Deconstructing Negative Symptoms in Individuals at Clinical High-Risk for Psychosis: Evidence for Volitional and Diminished Emotionality Subgroups That Predict Clinical Presentation and Functional Outcome

tDCS for the treatment of negative symptoms in youth at clinical-high-risk for psychosis: A feasibility study

Negative symptoms are often found in youth at clinical high risk (CHR) for psychosis. The present study explored the feasibility of using tDCS in conjunction with CBT in the treatment of negative symptoms in 5 youths at CHR. We sought to determine whether the protocol was feasible given the requirement for repeated visits over a three-week period, and to determine if measures of neurobiological change could be included, both acutely and following three weeks of stimulation. The results from this study suggest that the protocol is feasible for these youth, and the inclusion of MRI scanning sessions yielded good quality data.

Self-concept and Narrative Identity in Youth at Clinical High Risk for Psychosis

BACKGROUND AND HYPOTHESIS

Disturbances of the narrative self and personal identity accompany the onset of psychotic disorders in late adolescence and early adulthood (a formative developmental stage for self-concept and personal narratives). However, these issues have primarily been studied retrospectively after illness onset, limiting any inferences about their developmental course.

STUDY DESIGN

Youth at clinical high risk for psychosis (CHR) (n = 49) and matched healthy comparison youth (n = 52) completed a life story interview (including self-defining memory, turning point, life challenge, and psychotic-like experience) and questionnaires assessing self-esteem, self-beliefs, self-concept clarity, and ruminative/reflective self-focus. Trained raters coded interviews for narrative identity themes of emotional tone, agency, temporal coherence, context coherence, self-event connections, and meaning-making (intraclass correlations >0.75). Statistical analyses tested group differences and relationships between self-concept, narrative identity, symptoms, and functioning.

STUDY RESULTS

CHR participants reported more negative self-esteem and self-beliefs, poorer self-concept clarity, and more ruminative self-focus, all of which related to negative symptoms. CHR participants narrated their life stories with themes of negative emotion and passivity (ie, lack of personal agency), which related to positive and negative symptoms. Reflective self-focus and autobiographical reasoning were unaffected and correlated. Autobiographical reasoning was uniquely associated with preserved role functioning.

CONCLUSIONS

This group of youth at CHR exhibited some, but not all, changes to self-concept and narrative identity seen in psychotic disorders. A core theme of negativity, uncertainty, and passivity ran through their semantic and narrative self-representations. Preserved self-reflection and autobiographical reasoning suggest sources of resilience and potential footholds for cognitive-behavioral and metacognitive interventions.

N2 Responses in Youths With Psychosis Risk Syndrome and Their Association With Clinical Outcomes: A Cohort Follow-Up Study Based on the Three-Stimulus Visual Oddball Paradigm

OBJECTIVE

Schizophrenia often occurs during youth, and psychosis risk syndrome occurs before the onset of psychosis. The aim of this study was to determine whether the visual event-related potential responses in youths with psychosis risk syndrome were defective in the presence of interference stimuli and associated with their clinical outcomes.

METHODS

A total of 223 participants, including 122 patients with psychosis risk syndrome, 50 patients with emotional disorders, and 51 healthy control subjects, were assessed. Baseline EEG was recorded during the three-stimulus visual oddball task. The event-related potentials induced by square pictures with different colors were measured. Almost all patients with psychosis risk syndrome were followed up for 12 months and were reclassified into three subgroups: conversion, symptomatic, and remission. The differences in baseline event-related potential responses were compared among the clinical outcome subgroups.

RESULTS

The average N2 amplitude of the psychosis risk syndrome group was significantly less negative than that in the healthy control group (d=0.53). The baseline average N2 amplitude in the conversion subgroup was significantly less negative than that in the symptomatic (d=0.58) and remission (d=0.50) subgroups and in the healthy control group (d=0.97). The average N2 amplitude did not differ significantly between the symptomatic and remission subgroups (d=0.02). However, it was significantly less negative in the symptomatic and remission subgroups than in the healthy control group (d=0.46 and d=0.38). No statistically significant results were found in the P3 response.

CONCLUSIONS

Youths with psychosis risk syndrome had significant N2 amplitude defects in attention processing with interference stimuli. N2 amplitude shows potential as a prognostic biomarker of clinical outcome in the psychosis risk syndrome.

Anhedonia in adolescents at transdiagnostic familial risk for severe mental illness: Clustering by symptoms and mechanisms of association with behavior

BACKGROUND

Anhedonia is a transdiagnostic symptom of severe mental illness (SMI) and emerges during adolescence. Possible subphenotypes and neural mechanisms of anhedonia in adolescents at risk for SMI are understudied.

METHODS

Adolescents at familial risk for SMI (N = 81) completed anhedonia (e.g., consummatory, anticipatory, social), demographic, and clinical measures and one year prior, a subsample (N = 46) completed fMRI scanning during a monetary reward task. Profiles were identified using k-means clustering of anhedonia type and differences in demographics, suicidal ideation, impulsivity, and emotional processes were examined. Moderation analyses were conducted to investigate whether levels of brain activation of reward regions moderated the relationships between anhedonia type and behaviors.

RESULTS

Two-clusters emerged: a high anhedonia profile (high-anhedonia), characterized by high levels of all types of anhedonia, (N = 32) and a low anhedonia profile (low-anhedonia), characterized by low levels of anhedonia types (N = 49). Adolescents in the high-anhedonia profile reported more suicidal ideation and negative affect, and less positive affect and desire for emotional closeness than low-anhedonia profile. Furthermore, more suicidal ideation, less positive affect, and less desire for emotional closeness differentiated the familial high-risk, high-anhedonia profile adolescents from the familial high-risk, low-anhedonia profile adolescents. Across anhedonia profiles, moderation analyses revealed that adolescents with high dmPFC neural activation in response to reward had positive relationships between social, anticipatory, and consummatory anhedonia and suicidal ideation.

LIMITATIONS

Small subsample with fMRI data.

CONCLUSION

Profiles of anhedonia emerge transdiagnostically and vary on clinical features. Anhedonia severity and activation in frontostriatal reward areas have value for clinically important outcomes such as suicidal ideation.

The specificity of the auditory P300 responses and its association with clinical outcomes in youth with psychosis risk syndrome

Background

Schizophrenia often occurs in youth, and psychosis risk syndrome (PRS) occurs before the onset of psychosis. Assessing the neuropsychological abnormalities of PRS individuals can help in early identification and active intervention of mental illness. Auditory P300 amplitude defect is an important manifestation of attention processing abnormality in PRS, but it is still unclear whether there are abnormalities in the attention processing of rhythmic compound tone stimuli in PRS individuals, and whether the P300 amplitude induced by these stimuli is specific to PRS individuals and related to their clinical outcomes.

Methods

In total, 226 participants, including 122 patients with PRS, 51 patients with emotional disorders (ED), and 53 healthy controls (HC) were assessed. Baseline electroencephalography was recorded during the compound tone oddball task. The event-related potentials (ERPs) induced by rhythmic compound tone stimuli of two frequencies (20-Hz, 40-Hz) were measured. Almost all patients with PRS were followed up for 12 months and reclassified into four groups: PRS-conversion, PRS-symptomatic, PRS-emotional disorder, and PRS-complete remission. The differences in baseline ERPs were compared among the clinical outcome groups.

Results

Regardless of the stimulation frequency, the average P300 amplitude were significantly higher in patients with PRS than in those with ED (p = 0.003, d = 0.48) and in HC (p = 0.002, d = 0.44) group. The average P300 amplitude of PRS-conversion group was significantly higher than that of the PRS-complete remission (p = 0.016, d = 0.72) and HC group (p = 0.001, d = 0.76), and the average P300 amplitude of PRS-symptomatic group was significantly higher than that of the HC group (p = 0.006, d = 0.48). Regardless of the groups (PRS, ED, HC) or the PRS clinical outcome groups, the average P300 amplitude induced by 20-Hz tone stimulation was significantly higher than that induced by 40-Hz stimulation (ps < 0.001, Ƞ2 = 0.074-0.082). The average reaction times of PRS was significantly faster than that of ED (p = 0.01, d = 0.38), and the average reaction times of the participants to 20-Hz target stimulation was significantly faster than that to 40-Hz target stimulation (p < 0.001, d = 0.21).

Conclusion

The auditory P300 amplitude induced by rhythmic compound tone stimuli is a specific electrophysiological manifestation of PRS, and the auditory P300 amplitude induced by compound tone stimuli shows promise as a putative prognostic biomarker for PRS clinical outcomes, including conversion to psychosis and clinical complete remission.

[Willingness to expend effort for rewards in individuals at clinical high-risk for psychosis: a relationship with the severity and stability of negative symptoms]

OBJECTIVE

To identify the deficit in willingness to expend effort and its association with negative symptoms in the high-risk for psychosis (CHR) group.

MATERIAL AND METHODS

The study included young men: 45 patients, who met CHR criteria and were treated for a depressive episode, and 15 controls. All subjects completed a modified version of the Effort Expenditure for Rewards Task (EEfRT). The CHR group was assessed with the SOPS, SANS and HDRS at the beginning and at the end of treatment. EEfRT was performed only at the end of treatment.

RESULTS

The CHR group was significantly less likely to choose high effort tasks across reward probability and magnitude levels compared with the control group (all p<0.001). No significant correlations were found between the rate of selecting the high effort task and the negative syndrome domains of amotivation and diminished expression. The subgroups of CHR with stable and transient (i.e., with a reduction >50% during treatment) negative symptoms, which were identified by a cluster analysis, did not differ in the willingness to expend effort.

CONCLUSION

The study confirmed a decrease in the willingness to expend effort in the CHR group; however, this deficit was only weakly correlated with negative symptoms and persisted after the symptoms reduction during treatment, which requires future studies to investigate mechanisms underlying impaired effort expenditure for rewards in CHR.

Longitudinal evaluation on negative symptoms in young people at Ultra-High Risk (UHR) of psychosis: results from a 2-year follow-up study in a real-world care setting

Negative Symptoms (NS) severely affect real-world functioning also in young people at UHR for developing psychosis. However, longitudinal research on beneficial effects of specialized treatments for NS in UHR people is still relatively scarce and inconclusive, especially in real-world care settings. The aims of the present research were: (1) to evaluate the longitudinal stability of NS levels in young UHR subjects treated within a specialized "Early Intervention in Psychosis" (EIP) program across a 2-year follow-up period, and (2) to investigate any relevant association of NS changes with the specific treatment components offered within the EIP program. One hundred UHR individuals (aged 12-25 years) completed the Positive And Negative Syndrome Scale (PANSS). A multiple linear regression analysis was conducted to examine significant associations between longitudinal changes in NS severity levels and the EIP treatment components. Across the follow-up, a significant decrease in NS clinical severity was observed. This reduction was associated with the intensity of individual psychotherapy sessions provided in the first year of treatment, a shorter duration of untreated illness at entry and the 2-year longitudinal decrease in positive symptom levels. In conclusion, NS are relevant in UHR people, but decrease over time together with the delivery of specialized EIP interventions. Specifically, our results showed that individual psychotherapy may reduce the clinical severity of NS at least during the first year of treatment.

Reinforcement learning profiles and negative symptoms across chronic and clinical high-risk phases of psychotic illness

Negative symptoms are prominent in individuals with schizophrenia (SZ) and youth at clinical high-risk for psychosis (CHR). In SZ, negative symptoms are linked to reinforcement learning (RL) dysfunction; however, previous research suggests implicit RL remains intact. It is unknown whether implicit RL is preserved in the CHR phase where negative symptom mechanisms are unclear, knowledge of which may assist in developing early identification and prevention methods. Participants from two studies completed an implicit RL task: Study 1 included 53 SZ individuals and 54 healthy controls (HC); Study 2 included 26 CHR youth and 23 HCs. Bias trajectories reflecting implicit RL were compared between groups and correlations with negative symptoms were examined. Cluster analysis investigated RL profiles across the combined samples. Implicit RL was comparable between HC and their corresponding SZ and CHR groups. However, cluster analysis was able to parse performance heterogeneity across diagnostic boundaries into two distinct RL profiles: a Positive/Early Learning cluster (65% of participants) with positive bias scores increasing from the first to second task block, and a Negative/Late Learning cluster (35% of participants) with negative bias scores increasing from the second to third block. Clusters did not differ in the proportion of CHR vs. SZ cases; however, the Negative/Late Learning cluster had more severe negative symptoms. Although implicit RL is intact in CHR similar to SZ, distinct implicit RL phenotypic profiles with elevated negative symptoms were identified trans-phasically, suggesting distinct reward-processing mechanisms can contribute to negative symptoms independent of phases of illness.

Speech characteristics yield important clues about motor function: Speech variability in individuals at clinical high-risk for psychosis

BACKGROUND AND HYPOTHESIS

Motor abnormalities are predictive of psychosis onset in individuals at clinical high risk (CHR) for psychosis and are tied to its progression. We hypothesize that these motor abnormalities also disrupt their speech production (a highly complex motor behavior) and predict CHR individuals will produce more variable speech than healthy controls, and that this variability will relate to symptom severity, motor measures, and psychosis-risk calculator risk scores.

STUDY DESIGN

We measure variability in speech production (variability in consonants, vowels, speech rate, and pausing/timing) in N = 58 CHR participants and N = 67 healthy controls. Three different tasks are used to elicit speech: diadochokinetic speech (rapidly-repeated syllables e.g., papapa…, pataka…), read speech, and spontaneously-generated speech.

STUDY RESULTS

Individuals in the CHR group produced more variable consonants and exhibited greater speech rate variability than healthy controls in two of the three speech tasks (diadochokinetic and read speech). While there were no significant correlations between speech measures and remotely-obtained motor measures, symptom severity, or conversion risk scores, these comparisons may be under-powered (in part due to challenges of remote data collection during the COVID-19 pandemic).

CONCLUSION

This study provides a thorough and theory-driven first look at how speech production is affected in this at-risk population and speaks to the promise and challenges facing this approach moving forward.

History of trauma is a critical treatment target for individuals at clinical high-risk for psychosis

People meeting criteria for a clinical high-risk (CHR) for psychosis syndrome frequently represent a heterogeneous, help-seeking, and dynamic population. Among the numerous symptoms and risk factors for psychosis, exposure to trauma stands out as both highly prevalent and poorly understood. Indeed, while up to 80% of individuals meeting criteria for a CHR syndrome report trauma histories, there is currently limited research dedicated to this specific area. This is particularly problematic as trauma is tied to risk for conversion, leads to a range of clinical issues, and contributes to disability and poor quality of life. Fortunately, recent research in the general population has led to a significant evolution in the way trauma is assessed and understood, and further, some studies have indicated that targeted trauma interventions in formal psychotic disorders are highly effective. However, direct adoption is challenging as the CHR syndrome holds a number of unique concerns (e.g., clinical heterogeneity, developmental trauma), and characteristically, involves a developing pediatric or young adult population that also comes with specific considerations (e.g., living with caregivers, transitionary period in roles). In this "perspective" we frame the issues around understanding trauma in CHR individuals, discuss viable treatments and unique considerations, and provide suggestions for future steps in developing and incorporating trauma-focused interventions in this population.

Precision-medicine findings from the FACE-SZ cohort to develop motivation-enhancing programs in real-world schizophrenia

BACKGROUND

In people with schizophrenia, major areas of everyday life are impaired, including independent living, productive activities, social relationships and overall quality of life. Enhanced understanding of factors that hinder real-life functioning is vital for treatments to translate into more positive outcomes.

AIM

The goal of the present study was to identify factors associated with motivation deficits in real-life schizophrenia, and to assess its contribution to impaired functioning and quality of life.

METHODS

Based on previous literature and clinical experience, several factors were selected and grouped into factors potentially explaining motivation deficits. Some of these variables were never investigated before in relationship with motivation deficits.

RESULTS

In 561 patients with schizophrenia of the national FACE-SZ cohort living in the community, 235 (41.9%) reported severe motivation deficits. These deficits were found to be significantly associated with impaired socially useful activities, psychological and physical quality of life (in almost all domains), alcohol use disorder (aOR = 2.141, p = 0.021), severe nicotine dependence (aOR = 2.906, p < 0.001) independently of age and sex. No significant association was found for body mass index, metabolic syndrome or physical activity level. In the second model, we identified the following modifiable factors associated with motivation deficits: history of suicide attempt (aOR = 2.297, p = 0.001), positive symptoms (aOR = 1.052, p = 0.006), current major depressive episode (aOR = 2.627, p < 0.001), sleep disorders (aOR = 1.474, p = 0.024) and lower medication adherence (aOR = 0.836, p = 0.001) independently of gender, current alcohol use disorder, second-generation antipsychotics and akathisia. No significant association was found for negative symptoms, childhood trauma and inflammation. These results were maintained after removing patients with schizoaffective disorders or those with major depressive disorder.

INTERPRETATION

Motivation deficits are frequent and remain persistent unmet need in real-world schizophrenia that should be addressed in future guidelines. Based on our results, literature and clinical experience, we recommend to address in priority major depression, sleep, suicide, positive symptoms (when present and as early as possible) and medication adherence to improve motivation deficits of schizophrenia.

Genuine and non-genuine smiles in individuals meeting criteria for a clinical high-risk syndrome

AIM

Psychosis is characterized by both alterations in emotional functioning and environmental stressors including bullying victimization. Recent evidence suggests that some alterations in emotional functioning (e.g., blunted positive facial expressions) are already present in the psychosis risk period. Yet, some clinically relevant facial emotions have not been investigated such as genuine smiles (thought to reflect genuine positive emotions) and non-genuine smiles (thought to fake positive or mask negative emotions) in individuals meeting criteria for a clinical high-risk (CHR) syndrome. Further, despite a compelling conceptual basis to suggest a link between affective expression and exposure to environmental stress, to date, no investigations have sought to examine this association. Here, we aim to assess differences between a sample of CHR (N = 65) and control (N = 67) individuals in genuine and non-genuine smiles and associations with bullying victimization.

METHODS

Smiles (i.e., genuine; non-genuine) were objectively coded on a second-by-second basis using the Facial Action Coding System during a digitally recorded clinical interview segment. Bullying victimization was measured via parent report.

RESULTS

Findings revealed that the CHR group (1) showed blunted genuine (but not non-genuine) smiles compared to controls. Moreover, (2) bullying victimization was related to blunted genuine smiles, but not non-genuine smiles.

CONCLUSION

These findings expand our understanding of emotional alterations in this group with implications for diagnosis (highlighting blunted genuine smiles as a specific marker) and etiology (underscoring the role of bullying victimization in the etiology of emotional dysfunction).

Exercise Intervention in Individuals at Clinical High Risk for Psychosis: Benefits to Fitness, Symptoms, Hippocampal Volumes, and Functional Connectivity

BACKGROUND AND HYPOTHESIS

Individuals at clinical high risk for psychosis (CHR-p) are less fit than nonclinical peers and show hippocampal abnormalities that relate to clinical symptoms. Exercise generates hippocampal neurogenesis that may ameliorate these hippocampal abnormalities and related cognitive/clinical symptoms. This study examines the impact of exercise on deficits in fitness, cognitive deficits, attenuated psychotic symptoms, hippocampal volumes, and hippocampal connectivity in individuals at CHR-p.

STUDY DESIGN

In a randomized controlled trial, 32 individuals at CHR-p participated in either an exercise (n = 17) or waitlist (no exercise) (n = 15) condition. All participants were sedentary at use and absent of current antipsychotic medication, psychosis diagnoses, or a substance use disorder. The participants completed a series of fitness, cognitive tasks, clinical assessments, and an MRI session preintervention and postintervention. The exercise intervention included a high-intensity interval exercise (80% of VO2max) with 1-minute high-intensity intervals (95% of VO2max) every 10 minutes) protocol twice a week over 3 months.

STUDY RESULTS

The exercise intervention was well tolerated (83.78% retention; 81.25% completion). The exercising CHR-p group showed that improved fitness (pre/post-d = 0.53), increased in cognitive performance (pre/post-d = 0.49), decrease in positive symptoms (pre/post-d = 1.12) compared with the waitlist group. Exercising individuals showed stable hippocampal volumes; waitlist CHR-p individuals showed 3.57% decreased hippocampal subfield volume. Exercising individuals showed that increased exercise-related hippocampal connectivity compared to the waitlist individuals.

CONCLUSIONS

The exercise intervention had excellent adherence, and there were clear signs of mechanism engagement. Taken together, evidence suggests that high-intensity exercise can be a beneficial therapeutic tool in the psychosis risk period.

Clinical, Brain, and Multilevel Clustering in Early Psychosis and Affective Stages

Importance

Approaches are needed to stratify individuals in early psychosis stages beyond positive symptom severity to investigate specificity related to affective and normative variation and to validate solutions with premorbid, longitudinal, and genetic risk measures.

Objective

To use machine learning techniques to cluster, compare, and combine subgroup solutions using clinical and brain structural imaging data from early psychosis and depression stages.

Design, Setting, and Participants

A multisite, naturalistic, longitudinal cohort study (10 sites in 5 European countries; including major follow-up intervals at 9 and 18 months) with a referred patient sample of those with clinical high risk for psychosis (CHR-P), recent-onset psychosis (ROP), recent-onset depression (ROD), and healthy controls were recruited between February 1, 2014, to July 1, 2019. Data were analyzed between January 2020 and January 2022.

Main Outcomes and Measures

A nonnegative matrix factorization technique separately decomposed clinical (287 variables) and parcellated brain structural volume (204 gray, white, and cerebrospinal fluid regions) data across CHR-P, ROP, ROD, and healthy controls study groups. Stability criteria determined cluster number using nested cross-validation. Validation targets were compared across subgroup solutions (premorbid, longitudinal, and schizophrenia polygenic risk scores). Multiclass supervised machine learning produced a transferable solution to the validation sample.

Results

There were a total of 749 individuals in the discovery group and 610 individuals in the validation group. Individuals included those with CHR-P (n = 287), ROP (n = 323), ROD (n = 285), and healthy controls (n = 464), The mean (SD) age was 25.1 (5.9) years, and 702 (51.7%) were female. A clinical 4-dimensional solution separated individuals based on positive symptoms, negative symptoms, depression, and functioning, demonstrating associations with all validation targets. Brain clustering revealed a subgroup with distributed brain volume reductions associated with negative symptoms, reduced performance IQ, and increased schizophrenia polygenic risk scores. Multilevel results distinguished between normative and illness-related brain differences. Subgroup results were largely validated in the external sample.

Conclusions and Relevance

The results of this longitudinal cohort study provide stratifications beyond the expression of positive symptoms that cut across illness stages and diagnoses. Clinical results suggest the importance of negative symptoms, depression, and functioning. Brain results suggest substantial overlap across illness stages and normative variation, which may highlight a vulnerability signature independent from specific presentations. Premorbid, longitudinal, and genetic risk validation suggested clinical importance of the subgroups to preventive treatments.

The Latent Structure of Negative Symptoms in the General Population in Adolescence and Emerging Adulthood

Negative symptoms predict adverse outcomes within psychotic disorders, in individuals at high-risk for psychosis, and in young people in the community. There is considerable interest in the dimensional structure of negative symptoms in clinical samples, and accumulating evidence suggests a 5-factor structure. Little is known about the underlying structure of negative symptoms in young people despite the importance of this developmental stage for mental health. We used confirmatory factor analysis to test the structure of parent-reported negative symptoms at mean ages 16.32 (SD 0.68, N = 4974), 17.06 (SD 0.88, N = 1469) and 22.30 (SD 0.93, N = 5179) in a community sample. Given previously reported associations between total negative symptoms and genome-wide polygenic scores (GPS) for major depressive disorder (MDD) and schizophrenia in adolescence, we assessed associations between individual subdomains and these GPSs. A 5-factor model of flat affect, alogia, avolition, anhedonia, and asociality provided the best fit at each age and was invariant over time. The results of our linear regression analyses showed associations between MDD GPS with avolition, flat affect, anhedonia, and asociality, and between schizophrenia GPS with avolition and flat affect. We showed that a 5-factor structure of negative symptoms is present from ages 16 to 22 in the community. Avolition was most consistently associated with polygenic liability to MDD and schizophrenia, and alogia was least associated. These findings highlight the value of dissecting negative symptoms into psychometrically derived subdomains and may offer insights into early manifestation of genetic risk for MDD and schizophrenia.

Reduced Expression of Emotion: A Red Flag Signalling Conversion to Psychosis in Clinical High Risk for Psychosis (CHR-P) Populations

Objective: In this hypothesis-testing study, which is based on findings from a previous atheoretical machine-learning study, we test the predictive power of baseline "reduced expression of emotion" for psychosis.Method: Study participants (N = 96, mean age 16.55 years) were recruited from the Prevention of Psychosis Study in Rogaland, Norway. The Structured Interview for Prodromal Syndromes (SIPS) was conducted 13 times over two years. Reduced expression of emotion was added to positive symptoms at baseline (P1-P5) as a predictor of psychosis onset over a two-year period using logistic regression.Results: Participants with a score above zero on expression of emotion had over eight times the odds of conversion (OR = 8.69, p < .001). Data indicated a significant dose-response association. A model including reduced expression of emotion at baseline together with the positive symptoms of the SIPS rendered the latter statistically insignificant.Conclusions: The study findings confirm findings from the previous machine-learning study, indicating that observing reduced expression of emotion may serve two purposes: first, it may add predictive value to psychosis conversion, and second, it is readily observable. This may facilitate detection of those most at risk within the clinical high risk of psychosis population, as well as those at clinical high risk. A next step could be including this symptom within current high-risk criteria. Future research should consolidate these findings.

Alterations in Emotional Diversity Correspond With Increased Severity of Attenuated Positive and Negative Symptoms in the Clinical High-Risk Syndrome

Background: Alterations in emotional functioning are a key feature of psychosis and are present in individuals with a clinical high-risk (CHR) syndrome. However, little is known about alterations in emotional diversity (i.e., the variety and relative abundance of emotions that humans experience) and clinical correlates in this population. Methods: Individuals meeting criteria for a CHR syndrome (N = 47) and matched healthy controls (HC) (N = 58) completed the modified Differential Emotions Scale (used to derive scores of total, positive, and negative emotional diversity) and clinical interviews (i.e., Structured Interview for Psychosis-Risk Syndromes). Results: Findings showed that the CHR group experienced lower levels of positive emotional diversity compared to HCs. Among the CHR individuals, lower levels of positive and higher levels of negative emotional diversity were associated with more severe attenuated positive and negative symptoms. Analyses controlled for mean levels of emotion and current antipsychotic medication use. Discussion: Results demonstrate that altered emotional diversity (in particular lower levels of positive and higher levels of negative emotional diversity) is a clinically relevant marker in CHR individuals, above and beyond alterations in mean levels of emotional experiences. Future studies may probe sources, downstream consequences, and potential modifiability of decreased emotional diversity in individuals at CHR.

The COVID-19 Pandemic Introduces Diagnostic and Treatment Planning Complexity for Individuals at Clinical High Risk for Psychosis

COVID-19 has led to a great deal of general suffering and an increased prevalence of psychiatric illness worldwide. Within the area of psychosis-risk syndromes, a highly heterogeneous clinical population, the picture is quite nuanced as the social restrictions resulting from the pandemic have reduced stress for some and increased it for others. Further, a number of pandemic-related societal and cultural changes have obfuscated the diagnostic and treatment landscape in this area as well. In this opinion article, we describe several prototypical cases, representative of presentations seen in our clinical high-risk (CHR) research programs. The cases highlight considerable clinical variability and, in addition, speak to the current complexities faced by diagnosticians and treatment providers. In addition to discussing these issues, this piece introduces potential solutions highlighting the promise of incorporating data-driven strategies to identify more homogenous CHR subtypes and employ precision medicine.

Relationship of ventral striatum activation during effort discounting to clinical amotivation severity in schizophrenia

Motivational deficits play a central role in disability due to negative symptoms of schizophrenia (SZ), but limited pathophysiological understanding impedes critically needed therapeutic development. We applied an fMRI Effort Discounting Task (EDT) that quantifies motivation using a neuroeconomic decision-making approach, capturing the degree to which effort requirements produce reductions in the subjective value (SV) of monetary reward. An analyzed sample of 21 individuals with SZ and 23 group-matched controls performed the EDT during fMRI. We hypothesized that ventral striatum (VS) as well as extended brain motivation circuitry would encode SV, integrating reward and effort costs. We also hypothesized that VS hypoactivation during EDT decisions would demonstrate a dimensional relationship with clinical amotivation severity, reflecting greater suppression by effort costs. As hypothesized, VS as well as a broader cortico-limbic network were activated during the EDT and this activation correlated positively with SV. In SZ, activation to task decisions was reduced selectively in VS. Greater VS reductions correlated with more severe clinical amotivation in SZ and across all participants. However, these diagnosis and amotivation effects could not be explained by the response to parametric variation in reward, effort, or model-based SV. Our findings demonstrate that VS hypofunction in schizophrenia is manifested during effort-based decisions and reflects dimensional motivation impairment. Dysfunction of VS impacting effort-based decision-making can provide a target for biomarker development to guide novel efforts to assess and treat disabling amotivation.

Reciprocal Social Behavior and Related Social Outcomes in Individuals at Clinical High Risk for Psychosis

Reciprocal social behavior (RSB) deficits have been noted in formal psychotic disorders and may play a role in the clinical high-risk for psychosis (CHR) syndrome. The present study examined RSB deficits and clinical and social functioning correlates in 45 individuals meeting criteria for a CHR syndrome and 47 healthy comparisons (HC). Further, this study examined associations with number of friends, problematic social Internet use, and perceived social support. Compared to the HC group, the CHR group exhibited greater deficits in total RSB and in all RSB subdomains. Total RSB deficits were associated with greater negative but not positive symptom severity in the CHR group, and greater social functional impairment. RSB deficits also may have related to fewer friendships, more problematic social Internet use, and less perceived belonging and tangible social support, although relationships with Internet use and perceived social support did not survive FDR-correction. These findings provide further evidence that RSB is impaired in the CHR syndrome and suggest specific social outcomes that may be affected. Further investigations with larger, diverse samples and repeated measures can confirm these findings.

Secondary Sources of Negative Symptoms in Those Meeting Criteria for a Clinical High-Risk Syndrome

BACKGROUND

Negative symptoms are diagnostic characteristics of schizophrenia. They can result from primary (i.e., idiopathic) or secondary (i.e., due to other factors such as depression, anxiety, psychosis, disorganization, medication effects) features of the illness. Although secondary sources of negative symptoms are prevalent among individuals meeting criteria for clinical high-risk syndromes that are due to high rates of comorbidity, the extent to which secondary sources account for variance in negative symptom domains is unknown. Addressing this gap is an important step in informing vulnerability models and treatments for negative symptoms. This study aimed to investigate secondary sources of negative symptoms in those meeting criteria for a clinical high-risk syndrome (N = 192).

METHODS

Simultaneous regression and hierarchical partitioning methods were used to determine the proportion of variance explained by selective serotonin reuptake inhibitor use, anxiety, depression, unusual thought content, and disorganized communication in predicting severity of five negative symptom domains (avolition, anhedonia, asociality, blunted affect, and alogia).

RESULTS

Findings revealed that depression explained the largest proportion of variance in avolition, asociality, and anhedonia. Anxiety was the most predictive of blunted affect, and selective serotonin reuptake inhibitor use explained the most variance in alogia. Analyses within male and female samples revealed that in males, depression explained a large proportion of variance in several negative symptom domains, while in females, selective serotonin reuptake inhibitor use explained variance in alogia.

CONCLUSIONS

Results highlight heterogeneity in variance explained by secondary sources of negative symptoms. These findings guide treatment development for secondary sources of negative symptoms. Furthermore, results inform etiologic models of psychosis and negative symptom conceptualizations.

Abnormal Gesture Perception and Clinical High-Risk for Psychosis

Individuals diagnosed with psychotic disorders exhibit abnormalities in the perception of expressive behaviors, which are linked to symptoms and visual information processing domains. Specifically, literature suggests these groups have difficulties perceiving gestures that accompany speech. While our understanding of gesture perception in psychotic disorders is growing, gesture perception abnormalities and clues about potential causes and consequences among individuals meeting criteria for a clinical high-risk (CHR) syndrome is limited. Presently, 29 individuals with a CHR syndrome and 32 healthy controls completed an eye-tracking gesture perception paradigm. In this task, participants viewed an actor using abstract and literal gestures while presenting a story and eye gaze data (eg, fixation counts and total fixation time) was collected. Furthermore, relationships between fixation variables and both symptoms (positive, negative, anxiety, and depression) and measures of visual information processing (working memory and attention) were examined. Findings revealed that the CHR group gazed at abstract gestures fewer times than the control group. When individuals in the CHR group did gaze at abstract gestures, on average, they spent significantly less time fixating compared to controls. Furthermore, reduced fixation (ie, count and time) was related to depression and slower response time on an attentional task. While a similar pattern of group differences in the same direction appeared for literal gestures, the effect was not significant. These data highlight the importance of integrating gesture perception abnormalities into vulnerability models of psychosis and inform the development of targeted treatments for social communicative deficits.