Current psychopathological issues in psychosis: towards a phenome-wide scanning approach

20-Year trajectories of six psychopathological dimensions in patients with first-episode psychosis: Could they be predicted?

Patients with first-episode psychoses (FEP) exhibit heterogeneity in clinical manifestations and outcomes. This study investigated the long-term trajectories of six key psychopathological dimensions (reality-distortion, negative, disorganization, catatonia, mania and depression) in patients diagnosed with FEP. A total of 243 patients were followed up for 20 years and the trajectories of the dimensions were analysed using growth mixture modelling. These dimensions showed varied course patterns, ranging from two to five trajectories. Additionally, the study examined the predictive value of different factors in differentiating between the long-term trajectories. The exposome risk score showed that familial load, distal and intermediate risk factors, acute psychosocial stressors and acute onset were significant predictors for differentiating between long-term psychopathological trajectories. In contrast, polygenic risk score, duration of untreated psychosis and duration of untreated illness demonstrated little or no predictive value. The findings highlight the importance of conducting a multidimensional assessment not only at FEP but also during follow-up to customize the effectiveness of interventions. Furthermore, the results emphasize the relevance of assessing premorbid predictors from the onset of illness. This may enable the identification of FEP patients at high-risk of poor long-term outcomes who would benefit from targeted prevention programs on specific psychopathological dimensions.

Six-year trajectories and associated factors of positive and negative symptoms in schizophrenia patients, siblings, and controls: Genetic Risk and Outcome of Psychosis (GROUP) study

Positive and negative symptoms are prominent but heterogeneous characteristics of schizophrenia spectrum disorder (SSD). Within the framework of the Genetic Risk and Outcome of Psychosis (GROUP) longitudinal cohort study, we aimed to distinguish and identify the genetic and non-genetics predictors of homogenous subgroups of the long-term course of positive and negative symptoms in SSD patients (n = 1119) and their unaffected siblings (n = 1059) in comparison to controls (n = 586). Data were collected at baseline, and after 3- and 6-year follow-ups. Group-based trajectory modeling was applied to identify latent subgroups using positive and negative symptoms or schizotypy scores. A multinomial random-effects logistic regression model was used to identify predictors of latent subgroups. Patients had decreasing, increasing, and relapsing symptoms course. Unaffected siblings and healthy controls had three to four subgroups characterized by stable, decreasing, or increasing schizotypy. PRSSCZ did not predict the latent subgroups. Baseline symptoms severity in patients, premorbid adjustment, depressive symptoms, and quality of life in siblings predicted long-term trajectories while were nonsignificant in controls. In conclusion, up to four homogenous latent subgroups of symptom course can be distinguished within patients, siblings, and controls, while non-genetic factors are the main factors associated with the latent subgroups.

A network analysis and empirical validation of executive deficits in patients with psychosis and their healthy siblings

BACKGROUND

Psychopathological symptoms and cognitive impairment are core features of patients with psychotic disorders. Executive dysfunctions are commonly observed and typically assessed using tests like the Wisconsin Card Sorting Test (WCST). However, the structure of executive deficits remains unclear, and the underlying processes may be different. This study aimed to explore and compare the network structure of WCST measures in patients with psychosis and their unaffected siblings and to empirically validate the resulting network structure of the patients.

METHODS

The subjects were 298 patients with a DSM 5 diagnosis of a psychotic disorder and 89 of their healthy siblings. The dimensionality and network structure of the WCST were examined by means of exploratory graph analysis (EGA) and network centrality parameters.

RESULTS

The WCST network structure comprised 4 dimensions: perseveration (PER), inefficient sorting (IS), failure to maintain set (FMS) and learning (LNG). The patient and sibling groups showed a similar network structure, which was reliably estimated. PER and IS showed common and strong associations with antecedent, concurrent and outcome validators. The LNG dimension was also moderately associated with these validators, but FMS did not show significant associations.

CONCLUSIONS

Four cognitive processes underlying WCST performance were identified by the network analysis. PER, IS and LNG were associated with and shared common antecedent, concurrent and outcome validators, while FMS was not associated with external validators. These four underlying dysfunctions might help disentangle the neurofunctional basis of executive deficits in psychosis.

Emerging cycloid psychosis episodes during COVID-19 pandemic: a case series

AIMS

Cycloid psychosis (CP) is a clinical entity characterized by sudden onset of psychotic polymorphic symptomatology and fluctuant course. It has a reported rate of psychosocial precipitating factors ranging 30-65%. The aim of the study was to describe all cases of CP, admitted in our Psychiatry ward, during the first two months of the COVID-19 pandemic.

METHOD

In this retrospective and observational study, we reported a sample of eight patients who were treated as inpatients in the psychiatric ward of our hospital during the first two months of COVID-19 pandemic (mid-March to mid-May 2020) and compared it with previous years. All our patients fulfilled all four Perris & Brockington criteria for CP. We reported the sociodemographic, clinical and biological parameters.

RESULTS

In our sample, all of the patients had maladaptive personality traits; the major external stressing factor was COVID-19; all our patients had short prodromal symptomatology, short Duration of Untreated Psychosis (DUP) and high score at the Positive Scale at Positive and Negative Syndrome Scale (PANSS-P) at hospital admission with the majority showing psychotic symptoms related to the actual COVID-19 pandemic. The predominant treatment during admission was olanzapine and a short time to full remission of psychotic symptoms was observed in all patients.

CONCLUSION

We found an increase in the admission of patients with CP during the first two months of the actual pandemic. Stress caused by the COVID-19 situation has possibly incremented the frequency of stress-related disorders and it has also influenced its clinical presentation.

Cycloid psychosis as a psychiatric expression of anti-NMDAR encephalitis. A systematic review of case reports accomplished with the authors' cooperation

OBJECTIVE

We reviewed the psychotic symptoms of anti-NMDA receptor encephalitis (NMDARE) to differentiate its presentation from those found in a primary psychiatric disorder. We hypothesized that the cycloid psychosis (CP) phenotype would be a frequent clinical presentation in the psychiatric phase of NMDARE.

METHOD

A systematic literature review in PubMed of all case reports published on NMDARE was performed from database inception to March 2020. We included all cases where psychotic symptoms were reported and whose diagnoses were confirmed by the presence of anti-NMDAR antibodies in the cerebrospinal fluid (CSF). An email including a short test (CP phenotype, Perris and Brockington's criteria) was sent to all case report authors asking them to describe the psychotic symptoms.

RESULTS

We identified 335 case reports fulfilling our criteria, and the authors of 200 replied. Our analyses were based exclusively on those answers and data extracted from the articles. Median patient age was 25 years (+-11.4), 81% were female, and 39% had an ovarian teratoma. A complete CP phenotype was identified in 175 patients (87%). These were acute psychotic episodes with a sudden onset and a fluctuating clinical pattern mostly characterized by confusion (97%), delusions (75%), hallucinations (69%), motility disturbances (87%), and mood oscillations (80%).

CONCLUSION

The complete CP phenotype was frequently the expression of psychotic symptoms in NMDARE. We suggest that patients with a first psychotic episode who initially exhibit the CP phenotype should undergo CSF analysis to determine whether antibodies against neuronal cell surface or synaptic receptors are present to rule out a possible diagnosis of autoimmune encephalitis.

Schizophrenia Infrastructures: Local and Global Dynamics of Transformation in Psychiatric Diagnosis-Making in the Twentieth and Twenty-First Centuries

This article uses the concept of "diagnosis infrastructures" to propose a framework for narrating the history of schizophrenia as a global category in the twentieth century. Diagnosis infrastructures include the material and architectural arrangements, legal requirements, and professional models that enable both the ways in which patients come to clinics and navigate the world of schizophrenia as well as the means through which clinicians organize their diagnostic work. These infrastructures constitute a framework for how schizophrenia has been identified as a disorder. This article explores three moments in the history of schizophrenia infrastructures in the twentieth century. The first is the German psychiatrist Kurt Schneider's discussion of first- and second-rank symptoms in the interwar period. The second is the research on criteria for defining schizophrenia within the framework of the WHO International Pilot Study of Schizophrenia at the turn of the 1970s. The third corresponds to the changing infrastructures of mental health care in the context of both global mental health and the changing landscape of schizophrenia research over the last decades.

Exploring the predictive power of the unspecific risk category of the Basel Screening Instrument for Psychosis

AIM

Ultrahigh risk (UHR) criteria, consisting of brief limited intermittent psychotic symptoms (BLIPS), attenuated psychotic symptoms (APS) and genetic risk and deterioration (GRD) syndrome are the most widely used criteria for assessing the clinical high-risk state for psychosis (CHR-P). The Basel Screening Instrument for Psychosis (BSIP) includes a further risk category, the unspecific risk category (URC). However, little is known about the predictive power of this risk category compared to other risk categories.

METHODS

Two hundred CHR-P patients were detected as part of the Früherkennung von Psychosen (FePsy) study using the BSIP. Transition to psychosis was assessed in regular intervals for up to 7 years.

RESULTS

Patients meeting only the URC criterion (n = 40) had a significantly lower risk of transition to psychosis than the UHR group (including BLIPS, APS and GRD) (HR 0.19 [0.05; 0.80] (P = 0.024). Furthermore, the URC only risk group had a lower transition risk than the APS without BLIPS group (P = 0.015) and a trendwise lower risk than the BLIPS group (P = 0.066). However, despite the lower transition risk in the URC only group, there were still two patients (5%) in this group with a later transition to psychosis.

CONCLUSIONS

The URC includes patients who have a lower risk of transition than those included by the UHR categories and thereby increases the sensitivity of the BSIP. This offers the possibility of a stratified intervention, with these subjects receiving low intensity follow-up and treatment.

Sex and gender differences in schizophrenic psychoses-a critical review

Many sex and gender differences in schizophrenic psychoses have been reported, but few have been soundly replicated. A stable finding is the later age of onset in women compared to men. Gender differences in symptomatology, comorbidity, and neurocognition seem to reflect findings in the general population. There is increasing evidence for estrogens being psychoprotective in women and for hypothalamic-pituitary-gonadal dysfunction in both sexes.More methodologically sound, longitudinal, multi-domain, interdisciplinary research investigating both sex (biological) and gender (psychosocial) factors is required to better understand the different pathogenesis and etiologies of schizophrenic psychoses in women and men, thereby leading to better tailored treatments and improved outcomes.

Familiality of Psychotic Disorders: A Polynosologic Study in Multiplex Families

INTRODUCTION

Phenotype definition of psychotic disorders has a strong impact on the degree of familial aggregation. Nevertheless, the extent to which distinct classification systems affect familial aggregation (ie, familiality) remains an open question. This study was aimed at examining the familiality associated with 4 nosologic systems of psychotic disorders (DSM-IV, ICD-10, Leonhard's classification and a data-driven approach) and their constituting diagnoses in a sample of multiplex families with psychotic disorders.

METHODS

Participants were probands with a psychotic disorder, their parents and at least one first-degree relative with a psychotic disorder. The sample was made of 441 families comprising 2703 individuals, of whom 1094 were affected and 1709 unaffected.

RESULTS

The Leonhard classification system had the highest familiality (h (2) = 0.64), followed by the empirical (h (2) = 0.55), DSM-IV (h (2) = 0.50), and ICD-10 (h (2) = 0.48). Familiality estimates for individual diagnoses varied considerably (h (2) = 0.25-0.79). Regarding schizophrenia diagnoses, Leonhard's systematic schizophrenia (h (2) = 0.78) had the highest familiality, followed by latent class core schizophrenia (h (2) = 0.74), DSM-IV schizophrenia (h (2) = 0.48), and ICD-10 schizophrenia (h (2) = 0.41). Psychotic mood disorders showed substantial familiality across nosologic systems (h (2) = 0.60-0.77). Domains of psychopathology other than reality-distortion symptoms showed moderate familiality irrespective of diagnosis (h (2) = 0.22-0.52) with the deficit syndrome of schizophrenia showing the highest familiality (h (2) = 0.66).

CONCLUSIONS

While affective psychoses showed relatively high familiality estimates across classification schemes, those of nonaffective psychoses varied markedly as a function of the diagnostic scheme with a narrow schizophrenia phenotype maximizing its familial aggregation. Leonhard's classification of psychotic disorders may be better suited for molecular genetic studies than the official diagnostic systems.

The longitudinal interplay between negative and positive symptom trajectories in patients under antipsychotic treatment: a post hoc analysis of data from a randomized, 1-year pragmatic trial

BACKGROUND

Schizophrenia is a highly heterogeneous disorder with positive and negative symptoms being characteristic manifestations of the disease. While these two symptom domains are usually construed as distinct and orthogonal, little is known about the longitudinal pattern of negative symptoms and their linkage with the positive symptoms. This study assessed the temporal interplay between these two symptom domains and evaluated whether the improvements in these symptoms were inversely correlated or independent with each other.

METHODS

This post hoc analysis used data from a multicenter, randomized, open-label, 1-year pragmatic trial of patients with schizophrenia spectrum disorder who were treated with first- and second-generation antipsychotics in the usual clinical settings. Data from all treatment groups were pooled resulting in 399 patients with complete data on both the negative and positive subscale scores from the Positive and Negative Syndrome Scale (PANSS). Individual-based growth mixture modeling combined with interplay matrix was used to identify the latent trajectory patterns in terms of both the negative and positive symptoms. Pearson correlation coefficients were calculated to examine the relationship between the changes of these two symptom domains within each combined trajectory pattern.

RESULTS

We identified four distinct negative symptom trajectories and three positive symptom trajectories. The trajectory matrix formed 11 combined trajectory patterns, which evidenced that negative and positive symptom trajectories moved generally in parallel. Correlation coefficients for changes in negative and positive symptom subscale scores were positive and statistically significant (P < 0.05). Overall, the combined trajectories indicated three major distinct patterns: (1) dramatic and sustained early improvement in both negative and positive symptoms (n = 70, 18%), (2) mild and sustained improvement in negative and positive symptoms (n = 237, 59%), and (3) no improvement in either negative or positive symptoms (n = 82, 21%).

CONCLUSIONS

This study of symptom trajectories over 1 year shows that changes in negative and positive symptoms were neither inversely nor independently related with each other. The positive association between these two symptom domains supports the notion that different symptom domains in schizophrenia may depend on each other through a unified upstream pathological disease process.

Increased stress reactivity: a mechanism specifically associated with the positive symptoms of psychotic disorder

BACKGROUND

An increased reactivity to stress in the context of daily life is suggested to be an independent risk factor underlying the positive symptoms of psychotic disorder. The aim of this study was to investigate whether positive symptoms moderate the association between everyday stressful events and negative affect (NA), known as stress reactivity. This hypothesis was put to the test in patients with a diagnosis of psychotic disorder. Method The Comprehensive Assessment of Symptoms and History (CASH) and the Positive and Negative Syndrome Scale (PANSS) were used to assess positive and negative symptoms. The experience sampling method (ESM), a structured diary technique, was used to measure stress reactivity and psychotic symptoms in daily life.

RESULTS

Higher levels of positive symptoms (CASH: B = 0.14, p = 0.005; PANSS: B = 0.05, p = 0.000; ESM: B = 0.03, p = 0.000) and lower levels of negative symptoms (PANSS: B = - 0.05, p = 0.001) significantly moderate the association between unpleasant events and NA. No significant moderating effect was found for CASH negative symptoms. Moreover, the moderating effect of lifetime and current symptoms on the stress-NA association was significantly larger for those patients with predominantly positive symptoms (CASH: B = 0.09, p = 0.000; PANSS: B = 0.08, p = 0.000; ESM: B = 0.13, p = 0.000).

CONCLUSIONS

Patients with a 'psychotic syndrome' with high levels of positive symptoms and low levels of negative symptoms show increased reactivity to stress in daily life, indicating that stress reactivity is a possible risk factor underlying this syndrome.

Heterozygosity at catechol-O-methyltransferase Val158Met and schizophrenia: new data and meta-analysis

Catechol-O-methyltransferase (COMT) has been largely studied in relation to schizophrenia susceptibility. Most studies focused on the functional single nucleotide polymorphism (SNP) rs4680 that causes a substitution of Val by Met at codon 158 of the COMT protein. Recent meta-analyses do not support an association between allelic variants at rs4680 and schizophrenia. However, the putative role of overdominance has not been tested in meta-analyses, despite its biological plausibility. In this work, we tested the overdominant model in two Spanish samples (from Valencia and Santiago de Compostela), representing a total of 762 schizophrenic patients and 1042 controls, and performed a meta-analysis of the available studies under this model. A total of 51 studies comprising 13,894 schizophrenic patients and 16,087 controls were included in the meta-analysis, that revealed a small but significant protective effect for heterozygosity at rs4680 (pooled OR=0.947, P=0.023). Post-hoc analysis on southwestern European samples suggested a stronger effect in these populations (pooled OR=0.813, P=0.0009). Thus, the COMT functional polymorphism rs4680 contributes to schizophrenia genetic susceptibility under an overdominant model, indicating that both too high and too low levels of dopamine (DA) signalling may be risk factors. This effect can be modulated by genetic background.

Psychopathological assessment of schizophrenia: relevance for classification

Considerable effort has been focused on updating the clinical aspects of psychiatric classifications based on recent progress in the field of neurobiology. In this article, recent developments in the primary assessment methods within clinical psychiatry, which are based in phenomenological psychopathology, are reviewed as nosotaxies that are still embedded in clinical description. New directions for research on psychopathology are outlined to elicit better descriptions of subjective experience from patients. Finally, the known limitations of the Kraepelinian dichotomy are summarized, and future problems related to the inclusion of the new dimensional assessment methods in the next psychiatric classifications are described.