perhaps quality of life in social relationships appear to play a role and merit further investigation.

Relationship between drug-induced movement disorders and psychosis in adults living in precarious housing or homelessness

BACKGROUND

Studies have reported positive associations between drug-induced movement disorders (DIMDs) and symptoms of psychosis in patients with schizophrenia. However, it is not clear which subtypes of symptoms are related to each other, and whether one symptom precedes another. The current report assessed both concurrent and temporal associations between DIMDs and symptoms of psychosis in a community-based sample of homeless individuals.

METHODS

Participants were recruited in Vancouver, Canada. Severity of DIMDs and psychosis was rated annually, allowing for the analysis of concurrent associations between DIMDs and Positive and Negative Syndrome Scale (PANSS) five factors. A brief version of the PANSS was rated monthly using five psychotic symptoms, allowing for the analysis of their temporal associations with DIMDs. Mixed-effects linear and logistic regression models were used to assess the associations.

RESULTS

401 participants were included, mean age of 40.7 years (SD = 11.2) and 77.4% male. DIMDs and symptoms of psychosis were differentially associated with each other, in which the presence of parkinsonism was associated with greater negative symptoms, dyskinesia with disorganized symptoms, and akathisia with excited symptoms. The presence of DIMDs of any type was not associated with depressive symptoms. Regarding temporal associations, preceding delusions and unusual thought content were associated with parkinsonism, whereas dyskinesia was associated with subsequent conceptual disorganization.

CONCLUSIONS

The current study found significant associations between DIMDs and symptoms of psychosis in individuals living in precarious housing or homelessness. Moreover, there were temporal associations between parkinsonism and psychotic symptoms (delusions or unusual thought content), and the presence of dyskinesia was temporally associated with higher odds of clinically relevant conceptual disorganization.

Impaired emotional awareness is associated with childhood maltreatment exposure and positive symptoms in schizophrenia

Objectives

Evidence suggests that emotional awareness-the ability to identify and label emotions-may be impaired in schizophrenia and related to positive symptom severity. Exposure to childhood maltreatment is a risk factor for both low emotional awareness and positive symptoms.

Methods

The current investigation examines associations between a performance-based measure of emotional awareness, positive symptom severity, and childhood maltreatment exposure in 44 individuals with a schizophrenia-spectrum disorder and 48 healthy comparison participants using the electronic Levels of Emotional Awareness Scale (eLEAS), Positive and Negative Syndrome Scale (PANSS) and Childhood Trauma Questionnaire (CTQ).

Results

Patients demonstrated significant deficits in emotional awareness overall, which was true for both self and others. In patients, lower emotional awareness was significantly associated with more severe positive symptoms. Emotional awareness was significantly impaired in patients with schizophrenia with self-reported maltreatment exposure, relative to other groups. Severity of maltreatment was not significantly associated with emotional awareness or positive symptoms when looking continuously, and there was no significant indirect effect.

Conclusion

These data suggest that emotional awareness impairments observed in schizophrenia may be exacerbated by exposure to childhood maltreatment, possibly putting individuals at greater risk for experiencing positive symptoms of psychosis.

Psychometric properties of the mini international neuropsychiatric interview (MINI) psychosis module: a Sub-Saharan Africa cross country comparison

BACKGROUND

The Mini International Neuropsychiatric Inventory 7.0.2 (MINI-7) is a widely used tool and known to have sound psychometric properties; but very little is known about its use in low and middle-income countries (LMICs). This study aimed to examine the psychometric properties of the MINI-7 psychosis items in a sample of 8609 participants across four countries in Sub-Saharan Africa.

METHODS

We examined the latent factor structure and the item difficulty of the MINI-7 psychosis items in the full sample and across four countries.

RESULTS

Multiple group confirmatory factor analyses (CFAs) revealed an adequate fitting unidimensional model for the full sample; however, single group CFAs at the country level revealed that the underlying latent structure of psychosis was not invariant. Specifically, although the unidimensional structure was an adequate model fit for Ethiopia, Kenya, and South Africa, it was a poor fit for Uganda. Instead, a 2-factor latent structure of the MINI-7 psychosis items provided the optimal fit for Uganda. Examination of item difficulties revealed that MINI-7 item K7, measuring visual hallucinations, had the lowest difficulty across the four countries. In contrast, the items with the highest difficulty were different across the four countries, suggesting that MINI-7 items that are the most predictive of being high on the latent factor of psychosis are different for each country.

CONCLUSIONS

The present study is the first to provide evidence that the factor structure and item functioning of the MINI-7 psychosis vary across different settings and populations in Africa.

Cognitive subgroups and the relationships with symptoms, psychosocial functioning and quality of life in first-episode non-affective psychosis: a cluster-analysis approach

Introduction

Prior research examining cognitive heterogeneity in psychotic disorders primarily focused on chronic schizophrenia, with limited data on first-episode psychosis (FEP). We aimed to identify distinct cognitive subgroups in adult FEP patients using data-driven cluster-analytic approach, and examine relationships between cognitive subgroups and a comprehensive array of illness-related variables.

Methods

Two-hundred-eighty-nine Chinese patients aged 26-55 years presenting with FEP to an early intervention program in Hong Kong were recruited. Assessments encompassing premorbid adjustment, illness-onset profile, symptom severity, psychosocial functioning, subjective quality-of-life, and a battery of cognitive tests were conducted. Hierarchical cluster-analysis was employed, optimized with k-means clustering and internally-validated by discriminant-functional analysis. Cognitive subgroup comparisons in illness-related variables, followed by multivariable multinominal-regression analyzes were performed to identify factors independently predictive of cluster membership.

Results

Three clusters were identified including patients with globally-impaired (n = 101, 34.9%), intermediately-impaired (n = 112, 38.8%) and relatively-intact (n = 76, 26.3%) cognition (GIC, IIC and RIC subgroups) compared to demographically-matched healthy-controls' performance (n = 50). GIC-subgroup was older, had lower educational attainment, greater positive, negative and disorganization symptom severity, poorer insight and quality-of-life than IIC- and RIC-subgroups, and higher antipsychotic-dose than RIC-subgroup. IIC-subgroup had lower education levels and more severe negative symptoms than RIC-subgroup, which had better psychosocial functioning than two cognitively-impaired subgroups. Educational attainment and disorganization symptoms were found to independently predict cluster membership.

Discussion

Our results affirmed cognitive heterogeneity in FEP and identified three subgroups, which were differentially associated with demographic and illness-related variables. Further research should clarify longitudinal relationships of cognitive subgroups with clinical and functional outcomes in FEP.

Altered neutrophil-to-lymphocyte ratio in patients with non-affective first episode psychosis and its relationship with symptom severity and cognitive impairment

Signatures of immune dysregulation as clinical biomarker for psychosis have remained unclear. We aimed to compare the Neutrophil-to-lymphocyte ratio (NLR) of patients with acute non-affective first-episode psychosis (FEP) with healthy controls after accounting for emotional states. We also explored the associations of NLR with symptom severity, onset profile and cognitive functions. The NLR was enumerated from complete blood count taken within a week of assessment. All FEP patients were rated on the Positive and Negative Syndrome Scale (PANSS) and the Clinician Global Impression-Severity (CGI-S) with verbal memory and executive functions assessed with the Cambridge Neuropsychological Test Automated Battery. Prevailing emotional state was measured with Beck Depression Inventory-II and Beck Anxiety Inventory. Out of seventy-nine consecutive FEP patients presenting to the study site, twenty-seven subjects were eligible and recruited. Twenty-seven age-/sex-matched controls were recruited. FEP patients had an NLR of 1.886 over the controls after accounting for scores on emotional states. The NLR of FEP patients was positively associated with CGI-S scores, PANSS positive symptom, disorganization and excitation scores. There was no significant correlation between NLR with the duration of untreated psychosis and cognitive performances. These findings support using NLR as a clinical biomarker in FEP, purporting further prospective study to measure NLR changes in the course of treatment.

Rate and correlates of self-stigma in adult patients with early psychosis

Introduction

Self-stigma impedes recovery process and is associated with poorer clinical and functional outcomes in people with psychotic disorders. However, there is limited research specifically examining self-stigma in the early stage of illness, and mixed findings were observed regarding factors associated with increased self-stigma. We aimed to investigate the rate and correlates of self-stigma in a cohort of adult patients with early psychosis using a comprehensive array of clinical, treatment and other illness-related variables.

Methods

A total of 101 Chinese adult early psychosis patients aged 26-55 years who had received three-year psychiatric treatment for first psychotic episode in Hong Kong and completed self-stigma assessment were included for the current investigation. A broad range of assessments encompassing socio-demographics, premorbid adjustment, onset and illness profiles, symptom severity, psychosocial functioning, treatment characteristics and medication side-effects were conducted.

Results

Twenty-eight (27.7%) patients had moderate-to-high levels of self-stigma. Univariate linear regression analyses showed that age at study entry, sex, educational level, age at psychosis onset, duration of untreated psychosis (DUP), insight level, global psychosocial functioning, and the use of second-generation antipsychotic were related to self-stigma levels. Final multivariable regression model revealed that female sex, younger age at entry, longer DUP and better insight were independently associated with higher levels of self-stigma.

Conclusion

More than one-fourth of early psychosis patients experienced significant self-stigma, highlighting an unmet need for early detection and intervention of self-stigma in the initial years of illness. Further investigation is warranted to clarify trajectories and predictors of self-stigma in the early illness course.

Two Neuroanatomical Signatures in Schizophrenia: Expression Strengths Over the First 2 Years of Treatment and Their Relationships to Neurodevelopmental Compromise and Antipsychotic Treatment

BACKGROUND AND HYPOTHESIS

Two machine learning derived neuroanatomical signatures were recently described. Signature 1 is associated with widespread grey matter volume reductions and signature 2 with larger basal ganglia and internal capsule volumes. We hypothesized that they represent the neurodevelopmental and treatment-responsive components of schizophrenia respectively.

STUDY DESIGN

We assessed the expression strength trajectories of these signatures and evaluated their relationships with indicators of neurodevelopmental compromise and with antipsychotic treatment effects in 83 previously minimally treated individuals with a first episode of a schizophrenia spectrum disorder who received standardized treatment and underwent comprehensive clinical, cognitive and neuroimaging assessments over 24 months. Ninety-six matched healthy case-controls were included.

STUDY RESULTS

Linear mixed effect repeated measures models indicated that the patients had stronger expression of signature 1 than controls that remained stable over time and was not related to treatment. Stronger signature 1 expression showed trend associations with lower educational attainment, poorer sensory integration, and worse cognitive performance for working memory, verbal learning and reasoning and problem solving. The most striking finding was that signature 2 expression was similar for patients and controls at baseline but increased significantly with treatment in the patients. Greater increase in signature 2 expression was associated with larger reductions in PANSS total score and increases in BMI and not associated with neurodevelopmental indices.

CONCLUSIONS

These findings provide supporting evidence for two distinct neuroanatomical signatures representing the neurodevelopmental and treatment-responsive components of schizophrenia.

Association between early suicidal trajectories in first-episode psychosis and 10-year follow-up: TIPS registry-linked study

BACKGROUND

Although the risk of suicidality is high in first-episode psychosis, patterns and individual variability in suicidal thoughts and behaviours over time are under-researched. We aimed to identify early trajectories of suicidality over a 2-year follow-up, assess their baseline predictors, and explore associations between those trajectories and later suicidality.

METHODS

This longitudinal follow-up study was a part of the Early Treatment and Intervention in Psychosis (TIPS)study. Participants, linked to Norwegian and Danish death registries, were recruited from four catchment areas (665 000 inhabitants) in Norway and Denmark (both inpatient and outpatient). We included participants aged 15-65 years, with an intelligence quotient of more than 70, willing to give informed consent, and with a first episode of active psychotic symptoms. Individuals with comorbid neurological or endocrinal disorders, or those with contraindications to antipsychotics, were excluded. Growth mixture modelling was used to identify trajectories of suicidal thoughts and behaviours over the first 2 years. Multinomial logistic regression was applied to examine the baseline predictors of those trajectories and their associations with suicidality at 10-year follow-up.

FINDINGS

A total of 301 participants were recruited from Jan 1, 1997, to Dec 31, 2000. Of the 299 with completed suicidality data at baseline, 271 participated in 1-year follow-up, 250 in 2-year follow-up, 201 in 5-year follow-up, and 186 at 10-year follow-up. At baseline, 176 (58%) were male, 125 (42%) were female. The mean age was 27·80 years (SD 9·64; range 15-63). 280 (93%) participants were of Scandinavian origin. Four trajectories over 2 years were identified: stable non-suicidal (217 [72%]), stable suicidal ideation (45 [15%]), decreasing suicidal thoughts and behaviours (21 [7%]), and worsening suicidal thoughts and behaviours (18 [6%]). A longer duration of untreated psychosis (odds ratio [OR] 1·24, 95% CI 1·02-1·50, p=0·033), poorer premorbid childhood social adjustment (1·33, 1·01-1·73, p=0·039), more severe depression (1·10, 1·02-1·20, p=0·016), and substance use (2·33, 1·21-4·46, p=0·011) at baseline predicted a stable suicidal ideation trajectory. Individuals in the stable suicidal ideation trajectory tended to have suicidal thoughts and behaviours at 10-year follow-up (3·12, 1·33-7·25, p=0·008). Individuals with a worsening suicidal trajectory were at a higher risk of death by suicide between 2 and 10 years (7·58, 1·53-37·62, p=0·013).

INTERPRETATION

Distinct suicidal trajectories in first-episode psychosis were associated with specific predictors at baseline and distinct patterns of suicidality over time. Our findings call for early and targeted interventions for at-risk individuals with persistent suicidal ideation or deteriorating patterns of suicidal thoughts and behaviours, or both.

FUNDING

Health West, Norway; the Norwegian National Research Council; the Norwegian Department of Health and Social Affairs; the National Council for Mental Health and Health and Rehabilitation; the Theodore and Vada Stanley Foundation; the Regional Health Research Foundation for Eastern Region, Denmark; Roskilde County, Helsefonden, Lundbeck Pharma; Eli Lilly; Janssen-Cilag Pharmaceuticals, Denmark; a National Alliance for Research on Schizophrenia and Depression Distinguished Investigator Award and The National Institute of Mental Health grant; a National Alliance for Research on Schizophrenia & Depression Young Investigator Award from The Brain & Behavior Research Foundation; Health South East; Health West; and the Regional Centre for Clinical Research in Psychosis.

Validation and reliability test of Chinese language patient-reported impact of symptoms in schizophrenia scale

Background

Patient-reported outcomes, or subjective evaluations directly reflecting the patient's views, feelings, and judgments, are now being used to evaluate the outcomes of care and treatment of people with schizophrenia. In this study, we used an updated tool, the patient-reported impact of symptoms in schizophrenia scale (PRISS), translated into Chinese languages to assess the subjective experiences of schizophrenia patients.

Objective

This study aimed to test the psychometrics of the Chinese languages PRISS (CL-PRISS).

Method

This study used the Chinese version of PRISS (CL-PRISS), acquired from the harmonized English-language version. A total of 280 patients enrolled in this study were asked to complete the CL-PRISS, the positive and negative syndrome scale (PANSS), and the World Health Organization Disability Assessment Schedule (WHO-DAS). Construct and concurrent validity was tested using the confirmatory factor analysis (CFA) and Spearman correlation coefficient, respectively. The reliability of CL-PRISS was tested using Cronbach's α coefficient and the internal correlation coefficient.

Results

Confirmatory factor analysis (CFA) analysis demonstrated three major factors in CL_PRISS: the first factor is productive experiences, the second factor is affective-negative, and the third factor experiences. The factor loadings between items and factors ranged from 0.436 to 0.899 (RMSEA = 0.029, TLI = 0.940, CFI = 0.921). The correlation coefficient between the CL_PRISS and PANSS was 0.845, and between the CL-PRISS and WHO-DAS was 0.886. The ICC of the total CL_PRISS was 0.913, and Cronbach's α was 0.903.

Conclusion

The Chinese version of the PRISS (CL_PRISS) can be effectively used for assessing the subjective experience of Chinese patients with schizophrenia.

Investigation of momentary negative symptoms in patients with early psychosis in daily life: An experience sampling study

Negative symptoms are a key therapeutic target in promoting functional recovery in early psychosis intervention, but momentary negative symptom manifestations remain understudied in the early stage of illness. We employed an experience-sampling methodology (ESM) to evaluate momentary affective experiences, hedonic capacity for an event recalled, current activities and social interactions, and associated appraisals for 6 consecutive days in 33 clinically-stable early psychosis patients (within 3 years of treatment for first-episode psychosis) and 35 demographically-matched healthy controls. Adjusted multilevel linear-mixed models revealed higher intensity and variability of negative affect in patients than controls, but no group difference in affect instability as well as positive affect intensity and variability. Patients demonstrated no significantly greater anhedonia for event, activity or social interactions relative to controls. Higher preference for company (when alone) and to be alone (when in company) was observed in patients than controls. No significant group difference in pleasantness to be alone or proportion of time being alone. Our results indicate no evidence for blunting of affective experiences, anhedonia (social and non-social) and asociality in early psychosis. Future research complementing ESM with multiple digital phenotyping measures will facilitate more refined negative symptom assessment in the daily life of patients with early psychosis.

Weight changes following treatment with aripiprazole, risperidone and olanzapine: A 12-month study of first-episode schizophrenia patients in China

OBJECTIVES

This study aimed to assess weight changes following antipsychotic treatment in first-episode schizophrenia (FES) patients and make a comparison of aripiprazole, risperidone and olanzapine. Predictors for long-term clinically relevant weight gain (CRW, ≥7%) were examined.

METHODS

We carried out a second analysis of data from the Chinese First-Episode Schizophrenia Trial. Repeated measures general linear model (GLM) statistics were used to compare body weight at each follow-up point (month of 1, 2, 3, 6, 9and 12). Logistic regression models were constructed to evaluate possible predictors for CRW.

RESULTS

Body weight increased with an average rate of 0.93 % per month, with the fastest growth rate occurring in first 3 months. CRW was observed in 79 % of patients. Participants from olanzapine group showed significantly higher weight gain than risperidone group and aripiprozole group. Repeated measures GLM revealed a significant main effect of time (p < 0.001) and asignificant time*group interaction was revealed (p < 0.001), while the between-subject group effect was not statistically significant (p = 0.272). Multivariate logistic regressionmodel showed that with smaller baseline BMI (OR = 1.33, p < 0.001), with a family history of mental disorder (OR = 5.08, p = 0.004), receiving olanzapine (OR = 2.35, p = 0.001), and CRW at first-month (OR = 4.29, p = 0.032) were independent predictors for first-year CRW.

CONCLUSION

Antipsychotics are associated with a clinically significant weight gain in FES patients, which occurs mostly in first 3 months. Aripiprazole might not be an ideal choice in terms of long-term metabolic side-effects. Early and close metabolic monitoring should accompany antipsychotic prescription.

Association of perceived social support with sociodemographic, clinical, and psychosocial variables in patients with first-episode psychosis

Patients with first-episode psychosis (FEP) report deficits in social support (SS) and diminished and less satisfactory social networks than healthy controls (HC). These SS difficulties are linked with symptomatology. The study objectives were to: (a) compare perceived SS between patients with FEP and HC; (b) study sex differences regarding perceived SS in patients with FEP and HC; and (c) explore which sociodemographic, clinical and psychosocial variables are related to perceived SS in the onset of FEP. A total of 146 participants were included: 76 patients with FEP (24 females, 52 males) and 70 HC (20 females, 50 males). Perceived SS was assessed with the DUKE-UNK instrument, which is divided into two subscales: confidant support (CS) and affective support (AS). Significant differences regarding perceived SS were observed between the samples. No sex differences were found concerning perceived SS in each group. For the group with FEP, more years of education, less anxiety/depressive symptoms and better functioning were the most relevant variables for more overall perceived SS and perceived CS. Also, less suicidal risk was the only important indicator for more perceived AS. Interventions in perceived SS could contribute to a good evolution of FEP.

Antipsychotic treatment effects and structural MRI brain changes in schizophrenia

BACKGROUND

Progressive brain structural MRI changes are described in schizophrenia and have been ascribed to both illness progression and antipsychotic treatment. We investigated treatment effects, in terms of total cumulative antipsychotic dose, efficacy and tolerability, on brain structural changes over the first 24 months of treatment in schizophrenia.

METHODS

A prospective, 24-month, single-site cohort study in 99 minimally treated patients with first-episode schizophrenia, schizophreniform and schizoaffective disorder, and 98 matched healthy controls. We treated the patients according to a fixed protocol with flupenthixol decanoate, a long-acting injectable antipsychotic. We assessed psychopathology, cognition, extrapyramidal symptoms and BMI, and acquired MRI scans at months 0, 12 and 24. We selected global cortical thickness, white matter volume and basal ganglia volume as the regions of interest.

RESULTS

The only significant group × time interaction was for basal ganglia volumes. However, patients, but not controls, displayed cortical thickness reductions and increases in white matter and basal ganglia volumes. Cortical thickness reductions were unrelated to treatment. White matter volume increases were associated with lower cumulative antipsychotic dose, greater improvements in psychopathology and cognition, and more extrapyramidal symptoms. Basal ganglia volume increases were associated with greater improvements in psychopathology, greater increases in BMI and more extrapyramidal symptoms.

CONCLUSIONS

We provide evidence for plasticity in white matter and basal ganglia associated with antipsychotic treatment in schizophrenia, most likely linked to the dopamine blocking actions of these agents. Cortical changes may be more closely related to the neurodevelopmental, non-dopaminergic aspects of the illness.

The relevance of processing speed in the functioning of people with first-episode psychosis

Deficits in functioning affect people with first-episode psychosis. Deficits in cognitive performance are common in such individuals and appear to be related to functioning. The present study examined the relationship between the domains of cognitive performance and personal and social functioning, as well as evaluating which cognitive domains are the most closely related to personal and social functioning and whether they explain variations once other clinical and sociodemographic aspects are accounted for. Ninety-four people with first-episode psychosis participated in the study; they were assessed with the MATRICS battery. Symptoms were evaluated with the Emsley factors of the positive and negative syndrome scale. Cannabis use, duration of untreated psychosis, suicide risk, perceived stress, antipsychotic doses, and premorbid intelligence quotient was accounted for. Processing speed, attention/vigilance, working memory, visual learning, reasoning and problem solving correlated to personal and social functioning. Processing speed emerged as the strongest predictor of social and personal functioning and underscores the importance of targeting this domain in treatment. Moreover, suicide risk and excited symptoms were also significant variables in functioning. Early intervention, focusing on improvement of processing speed, may be crucial to the improvement of functioning in first-episode psychosis. The relationship of this cognitive domain with functioning in first-episode psychosis should be studied further.

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.

Genetic contributions to transdiagnostic symptom dimensions in patients with major depressive disorder, bipolar disorder, and schizophrenia spectrum disorders

Major depressive disorder (MDD), bipolar disorder (BD), and schizophrenia spectrum disorders (SZ) exhibit considerable phenotypic and genetic overlap. However, the contribution of genetic factors to their shared psychopathological symptom dimensions remains unclear. The present exploratory study investigated genetic contributions to the symptom dimensions "Depression", "Negative syndrome", "Positive formal thought disorder", "Paranoid-hallucinatory syndrome", and "Increased appetite" in a transdiagnostic subset of the German FOR2107 cohort (n = 1042 patients with MDD, BD, or SZ). As replication cohort, a subset of the German/Austrian PsyCourse study (n = 816 patients with MDD, BD, or SZ) was employed. First, the relationship between symptom dimensions and common variants associated with MDD, BD, and SZ was investigated via polygenic risk score (PRS) association analyses, with disorder-specific PRS as predictors and symptom dimensions as outcomes. In the FOR2107 study sample, PRS for BD and SZ were positively associated with "Positive formal thought disorder", the PRS for SZ was positively associated with "Paranoid-hallucinatory syndrome", and the PRS for BD was negatively associated with "Depression". The effects of PRS for SZ were replicated in PsyCourse. No significant associations were observed for the MDD PRS. Second, genome-wide association studies (GWAS) were performed for the five symptom dimensions. No genome-wide significant associations and no replicable suggestive associations (p < 1e-6 in the GWAS) were identified. In summary, our results suggest that, similar to diagnostic categories, transdiagnostic psychiatric symptom dimensions are attributable to polygenic contributions with small effect sizes. Further studies in larger thoroughly phenotyped psychiatric cohorts are required to elucidate the genetic factors that shape psychopathological symptom dimensions.

Clinical and Sociodemographic Profile of Psychomotor Agitation in Mental Health Hospitalisation: A Multicentre Study

Psychomotor agitation is characterised by an increase in psychomotor activity, restlessness and irritability. People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. The objective of this study is to assess the clinical and sociodemographic profile of psychomotor agitation in patients with severe mental disorders. The study was carried out in Spain by means of multicentre cross-sectional convenience sampling involving 140 patients who had been admitted to psychiatric hospital units and had experienced an episode of psychomotor agitation between 2018 and 2021.Corrigan's Agitated Behaviour Scale was used to assess psychomotor agitation. The results show that the predominant characteristic in psychomotor agitation is aggressiveness, which is also the most reported factor in patients with severe mental disorder. Patients who also have anxiety develop psychomotor agitation symptoms of moderate/severe intensity. The clinical and sociodemographic profile found in our study is consistent with other studies on the prevalence of psychomotor agitation.

Factor structure and item response of psychosis symptoms among Kenyan adults

BACKGROUND

The aim of this study was to evaluate the construct validity of the psychosis module of the Mini International Neuropsychiatric Interview version 7.0.2 (MINI-7).

METHOD

We utilized data collected from 2738 participants with a primary psychotic or bipolar disorder. Participants were drawn from two Kenyan sites of a large multi-center neuropsychiatric genetic study. The factor structure of the MINI-7 psychosis items were explored using confirmatory factor analyses (CFA) and Item Response Theory approach, for the full sample and by gender.

RESULTS

The CFA revealed that a 1-factor model provided adequate fit for the MINI-7 psychosis items for the full sample (x2 = 397.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.90) as well as for the female (x2 = 185.16.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.93; TLI = 0.91) and male groups (x2 = 242.09, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.89). Item thresholds for the full sample, and female and male groups were highest for 'odd beliefs' (-1.42, -1.33, and -1.51 respectively) and lowest for 'visual hallucinations' (-0.03, -0.04, and -0.01 respectively).

LIMITATIONS

Our study used a hospital-based population, which may have excluded patients with milder psychotic symptoms. Findings may therefore not be generalizable to the community setting.

CONCLUSIONS

Our findings indicate good construct validity of the MINI-7 psychosis module, and provides support for use of the tool in diagnosing psychotic disorders in clinical settings in Kenya.

Time of exposure to social defeat stress during childhood and adolescence and redox dysregulation on long-lasting behavioral changes, a translational study

Traumatic events during childhood/early adolescence can cause long-lasting physiological and behavioral changes with increasing risk for psychiatric conditions including psychosis. Genetic factors and trauma (and their type, degree of repetition, time of occurrence) are believed to influence how traumatic experiences affect an individual. Here, we compared long-lasting behavioral effects of repeated social defeat stress (SD) applied during either peripuberty or late adolescence in adult male WT and Gclm-KO mice, a model of redox dysregulation relevant to schizophrenia. As SD disrupts redox homeostasis and causes oxidative stress, we hypothesized that KO mice would be particularly vulnerable to such stress. We first found that peripubertal and late adolescent SD led to different behavioral outcomes. Peripubertal SD induced anxiety-like behavior in anxiogenic environments, potentiated startle reflex, and increased sensitivity to the NMDA-receptor antagonist, MK-801. In contrast, late adolescent SD led to increased exploration in novel environments. Second, the long-lasting impact of peripubertal but not late adolescent SD differed in KO and WT mice. Peripubertal SD increased anxiety-like behavior in anxiogenic environments and MK-801-sensitivity mostly in KO mice, while it increased startle reflex in WT mice. These suggest that a redox dysregulation during peripuberty interacts with SD to remodel the trajectory of brain maturation, but does not play a significant role during later SD. As peripubertal SD induced persisting anxiety- and fear-related behaviors in male mice, we then investigated anxiety in a cohort of 89 early psychosis male patients for whom we had information about past abuse and clinical assessment during the first year of psychosis. We found that a first exposure to physical/sexual abuse (analogous to SD) before age 12, but not after, was associated with higher anxiety at 6-12 months after psychosis onset. This supports that childhood/peripuberty is a vulnerable period during which physical/sexual abuse in males has wide and long-lasting consequences.

Emotional abuse and perceived stress: The most relevant factors in suicide behavior in first-episode psychosis patients

People with a mental disorder have a higher risk of suicidal behavior. Little research has examined the role of childhood trauma in suicide behavior, and even fewer studies have assessed the specific relevance of subtypes of childhood trauma and suicidal behavior in first-episode psychosis (FEP). The aims of the present study were: 1) to compare suicide behavior between FEP and HC; 2) to study the relationship between the five types of ChT and suicide risk in FEP controlling for confounding sociodemographic, clinical, and psychosocial variables. 95 patients diagnosed with FEP and 92 healthy control (HC) were recruited as a part of the PROFEP study. ChT was evaluated using The Childhood Trauma Questionnaire-Short Form (CTQ) and suicide behavior through The Suicide Risk Scale of Plutchik (SRSP). Our results showed that patients with FEP presented more suicide behavior (ideation, attempt, and suicide risk) than HC. Emotional abuse was the most relevant type of ChT in suicide ideation and suicide risk. After controlling for other relevant variables, perceived stress seemed to play an important role in suicide ideations, suicide attempt, and suicide risk. The results highlight the importance of assessing and considering in the clinical practice ChT and the perceived stress.

Theory of mind in schizophrenia: a comparison of subgroups with low and high IQ

BACKGROUND

Social cognitive impairment is common in schizophrenia, but it is unclear if it is present in individuals with high IQ. This study compared theory of mind (ToM) in schizophrenia participants with low or high IQ to healthy controls.

METHODS

One hundred and nineteen participants (71 healthy controls, 17 high IQ (IQ ≥115), and 31 low IQ (IQ ≤95) schizophrenia participants) were assessed with the Movie for the Assessment of Social Cognition, providing scores for total, cognitive, and affective ToM, along with overmentalizing, undermentalizing, and no-mentalizing errors. IQ was measured with Wechsler Abbreviated Scale of Intelligence; clinical symptoms with the Positive and Negative Syndrome Scale.

RESULTS

Healthy controls performed better than the low IQ schizophrenia group for all ToM scores, and better than the high IQ schizophrenia group for the total score and under- and no-mentalizing errors. The high IQ group made fewer overmentalizing errors and had better total and cognitive ToM than the low IQ group. Their number of overmentalizing errors was indistinguishable from healthy controls.

CONCLUSION

Global ToM impairment was present in the low IQ schizophrenia group. Overmentalizing was not present in the high IQ group and appears related to lower IQ. Intact higher-level reasoning may prevent the high IQ group from making overmentalizing errors, through self-monitoring or inhibition. We propose that high IQ patients are chiefly impaired in lower-level ToM, whereas low IQ patients also have impaired higher-level ToM. Conceivably, this specific impairment could help explain the lower functioning reported in persons with intact IQ.

Symptom dimensions stability over time in recent onset psychosis: A prospective study

BACKGROUND

The factorial structure of schizophrenia symptoms has been much debated but little is known on its degree of unicity, specificity as well as its dynamic over time. Symptom differentiation is a phenomenon according to which patients' symptoms could differentiate from one another during illness to form more independent, distinct dimensions. On the contrary, symptom dedifferentiation is an increase in the correlations between those symptoms over time. The goal of this study was to investigate symptom differentiation or dedifferentiation over time in recent onset psychosis using the Positive and Negative Syndrome Scale.

METHODS

A confirmatory factor analysis model based on the consensus five-factor model of the Positive and Negative Syndrome Scale for schizophrenia was estimated on seven different time points over a three-year period. A general factor capturing common variance between every symptom was also included. Explained common variance was computed for the general factor and each specific factor.

RESULTS

Three hundred and sixty-two recent onset psychosis patients were assessed. Results showed no evidence for either symptom differentiation or dedifferentiation over time. Specific symptoms accounted for >70 % of the variance suggesting a high degree of specificity of the symptomatology.

CONCLUSIONS

Overall, this study adds support for a highly multidimensional approach to clinical symptom assessment with an explicit focus on depression. The premise behind the staging approach being inherently one-dimensional, implications for further research is discussed.

Scalability of the Positive and Negative Syndrome Scale in first-episode schizophrenia assessed by Rasch models

OBJECTIVE

Historically, assessment of the psychometric properties of the Positive and Negative Syndrome Scale (PANSS) has had several foci: (1) calculation of reliability indexes, (2) extraction of subdimensions from the scale, and (3) assessment of the validity of the total score. In this study, we aimed to examine the scalability and to assess the clinical performance of the 30-item PANSS total score as well as the scalability of a shorter version (PANSS-6) of the scale.

METHODS

A composite data set of 1073 patients with first-episode schizophrenia or schizophrenia spectrum disorder was subjected to Rasch analysis of PANSS data from baseline and 4-6 weeks follow-up.

RESULTS

The central tests of fit of the Rasch model failed to satisfy the statistical requirements behind item homogeneity for the PANSS-30 as well as the PANSS-6 total score. For the PANSS-30, Differential Item Functioning was pronounced both for the 7-point Likert scale rating categories and when dichotomizing the rating categories. Subsequently, the Rasch structure analysis in the context of dichotomized items was used to isolate and estimate a systematic error because of item inhomogeneity, as well as a random error. The size of the combined sources of error for the PANSS-30 total score approximated 20% which is often regarded as clinical cut-off between response versus no-response.

CONCLUSION

The results demonstrate the operational consequences of a lack of statistical fit of the Rasch model and suggest that the calculated measure of uncertainty needs to be considered when using the PANSS-30 total score.

Evidence of mediation of severity of anxiety and depressive symptoms between abuse and positive symptoms of psychosis

BACKGROUND

Considerable evidence on general population suggests that an "Affective pathway to psychosis", involving depression and anxiety dimensions, mediates the abuse-psychosis association. However, this has never been tested in Early Psychosis (EP) patients. We aim at testing whether severity of depressive and anxiety mediates the abuse-positive symptoms dyad in an EP prospective sample.

METHODS

330 EP subjects aged 18-35 were assessed for psychopathology after 2, 6, 12, 18, 24, 30, and 36 months of treatment. Abuse was considered as facing at least one experience of physical, sexual, or emotional abuse before age 16. Positive psychotic symptoms and anxiety were measured with the Positive and Negative Syndrome Scale and depressive symptoms with the Montgomery-Asberg Depression Rating Scale. Mediation analyses were performed to study whether the abuse-positive symptom's link was mediated by depressive, anxiety, and a combination of anxiety/mood symptoms.

RESULTS

Among the 330 EP patient included, 104 (31.5% of the total) were exposed to abuse. Analyses across the 36 months of follow-up showed that depression and anxiety partially mediated 26.7% of the total effect of the abuse-positive symptoms association (indirect effects (IE) = 0.392 and 0.421 respectively), while the combined anxiety/mood model mediated 28.9% (IE = 0.475). Subanalyses at two and 36 months revealed a consistent role of depression, while that of anxiety was only present at baseline.

CONCLUSION

Our work confirms a mediating role of mood and anxiety in the association between abuse and positive symptoms during the first three years of treatment.

Patient-reported impact of symptoms in schizophrenia scale (PRISS): Development and validation

BACKGROUND

We report the psychometric properties of the Patient-Reported Impact of Symptoms in Schizophrenia Scale (PRISS), which assesses the impact of subjective experiences or qualia in outpatients with this condition.

METHODS

A cross-sectional study was carried out in 162 patients diagnosed with schizophrenia in Spain. The PRISS measures the presence, frequency, concern and interference with daily life of self-reported experiences related to the main symptoms observed in these patients. The psychometric analysis included test-retest reliability, internal consistency and structural and convergent validity.

RESULTS

The 28-item PRISS showed good test-retest reliability as 64.3% of the intraclass correlation coefficient values were between 0.40 and 0.79, which were statistically significant (p < 0.01). Analysis of the structural validity revealed a three-factor structure, (1) productive subjective experiences, (2) affective-negative subjective experiences and (3) excitation, which accounted for 56.11% of the variance. Of the Pearson's correlation coefficients analysed between the PRISS and the Positive and Negative Syndrome Scale (PANSS), Scale for Assessment of Negative Symptoms (SANS) and World Health Organization Disability Assessment Schedule (WHO-DAS), 72.2% were statistically significant (p < 0.05) and ranged from 0.38-0.42, 0.32-0.42 and 0.40-0.42, respectively.

CONCLUSION

Our results indicate that the PRISS appears to be a brief, reliable and valid scale to measure subjective experiences in schizophrenia and provides valuable information complementary to clinical evaluation.

The trajectories and correlates of two negative symptom subdomains in first-episode schizophrenia

BACKGROUND

Recent studies suggest a two-factor structure for negative symptoms as assessed by the Positive and Negative Syndrome Scale (PANSS) in schizophrenia, namely experiential and expressive subdomains. Little is known about their clinical correlates and treatment trajectories.

OBJECTIVES

We sought to replicate the two factor-analysis derived subdomains for PANSS negative symptoms in schizophrenia and to assess their independent demographic, premorbid and treatment-related characteristics.

METHODS

This was a longitudinal study of 106 minimally treated participants with a first episode of a schizophrenia spectrum disorder who received treatment with flupenthixol decanoate 2-weekly injections over two years. Factor analysis was used to characterize the PANSS negative symptom subdomains and linear mixed-effect models for continuous repeated measures were constructed to assess the temporal relations between the negative symptom subdomains and premorbid and treatment related variables.

RESULTS

Factor analysis confirmed a two-factor solution for experiential and expressive subdomains of negative symptoms, although they were strongly correlated. The treatment response trajectories for the two subdomains did not differ significantly, and neither subdomain was significantly associated with our premorbid variables. We found significant main effects for disorganised symptoms and extrapyramidal symptoms on the expressive subdomain, and for disorganised symptoms and depressive symptoms on the experiential subdomain. Post-hoc testing indicated that reductions in HDL-cholesterol levels were associated with less improvement in both expressive and experiential subdomain scores.

CONCLUSION

The two negative symptom subdomains are closely related, have similar premorbid correlates and respond similarly to antipsychotic treatment. Depression affects the experiential subdomain, whereas extrapyramidal symptoms affect the expressive subdomain.

Identifying strategies to improve PANSS based dimensional models in schizophrenia: Accounting for multilevel structure, Bayesian model and clinical staging

BACKGROUND

Dimensional approaches can decompose a construct in a set of continuous variables, improving the characterization of complex phenotypes, such as schizophrenia. However, the five-factor model of the Positive and Negative Syndrome Scale (PANSS), the most used instrument in schizophrenia research, yielded poor fits in most confirmatory factor analysis (CFA) studies, raising concerns about its applications. Thus, we aimed to identify dimensional PANSS CFA models with good psychometric properties by comparing the traditional CFA with three methodological approaches: Bayesian CFA, multilevel modeling, and Multiple Indicators Multiple Causes (MIMIC) modeling.

METHODS

Clinical data of 700 schizophrenia patients from four centers were analyzed. We first performed a traditional CFA. Next, we tested the three techniques: 1) a Bayesian CFA; 2) a multilevel analysis using the centers as level; and 3) a MIMIC modeling to evaluate the impact of clinical staging on PANSS factors and items.

RESULTS

CFA and Bayesian CFA produced poor fit models. However, when adding a multilevel structure to the CFA model, a good fit model emerged. MIMIC modeling yielded significant differences in the factor structure between the clinical stages of schizophrenia. Sex, age, age of onset, and duration of illness did not significantly affect the model fit.

CONCLUSION

Our comparison of different CFA methods highlights the need for multilevel structure to achieve a good fit model and the potential utility of staging models (rather than the duration of illness) to deal with clinical heterogeneity in schizophrenia. Large prospective samples with biological data should help to understand the interplay between psychometrics concerns and neurobiology research.

Sex and gender associations with indicators of neurodevelopmental compromise in schizophrenia spectrum disorders

BACKGROUND

It has been proposed that sex and gender differences described in schizophrenia can be explained from a neurodevelopmental perspective.

AIM

In this study, we examined the associations of biological sex and gender role endorsement with putative indicators of neurodevelopmental compromise.

METHODS

We used the Bem Sex Role Inventory to calculate masculinity scores in 77 patients with a first episode of a schizophrenia spectrum disorder, and selected the following indicators of neurodevelopmental compromise: family history of schizophrenia, obstetric complications, premorbid functioning, neurological soft signs, and cognitive function. Secondary objectives included the moderating effects of age of onset of illness, substance use and negative symptoms on these associations.

RESULTS

There were no significant sex differences across any of the indicators of neurodevelopmental compromise. However, lower masculinity scores correlated significantly with poorer premorbid adjustment, sensory integration deficits and worse overall cognitive performance. Stepwise linear regression identified poorer premorbid adjustment in early adolescence and lower verbal learning scores as independent predictors of lower masculinity scores. In contrast to sex, gender showed several associations with indicators of neurodevelopmental compromise.

CONCLUSIONS

Lower masculinity scores may represent part of a phenotype for a neurodevelopmental anomaly that places some individuals on a pathway to schizophrenia.

Clinical and psychological correlates of insight dimensions in patients with early psychosis

AIM

To investigate correlates of insight dimensions in Chinese adult patients with early psychosis.

METHODS

Insight dimensions including awareness of mental disorder (AMD), illness consequences (AIC) and medication effect (AME) were measured. A wide array of variables encompassing demographics, premorbid adjustment, onset profiles, symptomatology, treatment characteristics and psychological factors were comprehensively assessed.

RESULTS

Of 130 participants, 53.1%, 47.7% and 56.2% were categorized with good AMD, AIC and AME, respectively. Good AMD was associated with female gender, fewer positive and disorganization symptoms, more severe depression and greater self-stigma. Good AIC was related to female gender, more severe depression and greater self-stigma. Younger age of onset, fewer positive symptoms and greater service satisfaction associated with good AME.

CONCLUSIONS

Poor insight is prevalent in early psychosis. Differential relationships of insight dimensions with other illness variables underscore the importance of multidimensional approach in insight evaluation, and suggest potential treatment target for insight enhancement.

Motor cognition in schizophrenia: Control of automatic imitation and mapping of action context are reduced

The ability to imitate is considered impaired in schizophrenia patients. This assumption, however, is based on heterogeneous studies mostly targeting voluntary imitation, e.g., pantomime. Studies on automatic imitation, however, and on underlying mechanisms of top-down inhibition of automatic imitation and contextual modulation in schizophrenia are highly limited. We employed two sensorimotor paradigms to examine imitation-inhibition and action context mapping in 37 schizophrenia patients and 36 matched controls. In the first experiment, participants performed finger lifts while observing a hand executing compatible or incompatible finger lifts from the third-person perspective. The compatibility or incompatibility of these finger lifts affected participants' reaction times (RTs). The comparison of between-condition RT differences shows a larger movement compatibility effect in schizophrenia than in controls. The second experiment involved finger lifts while watching a still hand, from the first-person perspective, with constrained fingers that either corresponded or did not correspond to the participants' response fingers. Here, schizophrenia patients showed a diminished RT slowing in corresponding constraint trials. While the former results provide evidence for an impaired control of imitation in patients with schizophrenia, the latter results indicate a reduced encoding of action context. In conclusion, this study provides the first evidence for deficits of top-down control of imitation and motor context processing in the same sample of schizophrenia patients.

Prevalence and types of childhood trauma in first episode psychosis patients. Relation with clinical onset variables

OBJECTIVE

To study the prevalence and the type of childhood trauma (CT) in a first-episode psychosis (FEP) cohort and in a healthy control (HC) sample. To study which clinical and sociodemographic variables in the onset of the FEP are related to having suffered some traumatic experience in childhood.

METHOD

100 FEP patients and 94 HC participated in the study. The Childhood Traumatic Questionnaire (CTQ) was used to evaluate CT. The Positive and Negative Syndrome Scale (PANSS), the Personal and Social Performance (PSP), the Suicide Risk Scale of Plutchik (SRSP), and the Perceived Stress Scale (PSS) were also administered.

RESULTS

61% of FEP patients and 17% of HC reported having experienced some kind of CT. FEP showed more CT than controls in all subscales, except in sexual abuse. The most frequent CT was emotional abuse. For the FEP group, younger age, more years of education, have a first-degree family history, more positive and negative symptoms, more perceived stress and more personal and social functioning were the variables more influenced by having suffered some kind of CT.

CONCLUSIONS

There is a high prevalence of CT in FEP patients. Having a first-degree family history of mental illness, more positive symptoms, and more perception of stress at the time of hospital admission were related to having suffered CT. More research is needed to find out the best way to detect CT and its role in psychosis to be able to implement interventions to improve the evolution of these patients.

A review of risky decision-making in psychosis-spectrum disorders

The investigation of risky decision-making has a prominent place in clinical science, with sundry behavioral tasks aimed at empirically quantifying the psychological construct of risk-taking. However, use of differing behavioral tasks has resulted in lack of agreement on risky decision-making within psychosis-spectrum disorders, as findings fail to converge upon the typical, binary conceptualization of increased risk-seeking or risk-aversion. The current review synthesizes the behavioral, risky decision-making literature to elucidate how specific task parameters may contribute to differences in task performance, and their associations with psychosis symptomatology and cognitive functioning. A paring of the literature suggests that: 1) Explicit risk-taking may be characterized by risk imperception, evidenced by less discrimination between choices of varying degrees of risk, potentially secondary to cognitive deficits. 2) Ambiguous risk-taking findings are inconclusive with few published studies. 3) Uncertain risk-taking findings, consistently interpreted as more risk-averse, have not parsed risk attitudes from confounding processes that may impact decision-making (e.g. risk imperception, reward processing, motivation). Thus, overgeneralized interpretations of task-specific risk-seeking/aversion should be curtailed, as they may fail to appropriately characterize decision-making phenomena. Future research in psychosis-spectrum disorders would benefit from empirically isolating contributions of specific processes during risky decision-making, including the newly hypothesized risk imperception.

Males and females with first episode psychosis present distinct profiles of social cognition and metacognition

Deficits in social cognition and metacognition impact the course of psychosis. Sex differences in social cognition and metacognition could explain heterogeneity in psychosis. 174 (58 females) patients with first-episode psychosis completed a clinical, neuropsychological, social cognitive, and metacognitive assessment. Subsequent latent profile analysis split by sex yielded two clusters common to both sexes (a Homogeneous group, 53% and 79.3%, and an Indecisive group, 18.3% and 8.6% of males and females, respectively), a specific male profile characterized by presenting jumping to conclusions (28.7%) and a specific female profile characterized by cognitive biases (12.1%). Males and females in the homogeneous profile seem to have a more benign course of illness. Males with jumping to conclusions had more clinical symptoms and more neuropsychological deficits. Females with cognitive biases were younger and had lower self-esteem. These results suggest that males and females may benefit from specific targeted treatment and highlights the need to consider sex when planning interventions.

Sex differences in symptom severity, cognition and psychosocial functioning among individuals with at-risk mental state for psychosis

AIM

Sex differences are well documented in schizophrenia, but have been much less studied in at-risk mental state (ARMS) for psychosis. We aimed to examine sex differences in symptomatology, cognition, social and role functioning in individuals with ARMS, with specific focus on clarifying relationships between sex, negative symptoms and functioning.

METHODS

One hundred and seventy-seven Chinese participants aged 15-40 years with ARMS were recruited from a specialized early intervention service in Hong Kong. ARMS status was verified by Comprehensive Assessment of At-Risk Mental State. Assessments encompassing symptom profiles, a brief battery of cognitive tests and social and role functioning were conducted. Brief Negative Symptom Scale was adapted to measure negative symptoms at the level of five core domains.

RESULTS

Males with ARMS exhibited significantly poorer social functioning and more severe asociality of negative symptoms than female counterparts. Mediation analysis revealed that sex difference in social functioning became statistically insignificant when asocality was included in the model, indicating that asociality mediated the relationship between sex and social functioning. No sex differences were observed in other core domains of negative symptoms, other symptom dimensions, cognitive measures and role functioning.

CONCLUSIONS

This study suggests that sex differences in ARMS may be less pronounced that those observed in established psychotic disorders. Our findings of differential pattern of asociality between sexes and its mediating role on sex difference in social functioning underscore the importance in investigating negative symptoms at a separable domain-level. Further research is required to identify sex-specific predictors of longitudinal outcomes in at-risk populations.

Serum kynurenine metabolites might not be associated with risk factors of treatment-resistant schizophrenia

BACKGROUND

About a third of patients with schizophrenia do not respond adequately to currently available antipsychotics and thus experiences symptoms of greater severity, known as treatment-resistant schizophrenia (TRS). Some evidence suggests that the tryptophan (TRP) pathway (comprising 5-HT and kynurenine sub-pathways) has an important influence on response to antipsychotics. We therefore hypothesized that TRS is linked to metabolites of TRP pathway.

METHODS

We measured TRP metabolites in 54 patients with TRS and compared them to 49 age- and sex-matched patients who responded to antipsychotics (NTRS), and 62 healthy controls using liquid chromatography-tandem mass spectrometry. Psychopathology and clinical symptoms were assessed by means of schizophrenia positive and negative scales. Working memory abilities, cortical thickness and white matter diffusion tensor imaging fractional anisotropy were appraised in enrolled subjects by neurophysiological tests, as spatial span and digital sequencing tests, and 3T magnetic resonance imaging.

RESULTS

Patients with TRS had a significantly higher 5-HT/TRP ratio (p = 0.009) than patients with NTRS. However, the two groups did not differ in kynurenine-pathway metabolites or ratios. Additionally, 5-HT/TRP was positively correlated with disorganized symptoms in TRS (r = 0.59, p < 0.001), and negatively correlated with digit-sequencing test scores (r = -0.34, p = 0.02). These correlations were insignificant among patients with NTRS and healthy controls. In patients with TRS, 5-HT/TRP was strongly linked to the right supramarginal cortex (t = -3.2, p = 0.003), and in healthy controls, to the right transverse temporal (t = 3.40, p = 0.001), but significance disappeared after FDR correction.

CONCLUSIONS

Present results indicate that an upregulated 5-HT biosynthetic pathway can be associated to TRS, suggesting that targeting mechanisms of 5-HT conversion from tryptophan could shed light on the development of new pharmacological approaches of TRS.

Persons with first episode psychosis have distinct profiles of social cognition and metacognition

Subjects with first-episode psychosis experience substantial deficits in social cognition and metacognition. Although previous studies have investigated the role of profiles of individuals in social cognition and metacognition in chronic schizophrenia, profiling subjects with first-episode psychosis in both domains remains to be investigated. We used latent profile analysis to derive profiles of the abilities in 174 persons with first-episode psychosis using the Beck's Cognitive Insight Scale, the Faces Test, the Hinting Task, the Internal, Personal and Situational Attributions Questionnaire, and the Beads Task. Participants received a clinical assessment and a neuropsychological assessment. The best-fitting model was selected according to the Bayesian information criterion (BIC). We assessed the importance of the variables via a classification tree (CART). We derived three clusters with distinct profiles. The first profile (33.3%) comprised individuals with low social cognition. The second profile (60.9%) comprised individuals that had more proneness to present jumping to conclusions. The third profile (5.7%) presented a heterogeneous profile of metacognitive deficits. Persons with lower social cognition presented worse clinical and neuropsychological features than cluster 2 and cluster 3. Cluster 3 presented significantly worst functioning. Our results suggest that individuals with FEP present distinct profiles that concur with specific clinical, neuropsychological, and functional challenges. Each subgroup may benefit from different interventions.

Prevalence, clinical correlates and risk factors associated with Tardive Dyskinesia in Chinese patients with schizophrenia

Tardive Dyskinesia (TD) is a serious, nonrhythmic and iatrogenic movement disorder, and is a common comorbidity in patients with schizophrenia (SZ). The main goal of this study was to investigate the prevalence, clinical correlates, and risk factors of TD in Chinese patients with chronic SZ, which has not been fully studied. This study adopted a cross-sectional design. A total of 901 Chinese inpatients with SZ were recruited between 2008 and 2011. We used the Abnormal Involuntary Movement Scale (AIMS) to measure the severity of TD, and the Positive and Negative Syndrome Scale (PANSS) was used to measure the psychopathological symptoms of SZ. Blood samples were also collected for routine blood tests, including the levels of triglyceride (TG), cholesterol (CHO), HDL-cholesterol (HDL-CHO), LDL-cholesterol (LDL-CHO), Apolipoprotein A1 (ApoA1), and Apolipoprotein B (ApoB). Overall, 36% of patients with SZ had TD. Compared with the non-TD patients, the TD patients were more likely to be men, had older age, lower education level, higher smoking rate, higher hospitalization frequency, and longer duration of illness (DOI). Further, compared with the non-TD patients, the TD patients had higher PANSS total, PANSS negative subscale, and cognitive subscale scores, but had lower depressive subscale scores and lower mean levels of metabolic biomarkers, including TG, CHO, HDL-CHO, LDL-CHO, ApoA1 and ApoB. Moreover, binary regression analysis showed that antipsychotic type, BMI, gender, age, HDL-CHO, and ApoB were associated with TD. Our findings indicate that TD is a common movement disorder in patients with chronic SZ, with certain demographic and clinical variables being risk factors for the development of TD.

Cognitive functioning in first episode psychosis. Gender differences and relation with clinical variables

AIMS

to study the differences in cognitive functioning in patients and controls. In addition, study the influence of symptoms, cannabis consumption, chlorpromazine doses, DUP and IQ in cognitive performance in patients, both in the total sample and divided by gender.

METHODS

70 first episode psychosis patients and 63 healthy controls (HC) participated in the study and were assessed with the MATRICS battery and the Vocabulary subtest of WAIS-IV. Symptoms in FEP patients were evaluated with the Emsley factors of the PANSS scale.

RESULTS

patients showed lower scores than controls in all cognitive domains studied. There were no significant differences between FEP men and FEP women, but we found gender differences in favour of women in processing speed, working memory and composite total scored domains in the HC group. Finally, symptoms and Chlorpromazine doses showed an influence on cognitive performance in the total FEP sample. When splitting the sample by gender, positive symptoms may be more detrimental to women's cognitive functioning, while disorganized symptoms may play the most important role in cognitive performance in men.

CONCLUSIONS

patients showed worse cognitive performance in all cognitive domains compared to healthy controls. In our FEP sample, gender does not seem to influence cognitive performance measured with the MATRICS. Severity of symptoms influences positively in cognitive performance. The dose of Chlorpromazine and symptoms are influential variables to be taken into account in cognition rehabilitation programs.

Are There Gender Differences in Social Cognition in First-Episode Psychosis?

The aim of this study was to explore gender differences in social cognition in a sample of first-episode psychosis (FEP). An observational descriptive study was performed with 191 individuals with FEP. Emotion perception was assessed using the Faces Test, theory of mind was assessed using the Hinting Task, and attributional style was assessed using the Internal, Personal and Situational Attributions Questionnaire. No gender differences were found in any of the social cognitive domains. Our results suggest that men and women with FEP achieve similar performances in social cognition. Therefore, targeting specific needs in social cognition regarding gender may not be required in early interventions for psychosis.