Testing the psychopathology of psychosis: evidence for a general psychosis dimension

Unitary psychosis (Einheitspsychose): A conceptual history

AIMS

The objective of this paper is to explore the evolution of the forms of madness and the model that accounts for it over time. The classical distinction between several categories of mental disorders is contrasted with the idea of unitary psychosis.

METHODS

Historical conceptual analysis. The concept of unitary psychosis is explored in its basic features. Its origins in the nineteenth century and developments during the twentieth century are considered.

RESULTS

Following the publication of Kraepelin's fundamental handbook, the debate was shaped as pro or against the Kraepelinian dichotomy between dementia praecox and manic-depressive illness. However, the origins of the concept of unitary psychosis as well as some more recent developments are independent from it.

CONCLUSIONS

This article argues that, when viewed pragmatically, both positions (the pluralist and the unitary) bring advantages that can be complementary rather than mutually exclusive. The pluralist position allows us to recognize the qualitative differences between phenomena and structures of experience, while the unitary model prevents us from reifying them. This is achieved by paying attention to the diachronic evolution and the pathogenetic dynamics.

Shaping tomorrow's support: baseline clinical characteristics predict later social functioning and quality of life in schizophrenia spectrum disorder

PURPOSE

We aimed to explore the multidimensional nature of social inclusion (mSI) among patients diagnosed with schizophrenia spectrum disorder (SSD), and to identify the predictors of 3-year mSI and the mSI prediction using traditional and data-driven approaches.

METHODS

We used the baseline and 3-year follow-up data of 1119 patients from the Genetic Risk and Outcome in Psychosis (GROUP) cohort in the Netherlands. The outcome mSI was defined as clusters derived from combined analyses of thirteen subscales from the Social Functioning Scale and the brief version of World Health Organization Quality of Life questionnaires through K-means clustering. Prediction models were built through multinomial logistic regression (ModelMLR) and random forest (ModelRF), internally validated via bootstrapping and compared by accuracy and the discriminability of mSI subgroups.

RESULTS

We identified five mSI subgroups: "very low (social functioning)/very low (quality of life)" (8.58%), "low/low" (12.87%), "high/low" (49.24%), "medium/high" (18.05%), and "high/high" (11.26%). The mSI was robustly predicted by a genetic predisposition for SSD, premorbid adjustment, positive, negative, and depressive symptoms, number of met needs, and baseline satisfaction with the environment and social life. The ModelRF (61.61% [54.90%, 68.01%]; P =0.013) was cautiously considered outperform the ModelMLR (59.16% [55.75%, 62.58%]; P =0.994).

CONCLUSION

We introduced and distinguished meaningful subgroups of mSI, which were modestly predictable from baseline clinical characteristics. A possibility for early prediction of mSI at the clinical stage may unlock the potential for faster and more impactful social support that is specifically tailored to the unique characteristics of the mSI subgroup to which a given patient belongs.

Investigating the relationship between negative symptoms and metacognitive functioning in psychosis: An individual participant data meta-analysis

PURPOSE

Negative symptoms are a persistent, yet under-explored problem in psychosis. Disturbances in metacognition are a potential causal factor in negative symptom development and maintenance. This meta-analysis uses individual participant data (IPD) from existing research to assess the relationship between negative symptoms and metacognition treated as summed scores and domains.

METHODS

Data sets containing individuals with negative symptoms and metacognition data, aged 16+ with psychosis, were identified according to pre-specific parameters. IPD integrity and completeness were checked and data were synthesized in two-stage meta-analyses of each negative symptoms cluster compared with metacognition in seemingly unrelated regression using restricted maximum likelihood estimation. Planned and exploratory sensitivity analyses were also conducted.

RESULTS

Thirty-three eligible data sets were identified with 21 with sufficient similarity and availability to be included in meta-analyses, corresponding to 1301 participants. The strongest relationships observed were between summed scores of negative symptoms and metacognition. Metacognitive domains of self-reflectivity and understanding others' minds, and expressive negative symptoms emerged as significant in some meta-analyses. The uncertainty of several effect estimates increased significantly when controlling for covariates.

CONCLUSIONS

This robust meta-analysis highlights the impact of using summed versus domain-specific scores of metacognition and negative symptoms, and relationships are not as clear-cut as once believed. Findings support arguments for further differentiation of negative symptom profiles and continued granular exploration of the relationship between metacognition and negative symptoms.

Fibre density and fibre-bundle cross-section of the corticospinal tract are distinctly linked to psychosis-specific symptoms in antipsychotic-naïve patients with first-episode schizophrenia

Multiple lines of research support the dysconnectivity hypothesis of schizophrenia. However, findings on white matter (WM) alterations in patients with schizophrenia are widespread and non-specific. Confounding factors from magnetic resonance image (MRI) processing, clinical diversity, antipsychotic exposure, and substance use may underlie some of the variability. By application of refined methodology and careful sampling, we rectified common confounders investigating WM and symptom correlates in a sample of strictly antipsychotic-naïve first-episode patients with schizophrenia. Eighty-six patients and 112 matched controls underwent diffusion MRI. Using fixel-based analysis (FBA), we extracted fibre-specific measures such as fibre density and fibre-bundle cross-section. Group differences on fixel-wise measures were examined with multivariate general linear modelling. Psychopathology was assessed with the Positive and Negative Syndrome Scale. We separately tested multivariate correlations between fixel-wise measures and predefined psychosis-specific versus anxio-depressive symptoms. Results were corrected for multiple comparisons. Patients displayed reduced fibre density in the body of corpus callosum and in the middle cerebellar peduncle. Fibre density and fibre-bundle cross-section of the corticospinal tract were positively correlated with suspiciousness/persecution, and negatively correlated with delusions. Fibre-bundle cross-section of isthmus of corpus callosum and hallucinatory behaviour were negatively correlated. Fibre density and fibre-bundle cross-section of genu and splenium of corpus callosum were negative correlated with anxio-depressive symptoms. FBA revealed fibre-specific properties of WM abnormalities in patients and differentiated associations between WM and psychosis-specific versus anxio-depressive symptoms. Our findings encourage an itemised approach to investigate the relationship between WM microstructure and clinical symptoms in patients with schizophrenia.

A Systematic Review and Meta-Analysis of the Association Between Psychopathology and Social Functioning in Schizophrenia

BACKGROUND

Impaired social functioning is a major, but under-elucidated area of schizophrenia. It's typically understood as consequential to, eg, negative symptoms, but meta-analyses on the subject have not examined psychopathology in a broader perspective and there's severe heterogeneity in outcome measures. To enhance functional recovery from schizophrenia, a more comprehensive understanding of the nature of social functioning in schizophrenia is needed.

STUDY DESIGN

In this systematic review and meta-analysis, we searched PubMed, PsycInfo, and Ovid Embase for studies providing an association between psychopathology and social functioning. Meta-analyses of the regression and correlation coefficients were performed to explore associations between social functioning and psychopathology, as well as associations between their subdomains.

STUDY RESULTS

Thirty-six studies with a total of 4742 patients were included. Overall social functioning was associated with overall psychopathology (95% CI [-0.63; -0.37]), positive symptoms (95% CI [-0.39; -0.25]), negative symptoms (95% CI [-0.61; -0.42]), disorganized symptoms (95% CI [-0.54; -0.14]), depressive symptoms (95% CI [-0.33; -0.11]), and general psychopathology (95% CI [-0.60; -0.43]). There was significant heterogeneity in the results, with I2 ranging from 52% to 92%.

CONCLUSIONS

This is the first systematic review and meta-analysis to comprehensively examine associations between psychopathology and social functioning. The finding that all psychopathological subdomains seem to correlate with social functioning challenges the view that impaired social functioning in schizophrenia is mainly a result of negative symptoms. In line with classical psychopathological literature on schizophrenia, it may be more appropriate to consider impaired social functioning as a manifestation of the disorder itself.

Longitudinal study of the course and outcome of first-episode psychosis

Background

Study of first episode psychosis (FEP), an episode of psychotic nature, which manifests for the first time in an individual in the longitudinal continuum of his/her illness, has been a matter of research interest in recent years, as this may give more insight to the overall phenomenology and course of psychotic illnesses.

Methods

A study was undertaken to evaluate course and outcome of first episode psychosis. A total of 100 consecutive inpatients were selected for the study. Informed consent was obtained. Structured Proforma was used for recording psychosocial profiles and relevant medical history. Brief Psychiatric Rating Scale (BPRS) was given to assess the severity of psychopathology; Positive and Negative Symptom Scale (PANSS) to assess the severity of psychosis; Becks Suicidal Ideation Scale (BSI) to assess the extent of suicidality and Global Assessment of Functioning (GAF) to assess global functioning of the individual. The assessment was done at baseline, at six months, and at one year.

Results

First episode psychosis constituted around a tenth of the caseload. It commonly affected people in the third decade of life. There was an improvement in 92% of the cases over a year of study. Schizophrenia constituted the majority of first episode psychosis. The history of smoking was relatively higher in acute and transient psychotic disorders. Age inversely correlated with the severity of psychopathology. There was no difference in improvement in psychopathology over time in patients of schizophrenia and related disorder vis--vis other psychotic disorders.

Conclusion

Our study did not find any significantly varied sociodemographic factors in the course and outcome of the illness. It also refuted the schism between various types of psychosis based on the current classificatory system. It draws our attention toward the unitary concept of psychosis and is a call to re-think our strategies in the management of psychosis.

Exploring putative therapeutic mechanisms of change in a hybrid compassion-focused, ecological momentary intervention: Findings from the EMIcompass trial

Compassion-focused interventions represent a promising transdiagnostic approach, but the mechanisms involved in hybrid delivery combining face-to-face sessions and an ecological momentary intervention remain unexplored. The current study aimed at exploring associations of putative mechanisms with clinical outcomes at post-intervention/follow-up and mediation of outcome at follow-up by preceding pre-to post-intervention changes in putative mechanisms. The compassion-focused EMIcompass intervention was applied in an exploratory randomized controlled trial (treatment as usual (TAU) vs. TAU + EMIcompass) with youth with early mental health problems. Data was collected before randomization, at post-intervention and at four-week follow-up. We recruited N = 92 participants, N = 46 were allocated to the experimental condition. After control for baseline levels of the target outcomes, baseline-to post-intervention improvement in adaptive emotion regulation was associated with lower levels of clinical outcomes (e.g. psychological distress b = -1.15; 95%CI = -1.92 to -0.39) across time points. We could not detect indirect effects, but we observed associations of change in self-compassion and adaptive emotion regulation with outcomes at follow-up in the mediation analysis (e.g., β = -0.35, 95%CI = -0.52 to -0.16). If successfully targeted by interventions, self-compassion and emotion regulation may be promising putative therapeutic mechanisms of change.

A transdiagnostic approach to negative symptoms: exploring factor structure and negative symptoms in bipolar disorders

Background

Negative symptoms are increasingly recognized as transdiagnostic phenomena, linked to reduced quality of life and functioning, and often caused or worsened by amendable external factors such as depression, social deprivation, side-effects of antipsychotics or substance use. The structure of negative symptoms fits into two dimensions: diminished expression and apathy. These may differ in association with external factors that influence their severity and may thus require different treatment approaches. The dimensions are comprehensively established in non-affective psychotic disorders but are understudied in bipolar disorders.

Methods

We conducted exploratory and confirmatory factor analyses in a sample of 584 individuals with bipolar disorder to assess the latent factor structure of negative symptoms as measured by the Positive and Negative Syndrome Scale (PANSS), and performed correlational analyses and multiple hierarchical regression analyses to investigate links between the two dimensions of negative symptoms and clinical and sociodemographic correlates.

Results

The latent factor structure of negative symptoms fits into two dimensions, i.e., diminished expression and apathy. A diagnosis of bipolar type I or a history of psychotic episodes predicted more severe levels of diminished expression. Depressive symptoms were associated with more severe negative symptoms across dimensions, yet 26.3% of euthymic individuals still displayed at least one mild or more severe negative symptom (PANSS score ≥ 3).

Discussion

The two-dimensional structure of negative symptoms seen in non-affective psychotic disorders reproduces in bipolar disorders indicating similarities in their phenomenology. Diminished expression was associated with a history of psychotic episodes and a diagnosis of BD-I, which may infer closer connections to psychosis liability. We found significantly less severe negative symptoms in euthymic than depressed participants. Nevertheless, more than a quarter of the euthymic individuals had at least one mild negative symptom, demonstrating some degree of persistence beyond depressed states.

Psychotic-like experiences in general population: Psychiatric comorbidity and impact on quality of life across lifespan

BACKGROUND AND HYPOTHESIS

In this study, we aimed to determine the prevalence of Psychotics-Like Experiences according to age group and their association with psychiatric disorders through these different age-group, as well as their impact on quality of life.

STUDY DESIGN

Using data from the second wave of the NESARC, a large general population study, we considered 6 mutually exclusive groups according to the age at the interview: 20-29 years; 30-39 years; 40-49 years; 50-59 years; 60-69 years; 70+ years. We determined the frequency of PLEs defined as positive, negative, depressive, mania and disorganization symptoms with reference to the PANSS, and the association between the presence of PLEs in the previous year and the presence of lifetime psychiatric disorders and quality of life across different age groups.

STUDY RESULTS

The prevalence of PLEs decreased across age from a 34.7 % in the 20-29 years age group, to 19.7 % in the 70+ years age group. Across all age groups, individuals who reported PLEs in the previous year had higher risk of having any psychiatric disorder, (i.e any mood disorder, any anxiety disorder any substance abuse and any personality disorder) compared to individuals not reporting PLEs. All dimensions of quality of life on the SF12 scale were negatively associated with the presence of a PLE regardless of age group.

CONCLUSION

We found that the frequency of PLEs decreased with age and that the presence of PLE is associated with psychiatric disorders and with impaired quality of life in all age groups.

Stratification of adolescents across mental phenomena emphasizes the importance of transdiagnostic distress: a replication in two general population cohorts

Characterizing patterns of mental phenomena in epidemiological studies of adolescents can provide insight into the latent organization of psychiatric disorders. This avoids the biases of chronicity and selection inherent in clinical samples, guides models of shared aetiology within psychiatric disorders and informs the development and implementation of interventions. We applied Gaussian mixture modelling to measures of mental phenomena from two general population cohorts: the Avon Longitudinal Study of Parents and Children (ALSPAC, n = 3018) and the Neuroscience in Psychiatry Network (NSPN, n = 2023). We defined classes according to their patterns of both positive (e.g. wellbeing and self-esteem) and negative (e.g. depression, anxiety, and psychotic experiences) phenomena. Subsequently, we characterized classes by considering the distribution of diagnoses and sex split across classes. Four well-separated classes were identified within each cohort. Classes primarily differed by overall severity of transdiagnostic distress rather than particular patterns of phenomena akin to diagnoses. Further, as overall severity of distress increased, so did within-class variability, the proportion of individuals with operational psychiatric diagnoses. These results suggest that classes of mental phenomena in the general population of adolescents may not be the same as those found in clinical samples. Classes differentiated only by overall severity support the existence of a general, transdiagnostic mental distress factor and have important implications for intervention.

A Hybrid Ecological Momentary Compassion–Focused Intervention for Enhancing Resilience in Help-Seeking Young People: Prospective Study of Baseline Characteristics in the EMIcompass Trial

Background

Young people are a target population for mental health–related early intervention and prevention. Although evidence for early intervention is promising, availability of and access to youth mental health services remain limited. Therefore, the development of an evidence-based hybrid intervention is urgently needed.

Objective

This study aimed to present a manual for a hybrid intervention, combining an ecological momentary intervention and face-to-face sessions aimed for enhancing resilience in help-seeking young people based on compassion-focused interventions, and explore whether participants’ baseline characteristics are associated with putative mechanisms and outcomes of the EMIcompass intervention. Specifically, we aimed to explore initial signals as to whether participants’ sociodemographic, clinical, and functional characteristics at baseline are associated with putative mechanisms (ie, change in self-compassion, change in emotion regulation, working alliance, training frequency); and whether participants’ sociodemographic, clinical, and functional characteristics, self-compassion, and emotion regulation at baseline are associated with clinical outcomes (ie, psychological distress and general psychopathology at postintervention and 4-week follow-ups) in the experimental condition and obtain first parameter estimates.

Methods

We recruited young people aged 14 to 25 years, with psychological distress, Clinical High At-Risk Mental State, or first episodes of severe mental disorder for an exploratory randomized controlled trial with assessments at baseline and postintervention and 4-week follow-ups. A structured manual was developed and optimized based on a pilot study’s manual, a scoping review of existing literature and manuals, exchange with experts, the team’s clinical experience of working with compassion-focused interventions, and the principles of ecological momentary interventions. This analysis focuses on the experimental condition receiving the EMIcompass intervention.

Results

A total of 46 young individuals were randomized to the experimental condition. There was evidence for initial signals of effects of age (B=0.11, 95% CI 0.00-0.22), general psychopathology (B=0.08, 95% CI −0.01 to 0.16), and clinical stage (B=1.50, 95% CI 0.06-2.93) on change in momentary self-compassion and change in emotion regulation from baseline to postintervention assessments. There was no evidence for associations of other baseline characteristics (eg, gender, minority status, and level of functioning) and putative mechanisms (eg, overall self-compassion, working alliance, and training frequency). In addition, except for an initial signal for an association of momentary self-compassion at baseline and psychological distress (B=−2.83, 95% CI −5.66 to 0.00), we found no evidence that baseline characteristics related to clinical outcomes.

Conclusions

The findings indicated the reach of participants by the intervention largely independent of sociodemographic, clinical, and functional baseline characteristics. The findings need to be confirmed in a definitive trial.

Trial Registration

German Clinical Trials Register NDRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265

International Registered Report Identifier (IRRID)

RR2-10.2196/27462

Affective symptom dimensions in early-onset psychosis over time: a principal component factor analysis of the Young Mania Rating Scale and the Hamilton Depression Rating Scale

Early-onset psychosis (EOP) is a complex disorder characterized by a wide range of symptoms, including affective symptoms. Our aim was to (1) examine the dimensional structure of affective symptoms in EOP, (2) evaluate the predominance of the clinical dimensions and (3) assess the progression of the clinical dimensions over a 2-year period. STROBE-compliant prospective principal component factor analysis of Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale-21 (HDRS-21) at baseline, 6-months, 1-year and 2-year follow-up. We included 108 EOP individuals (mean age = 15.5 ± 1.8 years, 68.5% male). The factor analysis produced a four-factor model including the following dimensions: mania, depression/anxiety, sleep and psychosis. It explained 47.4% of the total variance at baseline, 60.6% of the total variance at 6-months follow-up, 54.5% of the total variance at 1-year follow-up and 49.5% of the total variance at 2-year follow-up. According to the variance explained, the mania factor was predominant at baseline (17.4%), 6-month follow-up (23.5%) and 2-year follow-up (26.1%), while the depression/anxiety factor was predominant at 1-year follow-up (23.1%). The mania factor was the most stable; 58.3% items that appeared in this factor (with a load > 0.4) at any time point appeared in the same factor at ≥ 3/4 time points. Affective symptoms are frequent and persistent in EOP. Mania seems to be the most predominant and stable affective dimension. However, depression and anxiety may gain predominance with time. A comprehensive evaluation of the dimensional structure and the progression of affective symptoms may offer clinical and therapeutic advantages.

Effects of a Novel, Transdiagnostic, Hybrid Ecological Momentary Intervention for Improving Resilience in Youth (EMIcompass): Protocol for an Exploratory Randomized Controlled Trial

BACKGROUND

Most mental disorders first emerge in youth and, in their early stages, surface as subthreshold expressions of symptoms comprising a transdiagnostic phenotype of psychosis, mania, depression, and anxiety. Elevated stress reactivity is one of the most widely studied mechanisms underlying psychotic and affective mental health problems. Thus, targeting stress reactivity in youth is a promising indicated and translational preventive strategy for adverse mental health outcomes that could develop later in life and for improving resilience. Compassion-focused interventions offer a wide range of innovative therapeutic techniques that are particularly amenable to being implemented as ecological momentary interventions (EMIs), a specific type of mobile health intervention, to enable youth to access interventions in a given moment and context in daily life. This approach may bridge the current gap in youth mental health care.

OBJECTIVE

This study aims to investigate the clinical feasibility, candidate underlying mechanisms, and initial signals of the efficacy of a novel, transdiagnostic, hybrid EMI for improving resilience to stress in youth-EMIcompass.

METHODS

In an exploratory randomized controlled trial, youth aged between 14 and 25 years with current distress, a broad Clinical High At-Risk Mental State, or the first episode of a severe mental disorder will be randomly allocated to the EMIcompass intervention (ie, EMI plus face-to-face training sessions) in addition to treatment as usual or a control condition of treatment as usual only. Primary (stress reactivity) and secondary candidate mechanisms (resilience, interpersonal sensitivity, threat anticipation, negative affective appraisals, and momentary physiological markers of stress reactivity), as well as primary (psychological distress) and secondary outcomes (primary psychiatric symptoms and general psychopathology), will be assessed at baseline, postintervention, and at the 4-week follow-up.

RESULTS

The first enrollment was in August 2019, and as of May 2021, enrollment and randomization was completed (N=92). We expect data collection to be completed by August 2021.

CONCLUSIONS

This study is the first to establish feasibility, evidence on underlying mechanisms, and preliminary signals of the efficacy of a compassion-focused EMI in youth. If successful, a confirmatory randomized controlled trial will be warranted. Overall, our approach has the potential to significantly advance preventive interventions in youth mental health provision.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27462.

Global fractional anisotropy predicts transition to psychosis after 12 months in individuals at ultra-high risk for psychosis

OBJECTIVE

Psychosis spectrum disorders are associated with cerebral changes, but the prognostic value and clinical utility of these findings are unclear. Here, we applied a multivariate statistical model to examine the predictive accuracy of global white matter fractional anisotropy (FA) for transition to psychosis in individuals at ultra-high risk for psychosis (UHR).

METHODS

110 UHR individuals underwent 3 Tesla diffusion-weighted imaging and clinical assessments at baseline, and after 6 and 12 months. Using logistic regression, we examined the reliability of global FA at baseline as a predictor for psychosis transition after 12 months. We tested the predictive accuracy, sensitivity and specificity of global FA in a multivariate prediction model accounting for potential confounders to FA (head motion in scanner, age, gender, antipsychotic medication, parental socioeconomic status and activity level). In secondary analyses, we tested FA as a predictor of clinical symptoms and functional level using multivariate linear regression.

RESULTS

Ten UHR individuals had transitioned to psychosis after 12 months (9%). The model reliably predicted transition at 12 months (χ²  = 17.595, p = 0.040), accounted for 15-33% of the variance in transition outcome with a sensitivity of 0.70, a specificity of 0.88 and AUC of 0.87. Global FA predicted level of UHR symptoms (R²  = 0.055, F = 6.084, p = 0.016) and functional level (R²  = 0.040, F = 4.57, p = 0.036) at 6 months, but not at 12 months.

CONCLUSION

Global FA provided prognostic information on clinical outcome and symptom course of UHR individuals. Our findings suggest that the application of prediction models including neuroimaging data can inform clinical management on risk for psychosis transition.

On top or underneath: where does the general factor of psychopathology fit within a dimensional model of psychopathology?

BACKGROUND

Dimensional models of psychopathology are increasingly common and there is evidence for the existence of a general dimension of psychopathology ('p'). The existing literature presents two ways to model p: as a bifactor or as a higher-order dimension. Bifactor models typically fit sample data better than higher-order models, and are often selected as better fitting alternatives but there are reasons to be cautious of such an approach to model selection. In this study the bifactor and higher-order models of p were compared in relation to associations with established risk variables for mental illness.

METHODS

A trauma exposed community sample from the United Kingdom (N = 1051) completed self-report measures of 49 symptoms of psychopathology.

RESULTS

A higher-order model with four first-order dimensions (Fear, Distress, Externalising and Thought Disorder) and a higher-order p dimension provided satisfactory model fit, and a bifactor representation provided superior model fit. Bifactor p and higher-order p were highly correlated (r = 0.97) indicating that both parametrisations produce near equivalent general dimensions of psychopathology. Latent variable models including predictor variables showed that the risk variables explained more variance in higher-order p than bifactor p. The higher-order model produced more interpretable associations for the first-order/specific dimensions compared to the bifactor model.

CONCLUSIONS

The higher-order representation of p, as described in the Hierarchical Taxonomy of Psychopathology, appears to be a more appropriate way to conceptualise the general dimension of psychopathology than the bifactor approach. The research and clinical implications of these discrepant ways of modelling p are discussed.

The Community Assessment of Psychic Experiences-Positive scale (CAPE-P15) accurately classifies and differentiates psychotic experience levels in adolescents from the general population

Background

There is increasing interest in studying psychotic symptoms in non-clinical populations, with the Community Assessment of Psychic Experiences-Positive scale (CAPE-P15) being one of the self-screening questionnaires used most commonly for this purpose. Further research is needed to evaluate the ability of the scale to accurately identify and classify positive psychotic experiences (PE) in the general population.

Aim

To provide psychometric evidence about the accuracy of the CAPE-P15 for detecting PE in a sample of Chilean adolescents from the general population and classifying them according to their PE severity levels.

Method

We administered the CAPE-P15 to a general sample of 1594 students aged 12 to 19. Based on Item Response Theory (IRT), we tested the accuracy of the instrument using two main parameters: difficulty and discrimination power of the 15 items.

Results

We found that the scale provides very accurate information about PE, particularly for high PE levels. The items with the highest capability to determine the presence of the latent trait were those assessing perceptual anomalies (auditory and visual hallucinations), bizarre experiences (a double has taken the place of others; being controlled by external forces), and persecutory ideation (conspiracy against me).

Conclusions

The CAPE-P15 is an accurate and suitable tool to screen PE and to accurately classify and differentiate PE levels in adolescents from the general population. Further research is needed to better understand how maladaptive psychological mechanisms influence relationships between PE and suicidal ideation (SI) in the general population.

Predicting Long-Term Outcomes in First-Admission Psychosis: Does the Hierarchical Taxonomy of Psychopathology Aid DSM in Prognostication?

The Hierarchical Taxonomy of Psychopathology (HiTOP) is an empirical, dimensional model of psychological symptoms and functioning. Its goals are to augment the use and address the limitations of traditional diagnoses, such as arbitrary thresholds of severity, within-disorder heterogeneity, and low reliability. HiTOP has made inroads to addressing these problems, but its prognostic validity is uncertain. The present study sought to test the prediction of long-term outcomes in psychotic disorders was improved when the HiTOP dimensional approach was considered along with traditional (ie, DSM) diagnoses. We analyzed data from the Suffolk County Mental Health Project (N = 316), an epidemiologic study of a first-admission psychosis cohort followed for 20 years. We compared 5 diagnostic groups (schizophrenia/schizoaffective, bipolar disorder with psychosis, major depressive disorder with psychosis, substance-induced psychosis, and other psychoses) and 5 dimensions derived from the HiTOP thought disorder spectrum (reality distortion, disorganization, inexpressivity, avolition, and functional impairment). Both nosologies predicted a significant amount of variance in most outcomes. However, except for cognitive functioning, HiTOP showed consistently greater predictive power across outcomes-it explained 1.7-fold more variance than diagnoses in psychiatric and physical health outcomes, 2.1-fold more variance in community functioning, and 3.4-fold more variance in neural responses. Even when controlling for diagnosis, HiTOP dimensions incrementally predicted almost all outcomes. These findings support a shift away from the exclusive use of categorical diagnoses and toward the incorporation of HiTOP dimensions for better prognostication and linkage with neurobiology.

A Compassion-Focused Ecological Momentary Intervention for Enhancing Resilience in Help-Seeking Youth: Uncontrolled Pilot Study

BACKGROUND

Digital interventions offer new avenues for low-threshold prevention and treatment in young people. Ecological momentary interventions (EMIs) represent a powerful approach that allows for adaptive, real-time, and real-world delivery of intervention components in daily life by real-time processing of ecological momentary assessment (EMA) data. Compassion-focused interventions (CFIs) may be particularly amenable to translation into an EMI to strengthen emotional resilience and modify putative risk mechanisms, such as stress sensitivity, in the daily lives of young help-seeking individuals.

OBJECTIVE

This study aims to investigate the feasibility, safety, and initial therapeutic effects of a novel, accessible, transdiagnostic, ecological momentary CFI for improving emotional resilience to stress (EMIcompass).

METHODS

In this uncontrolled pilot study, help-seeking youth with psychotic, depressive, or anxiety symptoms were offered the EMIcompass intervention in addition to treatment as usual. The EMIcompass intervention consisted of a 3-week EMI (including enhancing, consolidating, and EMA-informed interactive tasks) administered through a mobile health app and three face-to-face sessions with a trained psychologist intended to provide guidance and training on the CFI exercises presented in the app (ie, training session, follow-up booster session, and review session).

RESULTS

In total, 10 individuals (mean age 20.3 years, SD 3.8; range 14-25) were included in the study. Most (8/10, 80%) participants were satisfied and reported a low burden of app usage. No adverse events were observed. In approximately one-third of all EMAs, individuals scored high on stress, negative affect, or threat anticipation during the intervention period, resulting in real-time, interactive delivery of the CFI intervention components in addition to weekly enhancing and daily consolidating tasks. Although the findings should be interpreted with caution because of the small sample size, reduced stress sensitivity, momentary negative affect, and psychotic experiences, along with increased positive affect, were found at postintervention and the 4-week follow-up. Furthermore, reductions in psychotic, anxiety, and depressive symptoms were found (r=0.30-0.65).

CONCLUSIONS

Our findings provide evidence on the feasibility and safety of the EMIcompass intervention for help-seeking youth and lend initial support to beneficial effects on stress sensitivity and mental health outcomes. An exploratory randomized controlled trial is warranted to establish the feasibility and preliminary evidence of its efficacy.

Meta-analytic exploration of the joint factors of the Brief Psychiatric Rating Scale - Expanded (BPRS-E) and the positive and negative symptoms scales (PANSS)

Previous meta-analyses of the BPRS-E and PANSS were combined to analyze the joint factors across 77 factor analyses from 68 studies of 32,896 individuals. The BPRS-E and PANSS share the 18 original BPRS items and each has additional unique items (6 BPRS-E and 12 PANSS). Based on the combined data across the BPRS-E and PANSS four separate sets of factor analyses were conducted using sample weighting (weighted and unweighted) and matrix type (similarity coefficients and reproduced correlations). Five factors: Positive Symptoms, Affect, Negative Symptoms, Disorganization and Activation-Mania were consistent across all solutions. The factors Positive Symptoms and Affect were defined primarily by the original 18 BPRS items. The factors Negative Symptoms and Disorganization were largely defined by the PANSS additional items. The Activation-Mania factor was largely defined by the additional BPRS-E items. The results were similar to those found in previous meta-analyses but the current factors were substantially more comprehensive and better defined because they included all the items from both the BPRS-E and the PANSS. Future research should consider using all the items from both the PANSS and BPRS-E as the unique items from each scale improve the assessment and measurement of these factors.

Exploring the Psychometric Properties and the Factor Structure of the Calgary Depression Scale for Schizophrenia Across the Schizotypy Continuum

This study evaluated the psychometric properties and factor structure of the Calgary Depression Scale for Schizophrenia (CDSS) across different levels of the schizotypy continuum. A combined sample of high-schizotypy, at-risk mental states, and patients with first-episode psychosis was assessed for depression and other clinical and functional outcomes. Additionally, experience sampling methodology was used to assess depressive and psychotic-like experiences in daily life. The CDSS exhibited solid internal consistency, validity, and discrimination between depressed and nondepressed participants. Confirmatory factor analyses and the associations of the resulting factors with clinical and functional measures supported a two-factor structure that included general depression and guilt factors. Furthermore, both factors of the CDSS were differentially related to positive and negative symptoms of psychosis in daily life. The CDSS appears to have two underlying psychopathological dimensions and to be a reliable and valid measure for assessing depression across the schizotypy continuum.

Estimated Proportions and Characteristics of National Survey Respondents Reporting New Diagnoses of Schizophrenia or Other Psychoses in the Past Year as Compared With Prior Years

Epidemiologic data on first-episode psychosis is limited due to the infrequency of cases in the general population. This study uses the National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36,309) to examine population-based estimates of early psychosis based on adults who report a first-time diagnosis of schizophrenia from a doctor in the past year and compares them with those receiving diagnoses in previous years. Altogether, 60 respondents reported past-year schizophrenia (170 per 100,000) or 6.7% of 901 with any reported schizophrenia. Mean age was 41.4 ± 2.1, and they reported significantly higher rates of any past-year substance use disorder (44.7%) than individuals diagnosed in previous years (27.7%), specifically alcohol use disorder. Compared with other samples (many of which excluded older adults), this study suggests that early psychosis may affect older populations more than previously recognized, but comorbidity with substance use disorders showed similar elevations.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a scientific effort to address shortcomings of traditional mental disorder diagnoses, which suffer from arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. This paper synthesizes evidence on the validity and utility of the thought disorder and detachment spectra of HiTOP. These spectra are composed of symptoms and maladaptive traits currently subsumed within schizophrenia, other psychotic disorders, and schizotypal, paranoid and schizoid personality disorders. Thought disorder ranges from normal reality testing, to maladaptive trait psychoticism, to hallucinations and delusions. Detachment ranges from introversion, to maladaptive detachment, to blunted affect and avolition. Extensive evidence supports the validity of thought disorder and detachment spectra, as each spectrum reflects common genetics, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, biomarkers, and treatment response. Some of these characteristics are specific to one spectrum and others are shared, suggesting the existence of an overarching psychosis superspectrum. Further research is needed to extend this model, such as clarifying whether mania and dissociation belong to thought disorder, and explicating processes that drive development of the spectra and their subdimensions. Compared to traditional diagnoses, the thought disorder and detachment spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and higher acceptability to clinicians. Validated measures are available to implement the system in practice. The more informative, reliable and valid characterization of psychosis-related psychopathology offered by HiTOP can make diagnosis more useful for research and clinical care.

Affective dimensions as a diagnostic tool for bipolar disorder in first psychotic episodes

Objective

To examine the predictive diagnostic value of affective symptomatology in a first-episode psychosis (FEP) sample with 5 years’ follow-up.

Method

Affective dimensions (depressive, manic, activation, dysphoric) were measured at baseline and 5 years in 112 FEP patients based on a factor structure analysis using the Young Mania Rating Scale and Hamilton Depression Rating Scale. Patients were classified as having a diagnosis of bipolar disorder at baseline (BDi), bipolar disorder at 5 years (BDf), or “other psychosis”. The ability of affective dimensions to discriminate between these diagnostic groups and to predict a bipolar disorder diagnosis was analysed.

Results

Manic dimension score was higher in BDi vs. BDf, and both groups had higher manic and activation scores vs. “other psychosis”. Activation dimension predicted a bipolar diagnosis at 5 years (odds ratio = 1.383; 95% confidence interval, 1.205–1.587; P = 0.000), and showed high levels of sensitivity (86.2%), specificity (71.7%), positive (57.8%) and negative predictive value (90.5%). Absence of the manic dimension and presence of the depressive dimension were both significant predictors of an early misdiagnosis.

Conclusion

The activation dimension is a diagnostic predictor for bipolar disorder in FEP. The manic dimension contributes to a bipolar diagnosis and its absence can lead to early misdiagnosis.

Factor analyses of multidimensional symptoms in a large group of patients with major depressive disorder, bipolar disorder, schizoaffective disorder and schizophrenia

BACKGROUND

There is an ongoing discussion about which neurobiological correlates or symptoms separate the major psychoses (i.e. Major Depressive Disorder MDD, Bipolar Disorder BD, and Schizophrenia SZ). Psychopathological factor analyses within one of these disorders have resulted in models including one to five factors. Factor analyses across the major psychoses using a comprehensive set of psychopathological scales in the same patients are lacking. It is further unclear, whether hierarchical or unitarian models better summarize phenomena.

METHOD

Patients (n = 1182) who met DSM-IV criteria for MDD, BD, SZ or schizoaffective disorder were assessed with the SANS, SAPS, HAMA, HAM-D, and YMRS. The sample was split into two and analyzed using explorative and confirmatory factor analyses to extract psychopathological factors independent of diagnosis.

RESULTS

In the exploratory analysis of sample 1 (n = 593) we found 5 factors. The confirmatory analysis using sample 2 (n = 589) confirmed the 5-factor model (χ² = 1287.842, df = 571, p < .0001: CFI = 0.932; RMSEA = 0.033). The 5-factors were depression, negative syndrome, positive formal thought disorder, paranoid-hallucinatory syndrome, and increased appetite. Increased appetite was not related to medication. None of the factors was specific for one diagnosis. Second order factor analysis revealed two higher order factors: negative/affective (I) and positive symptoms (II).

CONCLUSION

This is the first study delineating psychopathological factors in a large group of patients across the spectrum of affective and psychotic disorders. In future neurobiological studies, we should consider transdiagnostic syndromes besides the traditional diagnoses.

Does physical activity reduce the risk of psychosis? A systematic review and meta-analysis of prospective studies

Longitudinal prospective cohorts have suggested that physical activity (PA) may be a protective factor against psychosis and schizophrenia. However, no meta-analysis has been conducted. The study aims to examine the prospective relationship between PA and incident psychosis/schizophrenia. Major databases were searched from inception to July 2019 for prospective studies that calculated the odds ratio (OR) or the adjusted odds ratio (AOR) of incident psychosis/schizophrenia in people with higher PA against people with lower PA. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects meta-analysis was conducted, for OR and AOR, separately. Across 4 cohorts (N = 30,025 median males = 50%, median follow-up = 32 years), people with high self-reported PA (versus low PA) were at reduced odds of developing psychosis/schizophrenia (OR = 0.73, 95%CI 0.532 to 0.995, p = 0.047). Analysis including 2 cohorts presenting AOR were not statistically significant (AOR = 0.59, 95%CI 0.253 to 1.383, p = 0.226). Overall study quality was high (mean NOS = 7.0). The literature on the topic is scarce, whilst crude analysis suggests that PA may be a protective factor against the emergence of psychosis/schizophrenia, but when adjusting for covariates, the association is no longer significant. Further studies with objective physical activity and adjustment for confounders are needed.

Ontological insecurity I: Psychometric development of a new measure and relationship to subclinical psychotic-like experiences

OBJECTIVES

The present study sought to develop a new psychometrically sound measure of ontological insecurity, the OIS-34 and, determine its relationship with subclinical psychotic-like experiences (PLEs).

METHODS

A nonclinical sample (N = 600) completed an initial 60-item version of the new scale along with measures of PLEs, psychosis proneness, and mental health history.

RESULTS

Exploratory factor analysis indicated a single factor, ontological insecurity, with 34 items loading positively and above a criterion of 0.4. Internal consistency and test-retest reliability were excellent. The OIS-34 correlated positively and significantly with psychosis proneness and subclinical positive and negative symptom PLEs. The OIS-34 also differentiated significantly between participants with and without a history of mental health problems, including psychosis.

CONCLUSIONS

The OIS-34 appears to represent a psychometrically sound measure of ontological insecurity. The results suggest that the concept is associated with PLEs. Directions for further research are discussed.

Reasoning bias, working memory performance and a transdiagnostic phenotype of affective disturbances and psychotic experiences in the general population

BACKGROUND

The jumping to conclusions (JTC) reasoning bias and decreased working memory performance (WMP) are associated with psychosis, but associations with affective disturbances (i.e. depression, anxiety, mania) remain inconclusive. Recent findings also suggest a transdiagnostic phenotype of co-occurring affective disturbances and psychotic experiences (PEs). This study investigated whether JTC bias and decreased WMP are associated with co-occurring affective disturbances and PEs.

METHODS

Data were derived from the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2). Trained interviewers administered the Composite International Diagnostic Interview (CIDI) at three time points in a general population sample (N = 4618). The beads and digit-span task were completed to assess JTC bias and WMP, respectively. CIDI was used to measure affective disturbances and an add-on instrument to measure PEs.

RESULTS

Compared to individuals with neither affective disturbances nor PEs, the JTC bias was more likely to occur in individuals with co-occurring affective disturbances and PEs [moderate psychosis (1-2 PEs): adjusted relative risk ratio (RRR) 1.17, 95% CI 0.98-1.41; and high psychosis (3 or more PEs or psychosis-related help-seeking behaviour): adjusted RRR 1.57, 95% CI 1.19-2.08], but not with affective disturbances and PEs alone, whereas decreased WMP was more likely in all groups. There was some evidence of a dose-response relationship, as JTC bias and decreased WMP were more likely in individuals with affective disturbances as the level of PEs increased or help-seeking behaviour was reported.

CONCLUSION

The findings suggest that JTC bias and decreased WMP may contribute to a transdiagnostic phenotype of co-occurring affective disturbances and PEs.

The Diagnostic Dilemma of Psychosis: Reviewing the Historical Case of Pseudoneurotic Schizophrenia

The term "pseudoneurotic schizophrenia" was introduced in 1949 by Hoch and Polatin to describe apparently neurotic patients showing formal thought disorders, emotional dysregulation, and transient psychotic symptoms. Even if this diagnostic entity is no longer included in modern diagnostic systems, its evolution is intertwined with the history of schizophrenia in the 20th century. This article retraces the development of pseudoneurotic (or "borderline") schizophrenia in modern psychiatry, finding it a pioneering concept in psychopathology. In particular, we demonstrate that recent findings about the positive syndrome, good-outcome, type I "distress" subtype of schizophrenia (associated with high emotionality, including anxiety, depression, and sensitivity to stress) show surprising consistency with the clinical concept of pseudoneurotic schizophrenia. Finally, we discuss the historical development of pseudoneurotic schizophrenia in modern psychiatry as a meaningful example of the difficulty of confining severe psychological disturbances lying at the edge of full-blown schizophrenia within a widely accepted diagnostic category.

Liberal Acceptance Bias, Momentary Aberrant Salience, and Psychosis: An Experimental Experience Sampling Study

Cognitive models of psychosis posit that reasoning biases are an important mechanism contributing to the formation of psychotic symptoms, in part through transforming anomalous experiences of aberrant salience into frank psychotic symptoms. This study aimed to investigate the interplay of liberal acceptance (LA) bias, which is a specific type of reasoning bias, and momentary aberrant salience in the development of paranoid and psychotic experiences in daily life in first-episode psychosis patients (FEP), at-risk mental state participants (ARMS), and controls. We used a novel experimental Experience Sampling Methodology (eESM) task for measuring LA bias (ie, decisions based on low probability estimates) and ESM measures of momentary aberrant salience and paranoid and psychotic experiences in 51 FEP, 46 ARMS, and 53 controls. We found evidence that LA bias was more likely to occur in FEP than in controls. Further, LA bias was associated with psychotic and paranoid experiences (all P < .007) and modified the association between momentary aberrant salience and psychotic experiences (χ2(df) = 7.4(2), P = .025) in ARMS, such that momentary salience was associated with more intense psychotic experiences in the presence of LA bias in ARMS, but not in FEP and controls. Our findings suggest that LA bias may be central for anomalous experiences such as momentary aberrant salience to increase intensity of psychotic experiences in at-risk individuals. Further, LA bias appears to be more likely to be present, but not directly linked to current intensity of psychotic experiences, in treated FEP. Novel eESM tasks open new avenues for targeting psychological processes under real-world conditions.

Childhood abuse and psychotic experiences - evidence for mediation by adulthood adverse life events

AIMS

We have previously reported an association between childhood abuse and psychotic experiences (PEs) in survey data from South East London. Childhood abuse is related to subsequent adulthood adversity, which could form one pathway to PEs. We aimed to investigate evidence of mediation of the association between childhood abuse and PEs by adverse life events.

METHODS

Data were analysed from the South East London Community Health Study (SELCoH, n = 1698). Estimates of the total effects on PEs of any physical or sexual abuse while growing up were partitioned into direct (i.e. unmediated) and indirect (total and specific) effects, mediated via violent and non-violent life events.

RESULTS

There was strong statistical evidence for direct (OR 1.58, 95% CI: 1.19-2.1) and indirect (OR 1.51, 95% CI: 1.32-1.72) effects of childhood abuse on PEs after adjustment for potential confounders, indicating partial mediation of this effect via violent and non-violent life events. An estimated 47% of the total effect of abuse on PEs was mediated via adulthood adverse life events, of which violent life events made up 33% and non-violent life events the remaining 14%.

CONCLUSIONS

The association between childhood abuse and PEs is partly mediated through the experience of adverse life events in adulthood. There is some evidence that a larger proportion of this effect was mediated through violent life events than non-violent life events.

Transdiagnostic dimensions of psychopathology at first episode psychosis: findings from the multinational EU-GEI study

BACKGROUND

The value of the nosological distinction between non-affective and affective psychosis has frequently been challenged. We aimed to investigate the transdiagnostic dimensional structure and associated characteristics of psychopathology at First Episode Psychosis (FEP). Regardless of diagnostic categories, we expected that positive symptoms occurred more frequently in ethnic minority groups and in more densely populated environments, and that negative symptoms were associated with indices of neurodevelopmental impairment.

METHOD

This study included 2182 FEP individuals recruited across six countries, as part of the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study. Symptom ratings were analysed using multidimensional item response modelling in Mplus to estimate five theory-based models of psychosis. We used multiple regression models to examine demographic and context factors associated with symptom dimensions.

RESULTS

A bifactor model, composed of one general factor and five specific dimensions of positive, negative, disorganization, manic and depressive symptoms, best-represented associations among ratings of psychotic symptoms. Positive symptoms were more common in ethnic minority groups. Urbanicity was associated with a higher score on the general factor. Men presented with more negative and less depressive symptoms than women. Early age-at-first-contact with psychiatric services was associated with higher scores on negative, disorganized, and manic symptom dimensions.

CONCLUSIONS

Our results suggest that the bifactor model of psychopathology holds across diagnostic categories of non-affective and affective psychosis at FEP, and demographic and context determinants map onto general and specific symptom dimensions. These findings have implications for tailoring symptom-specific treatments and inform research into the mood-psychosis spectrum.

Transdiagnostic dimensions of psychosis in the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP)

The validity of the classification of non-affective and affective psychoses as distinct entities has been disputed, but, despite calls for alternative approaches to defining psychosis syndromes, there is a dearth of empirical efforts to identify transdiagnostic phenotypes of psychosis. We aimed to investigate the validity and utility of general and specific symptom dimensions of psychosis cutting across schizophrenia, schizoaffective disorder and bipolar I disorder with psychosis. Multidimensional item-response modeling was conducted on symptom ratings of the Positive and Negative Syndrome Scale, Young Mania Rating Scale, and Montgomery-Åsberg Depression Rating Scale in the multicentre Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium, which included 933 patients with a diagnosis of schizophrenia (N=397), schizoaffective disorder (N=224), or bipolar I disorder with psychosis (N=312). A bifactor model with one general symptom dimension, two distinct dimensions of non-affective and affective psychosis, and five specific symptom dimensions of positive, negative, disorganized, manic and depressive symptoms provided the best model fit. There was further evidence on the utility of symptom dimensions for predicting B-SNIP psychosis biotypes with greater accuracy than categorical DSM diagnoses. General, positive, negative and disorganized symptom dimension scores were higher in African American vs. Caucasian patients. Symptom dimensions accurately classified patients into categorical DSM diagnoses. This study provides evidence on the validity and utility of transdiagnostic symptom dimensions of psychosis that transcend traditional diagnostic boundaries of psychotic disorders. Findings further show promising avenues for research at the interface of dimensional psychopathological phenotypes and basic neurobiological dimensions of psychopathology.

Dopamine and Working Memory: Genetic Variation, Stress and Implications for Mental Health

At the molecular level, the neurotransmitter dopamine (DA) is a key regulatory component of executive function in the prefrontal cortex (PFC) and dysfunction in dopaminergic (DAergic) circuitry has been shown to result in impaired working memory (WM). Research has identified multiple common genetic variants suggested to impact on the DA system functionally and also behaviourally to alter WM task performance. In addition, environmental stressors impact on DAergic tone, and this may be one mechanism by which stressors confer vulnerability to the development of neuropsychiatric conditions. This chapter aims to evaluate the impact of key DAergic gene variants suggested to impact on both synaptic DA levels (COMT, DAT1, DBH, MAOA) and DA receptor function (ANKK1, DRD2, DRD4) in terms of their influence on visuospatial WM. The role of stressors and interaction with the genetic background is discussed in addition to discussion around some of the implications for precision psychiatry. This and future work in this area aim to disentangle the neural mechanisms underlying susceptibility to stress and their impact and relationship with cognitive processes known to influence mental health vulnerability.

Izmir Mental Health Cohort for Gene-Environment Interaction in Psychosis (TürkSch): Assessment of the Extended and Transdiagnostic Psychosis Phenotype and Analysis of Attrition in a 6-Year Follow-Up of a Community-Based Sample

Objective: TürkSch is a prospective, longitudinal study in a representative community sample (İzmir, Turkey), consisting of several data collection stages, to screen and follow-up mental health outcomes, with a special focus on the extended and transdiagnostic psychosis phenotype. The aim of the present paper is to describe the research methodology, data collection results, and associations with noncontact and refusal in the longitudinal arm. Methods: Households were contacted in a multistage clustered probability sampling frame, covering 11 districts and 302 neighborhoods at baseline (n = 4,011) and at 6-year follow-up (n = 2,185). Both at baseline and at follow-up, participants were interviewed with the Composite International Diagnostic Interview. Participants with probable psychotic disorder were reinterviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID)-I either at the hospital or at the participant's residence. Relevant neighborhood-level measures were assessed in a separate sample (n = 5,124) in addition to individual-level measures. Candidate gene-by-environment interactions were investigated using two nested case-control studies. Results: Individuals with a mental health problem had lower refusal rates. Older and lower educated individuals had a lower probability of noncontact. Discussion: The TürkSch study has an advanced design to meet the challenges of evaluating the multidimensional etiological and phenomenological nature of the extended and transdiagnostic psychosis phenotype.

The component structure of the scales for the assessment of positive and negative symptoms in first-episode psychosis and its dependence on variations in analytic methods

A secondary analysis was undertaken on Scales for the Assessment of Positive and Negative Symptoms (SAPS/SANS) data from 345 first-episode psychosis (FEP) patients gathered in the West London FEP study. The purpose of this study was to determine: (i) the component structure of these measures in FEP (primary analyses), and (ii) the dependence of any findings in these primary analyses on variations in analytic methods. Symptom ratings were exposed to data reduction methods and the effects of the following manipulations ascertained: (i) level of analysis (individual symptom vs. global symptom severity ratings), (ii) extraction method (principal component vs. exploratory factor analysis) and (iii) retention method (scree test vs. Kaiser criterion). Whilst global ratings level analysis rendered the classic triad of psychotic syndromes (positive, negative and disorganisation), symptom level analyses revealed a hierarchical structure, with 11 first-order components subsumed by three second-order components, which also mapped on to this syndrome triad. These results were robust across data reduction but not component retention methods, suggesting that discrepancies in the literature regarding the component structure of the SAPS/SANS partly reflect the level of analysis and component retention method used. Further, they support a hierarchical symptom model, the implications of which are discussed.

Search for protective factors for psychosis - a population-based sample with special interest in unaffected individuals with parental psychosis

AIM

To find factors that are associated with not having psychotic illness in a prospective general population sample, with a special interest in individuals with parental psychosis.

METHODS

Data from the Northern Finland Birth Cohort 1966 (n = 10 458) and several registers were used to detect individuals with and without parental psychosis. Altogether, 594 persons had parent(s) with psychosis and 48 of them also had psychosis subsequently. Variables related to pregnancy and birth, family and childhood, health and habits in adolescence, school performance and physical activity were studied to identify determinants of unaffected status among individuals with and without parental psychosis.

RESULTS

In the parental psychosis group, the unaffected persons had more likely a mother who was non-depressed during pregnancy, and who worked outside the home or studied than among those who developed psychosis.

CONCLUSIONS

Protective factors for psychosis were surprisingly few in this sample. These factors were related to the mother's non-depressed mood and the mother's work outside the home or studies. This could relate to better health and functioning of a mother. This work highlights the need for more research on protective factors for psychosis in order to identify methods for prevention of psychosis.

Bifactor Modeling of the Positive and Negative Syndrome Scale: Generalized Psychosis Spans Schizoaffective, Bipolar, and Schizophrenia Diagnoses

OBJECTIVE

Common genetic variation spans schizophrenia, schizoaffective and bipolar disorders, but historically, these syndromes have been distinguished categorically. A symptom dimension shared across these syndromes, if such a general factor exists, might provide a clearer target for understanding and treating mental illnesses that share core biological bases.

METHOD

We tested the hypothesis that a bifactor model of the Positive and Negative Syndrome Scale (PANSS), containing 1 general factor and 5 specific factors (positive, negative, disorganized, excited, anxiety), explains the cross-diagnostic structure of symptoms better than the traditional 5-factor model, and examined the extent to which a general factor reflects the overall severity of symptoms spanning diagnoses in 5094 total patients with a diagnosis of schizophrenia, schizoaffective, and bipolar disorder.

RESULTS

The bifactor model provided superior fit across diagnoses, and was closer to the "true" model, compared to the traditional 5-factor model (Vuong test; P < .001). The general factor included high loadings on 28 of the 30 PANSS items, omitting symptoms associated with the excitement and anxiety/depression domains. The general factor had highest total loadings on symptoms that are often associated with the positive and disorganization syndromes, but there were also substantial loadings on the negative syndrome thus leading to the interpretation of this factor as reflecting generalized psychosis.

CONCLUSIONS

A bifactor model derived from the PANSS can provide a stronger framework for measuring cross-diagnostic psychopathology than a 5-factor model, and includes a generalized psychosis dimension shared at least across schizophrenia, schizoaffective, and bipolar disorder.

The factor structure of the short form of the Wisconsin schizotypy scales

The Chapman psychosis-proneness scales-also known as Wisconsin schizotypy scales (WSS)-are among the most used tools to measure schizotypy. The factor structure of the short-form WSS was investigated in a mixed sample of patients with chronic mental disorders and of healthy subjects from the general population. One hundred patients with a chronic mental disorder were enrolled over a 6-month period. For each patient, two controls of same sex and similar age (±5 years) were enrolled; 131 accepted to take part in the study. The unidimensional, the correlated four-factor, the second-order two-factor models, and the bifactor model with two or four orthogonally independent factors of the short-form WSS were tested with confirmatory factor analysis. Good reliability of the short-form WSS was confirmed, as its capacity of differentiating people with and without schizotypy. The bifactor models were superior to other models. However, in both bifactor models the explained common variance (ECV) attributable to the general factor and the percentage of uncontaminated correlations (PUC) were too low to use a general summary score as a measure of a single latent schizotypy variable. Symptoms scores derived from the short-form WSS can be better appreciated within a multidimensional model of schizotypy.

Symptom dimensions and subgroups in childhood-onset schizophrenia

OBJECTIVE

This study investigated symptom dimensions and subgroups in the National Institute of Mental Health (NIMH) childhood-onset schizophrenia (COS) cohort and their similarities to adult-onset schizophrenia (AOS) literature.

METHOD

Scores from the Scales for the Assessment of Positive and Negative Symptoms (SAPS & SANS) from 125 COS patients were assessed for fit with previously established symptom dimensions from AOS literature using confirmatory factor analysis (CFA). K-means cluster analysis of each individual's scores on the best fitting set of dimensions was used to form patient clusters, which were then compared using demographic and clinical data.

RESULTS

CFA showed the SAPS & SANS data was well suited to a 2-dimension solution, including positive and negative dimensions, out of five well established models. Cluster analysis identified three patient groups characterized by different dimension scores: (1) low scores on both dimensions, (2) high negative, low positive scores, and (3) high scores on both dimensions. These groups had different Full scale IQ, Children's Global Assessment Scale (CGAS) scores, ages of onset, and prevalence of some co-morbid behavior disorders (all p<3.57E-03).

CONCLUSION

Our analysis found distinct symptom-based subgroups within the NIMH COS cohort using an established AOS symptom structure. These findings confirm the heterogeneity of COS and were generally consistent with AOS literature.

Utilising symptom dimensions with diagnostic categories improves prediction of time to first remission in first-episode psychosis

There has been much recent debate concerning the relative clinical utility of symptom dimensions versus conventional diagnostic categories in patients with psychosis. We investigated whether symptom dimensions rated at presentation for first-episode psychosis (FEP) better predicted time to first remission than categorical diagnosis over a four-year follow-up. The sample comprised 193 FEP patients aged 18-65years who presented to psychiatric services in South London, UK, between 2006 and 2010. Psychopathology was assessed at baseline with the Positive and Negative Syndrome Scale and five symptom dimensions were derived using Wallwork/Fortgang's model; baseline diagnoses were grouped using DSM-IV codes. Time to start of first remission was ascertained from clinical records. The Bayesian Information Criterion (BIC) was used to find the best fitting accelerated failure time model of dimensions, diagnoses and time to first remission. Sixty percent of patients remitted over the four years following first presentation to psychiatric services, and the average time to start of first remission was 18.3weeks (SD=26.0, median=8). The positive (BIC=166.26), excited (BIC=167.30) and disorganised/concrete (BIC=168.77) symptom dimensions, and a diagnosis of schizophrenia (BIC=166.91) predicted time to first remission. However, a combination of the DSM-IV diagnosis of schizophrenia with all five symptom dimensions led to the best fitting model (BIC=164.35). Combining categorical diagnosis with symptom dimension scores in FEP patients improved the accuracy of predicting time to first remission. Thus our data suggest that the decision to consign symptom dimensions to an annexe in DSM-5 should be reconsidered at the earliest opportunity.

Early onset first episode psychosis: dimensional structure of symptoms, clinical subtypes and related neurodevelopmental markers

Despite the growing interest in a dimensional approach to the assessment of symptoms and clinically relevant phenomena in schizophrenia spectrum disorders, very few studies, to date, have examined the dimensional structure of symptoms in early onset first episode psychosis. In the present study, we assessed a sample of 60 children and adolescents of both sexes with first episode schizophrenia spectrum psychosis. A principal component analysis (PCA) of the Positive and Negative Syndrome Scale (PANSS) was performed and the factors obtained were used to carry out a cluster analysis. Sex, age of onset before or after 13, markers of early neurodevelopmental impairment and intellectual disabilities were considered as variables to characterized potential clinical subtypes, applying a one-way analysis of variance. Four factors were extracted ("negative symptoms", "delusions", "conceptual disorganization" and "paranoid/hostility"), each of them identifying a discrete clinical subtype of patients. No difference was found among the groups about sex and age of onset; delayed speech/language development was significantly associated with the "delusions" subtype and both "conceptual disorganization" and "delusions" subtypes showed a lower intelligence quotient (IQ). The four factors model we presented highlights "negative symptoms" as the most consistent factor; among positive symptoms, unusual thought content and conceptual disorganization resulted more distinctive of psychosis, at this age range, than perceptual abnormalities. Evolutionary trajectories of the four clinical subtypes we obtained seem to be influenced by cognitive and neurodevelopmental impairment rather than sex and age of onset.

The slow death of the concept of schizophrenia and the painful birth of the psychosis spectrum

The concept of schizophrenia only covers the 30% poor outcome fraction of a much broader multidimensional psychotic syndrome, yet paradoxically has become the dominant prism through which everything 'psychotic' is observed, even affective states with mild psychosis labelled 'ultra-high risk' (for schizophrenia). The inability of psychiatry to frame psychosis as multidimensional syndromal variation of largely unpredictable course and outcome - within and between individuals - hampers research and recovery-oriented practice. 'Psychosis' remains firmly associated with 'schizophrenia', as evidenced by a vigorous stream of high-impact but non-replicable attempts to 'reverse-engineer' the hypothesized biological disease entity, using case-control paradigms that cannot distinguish between risk for illness onset and risk for poor outcome. In this paper, the main issues surrounding the concept of schizophrenia are described. We tentatively conclude that with the advent of broad spectrum phenotypes covering autism and addiction in DSM5, the prospect for introducing a psychosis spectrum disorder - and modernizing psychiatry - appears to be within reach.

Stress sensitivity as a putative mechanism linking childhood trauma and psychopathology in youth's daily life

OBJECTIVE

Childhood trauma (CT) is associated with a range of psychopathologies, including psychosis. However, evidence on underlying mechanisms remains limited. The study aimed to investigate whether CT impacts on youth mental health by modifying sensitivity to stress in daily life.

METHOD

The experience sampling method (ESM) was used to measure momentary stress, negative affect and psychotic experiences in 99 adolescents and young adults (43 help-seeking service users, 16 siblings and 40 controls). Before ESM assessments, CT and depressive, anxiety and psychotic symptoms were assessed.

RESULTS

Stress sensitivity, that is, the association between momentary stress and (i) negative affect and (ii) psychotic experiences, was modified by physical and emotional abuse and, partially, emotional and physical neglect, but not sexual abuse in service users and controls. While there was strong evidence for increased stress sensitivity in service users when high vs. low levels of CT were compared, a pattern of resilience was evident in controls, with attenuated, or no differences in, stress sensitivity in those with high vs. low CT levels. Less consistent findings were observed in siblings.

CONCLUSIONS

Stress sensitivity may be an important risk and resilience mechanism through which CT impacts on mental health in youth.

The Structure and Measurement of Unusual Sensory Experiences in Different Modalities: The Multi-Modality Unusual Sensory Experiences Questionnaire (MUSEQ)

Hallucinations and other unusual sensory experiences (USE) can occur in all modalities in the general population. Yet, the existing literature is dominated by investigations into auditory hallucinations (“voices”), while other modalities remain under-researched. Furthermore, there is a paucity of measures which can systematically assess different modalities, which limits our ability to detect individual and group differences across modalities. The current study explored such differences using a new scale, the Multi-Modality Unusual Sensory Experiences Questionnaire (MUSEQ). The MUSEQ is a 43-item self-report measure which assesses USE in six modalities: auditory, visual, olfactory, gustatory, bodily sensations, and sensed presence. Scale development and validation involved a total of 1,300 participants, which included: 513 students and community members for initial development, 32 individuals with schizophrenia spectrum disorder or bipolar disorder for validation, 659 students for factor replication, and 96 students for test-retest reliability. Confirmatory factor analyses showed that a correlated-factors model and bifactor model yielded acceptable model fit, while a unidimensional model fitted poorly. These findings were confirmed in the replication sample. Results showed contributions from a general common factor, as well as modality-specific factors. The latter accounted for less variance than the general factor, but could still detect theoretically meaningful group differences. The MUSEQ showed good reliability, construct validity, and could discriminate non-clinical and clinical groups. The MUSEQ offers a reliable means of measuring hallucinations and other USE in six different modalities.

Sensory integration deficits support a dimensional view of psychosis and are not limited to schizophrenia

Visual dysfunction is commonplace in schizophrenia and occurs alongside cognitive, psychotic and affective symptoms of the disorder. Psychophysical evidence suggests that this dysfunction results from impairments in the integration of low-level neural signals into complex cortical representations, which may also be associated with symptom formation. Despite the symptoms of schizophrenia occurring in a range of disorders, the integration deficit has not been tested in broader patient populations. Moreover, it remains unclear whether such deficits generalize across other sensory modalities. The present study assessed patients with a range of psychotic and nonpsychotic disorders and healthy controls on visual contrast detection, visual motion integration, auditory tone detection and auditory tone integration. The sample comprised a total of 249 participants (schizophrenia spectrum disorder n=98; bipolar affective disorder n=35; major depression n=31; other psychiatric conditions n=31; and healthy controls n=54), of whom 178 completed one or more visual task and 71 completed auditory tasks. Compared with healthy controls and nonpsychotic patients, psychotic patients trans-diagnostically were impaired on both visual and auditory integration, but unimpaired in simple visual or auditory detection. Impairment in visual motion integration was correlated with the severity of positive symptoms, and could not be accounted for by a reduction in processing speed, inattention or medication effects. Our results demonstrate that impaired sensory integration is not specific to schizophrenia, as has previously been assumed. Instead, sensory deficits are closely related to the presence of positive symptoms independent of diagnosis. The finding that equivalent integrative sensory processing is impaired in audition is consistent with hypotheses that propose a generalized deficit of neural integration in psychotic disorders.

Progressive Decline in Hippocampal CA1 Volume in Individuals at Ultra-High-Risk for Psychosis Who Do Not Remit: Findings from the Longitudinal Youth at Risk Study

Most individuals identified as ultra-high-risk (UHR) for psychosis do not develop frank psychosis. They continue to exhibit subthreshold symptoms, or go on to fully remit. Prior work has shown that the volume of CA1, a subfield of the hippocampus, is selectively reduced in the early stages of schizophrenia. Here we aimed to determine whether patterns of volume change of CA1 are different in UHR individuals who do or do not achieve symptomatic remission. Structural MRI scans were acquired at baseline and at 1-2 follow-up time points (at 12-month intervals) from 147 UHR and healthy control subjects. An automated method (based on an ex vivo atlas of ultra-high-resolution hippocampal tissue) was used to delineate the hippocampal subfields. Over time, a greater decline in bilateral CA1 subfield volumes was found in the subgroup of UHR subjects whose subthreshold symptoms persisted (n=40) and also those who developed clinical psychosis (n=12), compared with UHR subjects who remitted (n=41) and healthy controls (n=54). No baseline differences in volumes of the overall hippocampus or its subfields were found among the groups. Moreover, the rate of volume decline of CA1, but not of other hippocampal subfields, in the non-remitters was associated with increasing symptom severity over time. Thus, these findings indicate that there is deterioration of CA1 volume in persistently symptomatic UHR individuals in proportion to symptomatic progression.