Hallucinatory experiences in a community sample of Japanese children

Relationship between social cognition and emotional markers and acoustic-verbal hallucination in youth with post-traumatic stress disorder: Protocol for a prospective, 2-year, longitudinal case-control study

INTRODUCTION

Auditory-verbal hallucinatory experiences (AVH) have a 12% prevalence in the general pediatric population. Literature reports a higher risk of developing AVH in post-traumatic stress disorder (PTSD). The persistence of AVHs during adolescence represents a risk of evolution into psychotic disorders. Social cognition and emotional markers could be considered prodromes markers of this evolution. The objectives of this prospective observational study are to observe social cognition and emotional markers correlation with the presence and persistence of AVH over two years and with the evolution of PTSD and psychotic diagnosis.

METHODS AND ANALYSIS

This prospective case-control study, longitudinal over two years (with an interim reassessment at six months and one year), will include 40 participants aged 8 to 16 years old with a diagnosis of PTSD and without a diagnosis of psychosis according to the criteria of DSM-5 (K-SADS-PL). Subjects included are divided into two groups with AVH and without AVH matched by gender, age and diagnosis. The primary outcome measure will be the correlation between social cognition and emotional makers and the presence of AVH in the PTSD pediatric population without psychotic disorders. The social cognition marker is assessed with the NEPSY II test. The emotional marker is assessed with the Differential Emotion Scale IV and the Revised Beliefs About Voices Questionnaire. The secondary outcome measures are the correlation of these markers with the persistence of AVH and the evolution of the patient's initial diagnosis two years later.

DISCUSSION

The originality of our protocol is to explore the potential progression to psychosis from PTSD by cognitive biases. This study supports the hypothesis of connections between PTSD and AVH through sensory, emotional and cognitive biases. It proposes a continuum model from PTSD to psychotic disorder due to impaired perception like AVH.

TRIAL REGISTRATION

Clinical trial registration: ClinicalTrials.gov Identifier: NCT03356028.

Depression and anxiety mediate the relationship between the retrospectively measured symptoms of premenstrual disorders and negative but not positive psychotic-like experiences

The aim of this study was to examine the relationship between retrospectively measured premenstrual symptoms and subclinical forms of positive and negative psychotic symptoms (psychotic-like experiences; PLEs). It was hypothesised that subjective intensity of the symptoms of premenstrual disorders predicts PLEs frequency and that this relationship is mediated by anxiety and depression. The study sample comprised 108 non-clinical subjects. Study variables were assessed with self-report questionnaires: the Premenstrual Symptoms Screening Tool (PSST); the Beck Depression Inventory Second Edition (BDI-II); the State-Trait Anxiety Inventory (STAI; trait sub-scale); the Community Assessment of Psychic Experiences (CAPE). Regression and mediation analyses were performed. The PSST scores were significantly and positively associated with psychotic-like experiences frequency. The relation was stronger for positive PLEs. Anxiety and depression partially mediated the relationship between premenstrual symptoms and negative PLEs, but not between premenstrual symptoms and positive PLEs. Although the design of the study does not allow to infer causality, it demonstrates strong, positive relationship between the symptoms of premenstrual disorders and psychotic-like experiences. The relationship between premenstrual disorders and negative PLEs seems to be partially based on a general psychopathological factor. Further longitudinal studies are needed to test whether premenstrual disturbances increase risk of psychotic symptoms.

Socioenvironmental Adversity and Adolescent Psychotic Experiences: Exploring Potential Mechanisms in a UK Longitudinal Cohort

BACKGROUND AND HYPOTHESIS

Children exposed to socioenvironmental adversities (eg, urbanicity, pollution, neighborhood deprivation, crime, and family disadvantage) are more likely to subsequently develop subclinical psychotic experiences during adolescence (eg, hearing voices, paranoia). However, the pathways through which this occurs have not been previously investigated. We hypothesized that cognitive ability and inflammation would partly explain this association.

STUDY DESIGN

Data were utilized from the Environmental-Risk Longitudinal Twin Study, a cohort of 2232 children born in 1994-1995 in England and Wales and followed to age 18. Socioenvironmental adversities were measured from birth to age 10 and classified into physical risk (defined by high urbanicity and air pollution) and socioeconomic risk (defined by high neighborhood deprivation, neighborhood disorder, and family disadvantage). Cognitive abilities (overall, crystallized, fluid, and working memory) were assessed at age 12; and inflammatory markers (C-reactive protein, interleukin-6, soluble urokinase plasminogen activator receptor) were measured at age 18 from blood samples. Participants were interviewed at age 18 regarding psychotic experiences.

STUDY RESULTS

Higher physical risk and socioeconomic risk were associated with increased odds of psychotic experiences in adolescence. The largest mediation pathways were from socioeconomic risk via overall cognitive ability and crystallized ability, which accounted for ~11% and ~19% of the association with psychotic experiences, respectively. No statistically significant pathways were found via inflammatory markers in exploratory (partially cross-sectional) analyses.

CONCLUSIONS

Cognitive ability, especially crystallized ability, may partly explain the association between childhood socioenvironmental adversity and adolescent psychotic experiences. Interventions to support cognitive development among children living in disadvantaged settings could buffer them against developing subclinical psychotic phenomena.

Association between suicidal behaviors and auditory and visual hallucinations in Japanese adolescent psychiatric outpatients at first visit: a cross-sectional study

BACKGROUND

Suicide remains one of the leading causes of death among adolescents. Although recent studies have suggested a strong association between auditory hallucinations and suicidal behaviors, little is known regarding the association between suicidal behaviors and visual hallucinations, which are also common among adolescent psychiatric patients.

METHOD

A cross-sectional study of all first-time patients aged 10-15 years was conducted at three child and adolescent psychiatric outpatient facilities in Kanagawa Prefecture, Japan, from April 2015 to March 2018. Self-reported questionnaires were administered to evaluate auditory and visual hallucinations, suicide planning, and suicide attempts within the two weeks prior to the first visit. Our logistic regression model included three covariates (sex, age, and presence of major depressive episode) for adjustments. Among the 1285 respondents, 37 who had moderate or severe intellectual disability were excluded, leaving 1248 for analysis.

RESULTS

Among the 1069 patients who completed questionnaire items on hallucinations, 230 (21.5%) experienced auditory or visual hallucinations. After controlling for all confounders, visual hallucinations, but not auditory hallucinations, were significantly associated with increased odds of suicide planning (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.5-4.1). In contrast, auditory hallucinations, but not visual hallucinations, were significantly associated with increased odds of suicide attempts (OR 2.8, 95% CI 1.3-6.1). No interaction effects were observed between suicidal behaviors and auditory or visual hallucinations.

CONCLUSIONS

Clinicians should consider the prevalence of both auditory and visual hallucinations among young adolescent patients, with emphasis on auditory hallucinations, given their association with suicide attempts.

Association between genetic and socioenvironmental risk for schizophrenia during upbringing in a UK longitudinal cohort

BACKGROUND

Associations of socioenvironmental features like urbanicity and neighborhood deprivation with psychosis are well-established. An enduring question, however, is whether these associations are causal. Genetic confounding could occur due to downward mobility of individuals at high genetic risk for psychiatric problems into disadvantaged environments.

METHODS

We examined correlations of five indices of genetic risk [polygenic risk scores (PRS) for schizophrenia and depression, maternal psychotic symptoms, family psychiatric history, and zygosity-based latent genetic risk] with multiple area-, neighborhood-, and family-level risks during upbringing. Data were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 British twins born in 1994-1995 and followed to age 18 (93% retention). Socioenvironmental risks included urbanicity, air pollution, neighborhood deprivation, neighborhood crime, neighborhood disorder, social cohesion, residential mobility, family poverty, and a cumulative environmental risk scale. At age 18, participants were privately interviewed about psychotic experiences.

RESULTS

Higher genetic risk on all indices was associated with riskier environments during upbringing. For example, participants with higher schizophrenia PRS (OR = 1.19, 95% CI = 1.06-1.33), depression PRS (OR = 1.20, 95% CI = 1.08-1.34), family history (OR = 1.25, 95% CI = 1.11-1.40), and latent genetic risk (OR = 1.21, 95% CI = 1.07-1.38) had accumulated more socioenvironmental risks for schizophrenia by age 18. However, associations between socioenvironmental risks and psychotic experiences mostly remained significant after covariate adjustment for genetic risk.

CONCLUSION

Genetic risk is correlated with socioenvironmental risk for schizophrenia during upbringing, but the associations between socioenvironmental risk and adolescent psychotic experiences appear, at present, to exist above and beyond this gene-environment correlation.

Visual-Tactile Phobic Hallucinations in a Child With Stimulant-Managed Attention-Deficit/Hyperactivity Disorder (ADHD)

Hallucinations are not uncommon in the pediatric population, and they can occur in a variety of presentations influenced by medical and non-medical factors. This case report summarizes existing literature concerning visual-tactile phobic hallucinations (VTPH) and describes a case with a unique presentation: VTPH in a child with stimulant-managed attention-deficit/hyperactivity disorder (ADHD). Observations made in this case and in those like it are used to characterize VTPH as a distinct psychiatric phenomenon that is observed in children without metabolic, neurologic, or other medical involvement. When it is a primary psychiatric symptom, VTPH typically has an acute but benign course that benefits not from a medically intensive approach, but rather one that explores psychosocial influences and provides reassurance and support.

Associations between childhood victimization, inflammatory biomarkers and psychotic phenomena in adolescence: A longitudinal cohort study

Exposure to victimization in childhood has been linked to the development of psychosis. However, little is known about how childhood victimization is translated into biological risk for psychosis. One possibility is via increased inflammation. This study aimed to investigate the association between childhood victimization, psychotic experiences (PEs) in adolescence and inflammatory markers using data from a general population cohort. Participants were 1,419 British-born children followed from birth to age 18 years as part of the Environmental Risk Longitudinal Twin Study. Childhood victimization was measured prospectively using multiple sources from birth to age 12 years. PEs were assessed during private interviews with participants at age 18 years for the period since age 12. Plasma C-reactive protein (CRP), interleukin-6 (IL-6), and soluble urokinase plasminogen activator receptor (suPAR) levels were measured from plasma samples collected from participants at 18 years. Young people with both PEs and childhood victimization were more likely to belong to a group with elevated suPAR, CRP and IL-6 levels at 18 years of age (OR = 3.34, 95% CI 1.69-6.59, p = 0.001) than those with no childhood victimization and without PEs. However, this association was attenuated when adjusted for other risk factors for elevated inflammation at age 18 (OR = 1.94, 95% CI 0.94-4.04, p = 0.075). In contrast, presence of PEs without childhood victimization was not significantly associated with age-18 inflammatory markers and neither was childhood victimization without PEs (all p's greater than 0.05). The current study highlights that inflammatory dysregulation is mostly present in adolescents reporting PEs who also experienced childhood victimization, though this seemed to be largely due to concurrent inflammation-related risk factors.

Don't worry, be happy: Protective factors to buffer against distress associated with psychotic experiences

BACKGROUND

Around 6-7% of the general population report psychotic experiences (PEs). Positive PEs (e.g. hearing voices) may increase the risk of development of psychotic disorder. An important predictor of the transition to a psychotic disorder is secondary distress associated with PEs. We examined the moderating effect of potential protective factors on this secondary distress.

METHODS

Data come from 2870 individuals of the HowNutsAreTheDutch study. PEs were assessed with the Community Assessment of Psychic Experience (CAPE) questionnaire and were divided into three subdomains ("Bizarre experiences", "Delusional ideations", and "Perceptual anomalies"). Protective factors explored were having a partner, having a pet, benevolent types of humor, optimism and the high levels of personality traits emotional stability (reversed neuroticism), extraversion, openness to experience, conscientiousness, and agreeableness. We examined whether these protective factors moderated (lowered) the association between frequency of PEs and PE-associated distress.

RESULTS

Due to low prevalence of perceptual anomalies in the sample, this domain was excluded from analysis. No moderating effects were observed of protective factors on the association between bizarre experiences and distress. Having a partner and high levels of optimism, self-enhancing humor, openness, extraversion and emotional stability moderated the association between delusional ideations and secondary distress, leading to lower levels of distress.

CONCLUSIONS

Several protective factors were found to moderate the association between frequency and secondary distress of delusional ideations, with high levels of the protective factors being associated with lower levels of distress. A focus on protective factors could be relevant for interventions and prevention strategies regarding psychotic phenomena.

Using discordant twin methods to investigate an environmentally mediated pathway between social support and the reduced likelihood of adolescent psychotic experiences

BACKGROUND

Social support has been shown to be associated with a reduced likelihood of developing psychotic experiences in the general population and even amongst those at high risk due to exposure to multiple forms of victimisation (poly-victimised). However, it is unclear whether this association is merely due to the confounding effects of shared environmental and genetic influences, or reverse causality. Therefore, we investigated whether social support has a unique environmentally mediated effect on adolescent psychotic experiences after accounting for familial factors, including genetic factors, and also prior psychopathology.

METHODS

Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 UK-born twins. Adolescents were interviewed at age 18 about psychotic experiences and victimisation exposure since age 12, and their perceptions of social support. Prior childhood mental health problems and psychotic symptoms were assessed at age 12. The discordant twin method was used to disentangle the relative family-wide and unique-environmental effects of social support on psychotic experiences in the general population and among poly-victimised adolescents.

RESULTS

Perceived social support, particularly from friends, was found to have a unique environmentally mediated buffering effect on adolescent psychotic experiences in the whole sample and in the high-risk poly-victimised group.

CONCLUSIONS

The protective effects of social support on adolescent psychotic experiences cannot be accounted for by shared environmental or genetic factors, nor by earlier psychopathology. Our findings suggest that early intervention programmes focused on increasing perceptions of social support have the potential to prevent the emergence of psychotic experiences amongst adolescents.

Association of Air Pollution Exposure With Psychotic Experiences During Adolescence

IMPORTANCE

Urbanicity is a well-established risk factor for clinical (eg, schizophrenia) and subclinical (eg, hearing voices and paranoia) expressions of psychosis. To our knowledge, no studies have examined the association of air pollution with adolescent psychotic experiences, despite air pollution being a major environmental problem in cities.

OBJECTIVES

To examine the association between exposure to air pollution and adolescent psychotic experiences and test whether exposure mediates the association between urban residency and adolescent psychotic experiences.

DESIGN, SETTING, AND PARTICIPANTS

The Environmental-Risk Longitudinal Twin Study is a population-based cohort study of 2232 children born during the period from January 1, 1994, through December 4, 1995, in England and Wales and followed up from birth through 18 years of age. The cohort represents the geographic and socioeconomic composition of UK households. Of the original cohort, 2066 (92.6%) participated in assessments at 18 years of age, of whom 2063 (99.9%) provided data on psychotic experiences. Generation of the pollution data was completed on October 4, 2017, and data were analyzed from May 4 to November 21, 2018.

EXPOSURES

High-resolution annualized estimates of exposure to 4 air pollutants-nitrogen dioxide (NO2), nitrogen oxides (NOx), and particulate matter with aerodynamic diameters of less than 2.5 (PM2.5) and less than 10 μm (PM10)-were modeled for 2012 and linked to the home addresses of the sample plus 2 commonly visited locations when the participants were 18 years old.

MAIN OUTCOMES AND MEASURES

At 18 years of age, participants were privately interviewed regarding adolescent psychotic experiences. Urbanicity was estimated using 2011 census data.

RESULTS

Among the 2063 participants who provided data on psychotic experiences, sex was evenly distributed (52.5% female). Six hundred twenty-three participants (30.2%) had at least 1 psychotic experience from 12 to 18 years of age. Psychotic experiences were significantly more common among adolescents with the highest (top quartile) level of annual exposure to NO2 (odds ratio [OR], 1.71; 95% CI, 1.28-2.28), NOx (OR, 1.72; 95% CI, 1.30-2.29), and PM2.5 (OR, 1.45; 95% CI, 1.11-1.90). Together NO2 and NOx statistically explained 60% of the association between urbanicity and adolescent psychotic experiences. No evidence of confounding by family socioeconomic status, family psychiatric history, maternal psychosis, childhood psychotic symptoms, adolescent smoking and substance dependence, or neighborhood socioeconomic status, crime, and social conditions occurred.

CONCLUSIONS AND RELEVANCE

In this study, air pollution exposure-particularly NO2 and NOx-was associated with increased odds of adolescent psychotic experiences, which partly explained the association between urban residency and adolescent psychotic experiences. Biological (eg, neuroinflammation) and psychosocial (eg, stress) mechanisms are plausible.

Psychotic-Like Experiences in Offspring of Parents With Bipolar Disorder and Community Controls: A Longitudinal Study

OBJECTIVE

To compare the prevalence and risk factors associated with psychotic-like experiences (PLE) in offspring of parents with bipolar disorder (BP) and offspring of community control parents.

METHOD

Delusional and hallucinatory subclinical psychotic experiences were evaluated at intake and longitudinally in a cohort study of 390 offspring of BP parents and 247 offspring of control parents; all offspring were between 6 and 18 years of age. The sample was followed up every 2.5 years on average for 8.3 years. Of the sample, 91.7% completed at least one follow-up. Risk factors at intake and at each assessment until the onset of PLE were analyzed using survival models.

RESULTS

In all, 95 offspring (14.9%) reported PLE at some point of the study, 16.9% of BP parents and 11.7% of controls, without statistically significant differences. Psychotic disorders were less frequent, with 16 (2.5%) in both groups. During follow-up, three variables remained as the most significant associated with PLE in the multivariate models: (1) presence of any psychiatric disorder (hazard ratio [HR] = 3.1; p = .01); (2) low psychosocial functioning (HR = 2.94; p < .0001); and (3) current or past history of physical or sexual abuse (HR = 1.85; p = .04). There were no effects of any subtype of BP, IQ, history of medical illnesses, exposure to medications, or perinatal complications.

CONCLUSION

In line with previous studies, PLE in our sample were relatively common, and were associated with higher morbidity during the follow-up. Contrary to the literature, neither family risk for bipolar nor early neurodevelopmental insults were associated with PLE.

Protective factors for psychotic experiences amongst adolescents exposed to multiple forms of victimization

Experiencing multiple types of victimization (poly-victimization) during adolescence is associated with the onset of psychotic experiences (such as hearing voices, having visions, or being extremely paranoid). However, many poly-victimized adolescents will not develop such subclinical phenomena and the factors that protect them are unknown. This study investigated whether individual, family, or community-level characteristics were associated with an absence of psychotic experiences amongst poly-victimized adolescents. Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 UK-born twins. Exposure to seven different types of victimization between ages 12-18 was ascertained using a modified version of the Juvenile Victimization Questionnaire at age 18. Adolescents were also interviewed about psychotic experiences at age 18. Protective factors were measured at ages 12 and 18. We found that exposure to poly-victimization during adolescence was associated with age-18 psychotic experiences (OR = 4.62, 95% CI 3.59-5.94, P < 0.001), but more than a third of the poly-victimized adolescents reported having no psychotic experiences (40.1%). Greater social support was found to be protective against adolescent psychotic experiences even amongst those exposed to poly-victimization. Engaging in physical activity and greater neighborhood social cohesion were also associated with a reduced likelihood of age-18 psychotic experiences in the whole sample, with non-significant trends in the poly-victimized group. Increasing social support and promoting physical activity appear to be important areas for future research into the development of preventive interventions targeting adolescent psychotic experiences. This adds further weight to calls to increase the promotion of these factors on a public health scale.

Assessment of the Prodromal Questionnaire-Brief Child Version for Measurement of Self-reported Psychoticlike Experiences in Childhood

IMPORTANCE

Childhood psychoticlike experiences (PLEs) are associated with greater odds of a diagnosis of a psychotic disorder during adulthood. However, no known, well-validated self-report tools have been designed to measure childhood PLEs.

OBJECTIVE

To examine the construct validity and psychometric properties of a measure of PLEs, the Prodromal Questionnaire-Brief Child Version (PQ-BC).

DESIGN, SETTING, AND PARTICIPANTS

This validation study used data from the first wave of the Adolescent Brain and Cognitive Development (ABCD) Study, a prospective longitudinal study aimed at assessing risk factors associated with adverse physical and mental health outcomes from ages 9 to 10 years into late adolescence and early adulthood. The population-based sample of 3984 children within the ABCD data set was recruited from 20 research sites across the United States. Data for this study were collected from June 1, 2016, through August 31, 2017.

MAIN OUTCOMES AND MEASURES

The PQ-BC Total and Distress scores were analyzed for measurement invariance across race/ethnicity and sex, their associations with measures of PLEs, and their associations with known correlates of PLEs, including internalizing and externalizing symptoms, neuropsychological test performance, and developmental milestones.

RESULTS

The study analyses included 3984 participants (1885 girls [47.3%] and 2099 boys [52.7%]; mean [SE] age, 10.0 [0.01] years). The results demonstrated measurement invariance across race/ethnicity and sex. A family history of psychotic disorder was associated with higher mean (SE) PQ-BC Total (3.883 [0.352]; β = 0.061; 95% CI, 0.027-0.094) and Distress (10.210 [1.043]; β = 0.051; 95% CI, 0.018-0.084) scores, whereas a family history of depression or mania was not. Higher PQ-BC scores were associated with higher rates of child-rated internalizing symptoms (Total score: β range, 0.218 [95% CI, 0.189-0.246] to 0.273 [95% CI, 0.245-0.301]; Distress score: β range, 0.248 [95% CI, 0.220-0.277] to 0.310 [95% CI, 0.281-0.338]), neuropsychological test performance deficits such as working memory (Total score: β = -0.042 [95% CI, -0.077 to -0.008]; Distress score: β = -0.051 [95% CI, -0.086 to -0.017]), and motor and speech developmental milestone delays (Total score: β = 0.057 [95% CI, 0.026-0.086] for motor; β = 0.042 [95% CI, 0.010-0.073] for speech; Distress score: β = 0.048 [95% CI, 0.017-0.079] for motor; β = 0.049 [95% CI, 0.018-0.081] for speech).

CONCLUSIONS AND RELEVANCE

These results provide support for the construct validity and demonstrate adequate psychometric properties of a self-report instrument designed to measure childhood PLEs, providing evidence that the PQ-BC may be a useful measure of early risk for psychotic disorders. Furthermore, these data suggest that PLEs at school age are associated with many of the same familial, cognitive, and emotional factors associated with psychotic symptoms in older populations, consistent with the dimensionality of psychosis across the lifespan.

In the eye of the beholder: Perceptions of neighborhood adversity and psychotic experiences in adolescence

Adolescent psychotic experiences increase risk for schizophrenia and other severe psychopathology in adulthood. Converging evidence implicates urban and adverse neighborhood conditions in the etiology of adolescent psychotic experiences, but the role of young people's personal perceptions of disorder (i.e., physical and social signs of threat) in their neighborhood is unknown. This was examined using data from the Environmental Risk Longitudinal Twin Study, a nationally representative birth cohort of 2,232 British twins. Participants were interviewed at age 18 about psychotic phenomena and perceptions of disorder in the neighborhood. Multilevel, longitudinal, and genetically sensitive analyses investigated the association between perceptions of neighborhood disorder and adolescent psychotic experiences. Adolescents who perceived higher levels of neighborhood disorder were significantly more likely to have psychotic experiences, even after accounting for objectively/independently measured levels of crime and disorder, neighborhood- and family-level socioeconomic status, family psychiatric history, adolescent substance and mood problems, and childhood psychotic symptoms: odds ratio = 1.62, 95% confidence interval [1.27, 2.05], p < .001. The phenotypic overlap between adolescent psychotic experiences and perceptions of neighborhood disorder was explained by overlapping common environmental influences, rC = .88, 95% confidence interval [0.26, 1.00]. Findings suggest that early psychological interventions to prevent adolescent psychotic experiences should explore the role of young people's (potentially modifiable) perceptions of threatening neighborhood conditions.

Protective Factors for Psychotic Symptoms Among Poly-victimized Children

BACKGROUND

Experiencing victimization in early life has been repeatedly shown to be associated with the emergence of psychotic symptoms in childhood. However, most victimized children do not develop psychotic symptoms and why this occurs is not fully understood. This study investigated which individual, family-level, and wider community characteristics were associated with an absence of psychotic symptoms among children at risk for psychosis by virtue of their exposure to multiple victimization experiences (poly-victimization).

METHODS

Participants were from the Environmental Risk Longitudinal Twin Study, a nationally representative cohort of 2232 UK-born twins. Exposure to maltreatment, bullying and domestic violence prior to age 12 was determined from interviews with mothers, children, and observations by research workers at ages 5, 7, 10, and 12. Children were interviewed about psychotic symptoms at age 12. Protective factors were measured at ages 5, 7, 10, and 12.

RESULTS

Childhood poly-victimization was associated with age-12 psychotic symptoms (OR = 4.61, 95% CI 2.82-7.52), but the majority of poly-victimized children did not report symptoms (80.7%). Having a relatively high IQ, more positive atmosphere at home, and higher levels of neighborhood social cohesion were found to be protective against childhood psychotic symptoms among poly-victimized children and also in the whole sample. However, "protected" poly-victimized children displayed elevated levels of other mental health problems compared to nonvictimized children.

CONCLUSIONS

Children's characteristics, family context, and the wider community were all found to protect children from developing early psychotic symptoms, even when they were victimized multiple times. These findings indicate targets for multilevel preventive interventions.

Auditory hallucinations across the lifespan: a systematic review and meta-analysis

BACKGROUND

Auditory Hallucinations (AH) are nowadays regarded as symptoms following a continuum; from a (transient) phenomenon in healthy individuals on one end to a symptom of (psychiatric) illnesses at the other. An accumulating number of epidemiological studies focused on the prevalence of AH in the general population, but results vary widely. The current meta-analysis aims to synthesize existing evidence on lifetime prevalence of AH across the lifespan.

METHODS

We conducted a quantitative review and meta-analysis according to PRISMA guidelines. Studies were combined to calculate a mean lifetime general population AH prevalence rate. Moreover, prevalences were calculated for four age groups: children (5-12 years), adolescents (13-17 years), adults (18-60 years) and elderly (⩾60 years).

RESULTS

We retrieved 25 study samples including 84 711 participants. Mean lifetime prevalence rate of AH was 9.6% (95% CI 6.7-13.6%). The mean lifetime prevalence was similar in children (12.7%) and adolescents (12.4%), but these two groups differed significantly from the adults (5.8%) and the elderly (4.5%). Significant heterogeneity indicated that there is still dispersion in true prevalence rates between studies, even within the different age categories.

CONCLUSIONS

Current meta-analysis shows that AH are quite common (up to one in ten individuals) in the general population during lifetime, with children and adolescents reporting these experiences significantly more often compared with adults and elderly. Large follow-up studies on the longitudinal course of AH are needed to reveal associated risk and resilience factors.

Cumulative Effects of Neighborhood Social Adversity and Personal Crime Victimization on Adolescent Psychotic Experiences

BACKGROUND

Little is known about the impact of urbanicity, adverse neighborhood conditions and violent crime victimization on the emergence of adolescent psychotic experiences.

METHODS

Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 British twins who were interviewed about adolescent psychotic experiences at age 18. Urbanicity, neighborhood characteristics, and personal victimization by violent crime were measured during childhood and adolescence via geocoded census data, surveys of over 5000 immediate neighbors of the E-Risk participants, and interviews with participants themselves.

RESULTS

Adolescents raised in urban vs rural neighborhoods were significantly more likely to have psychotic experiences (OR = 1.67, 95% CI = 1.21-2.30, P = .002). This association remained significant after considering potential confounders including family socioeconomic status, family psychiatric history, and adolescent substance problems (OR = 1.43, 95% CI = 1.01-2.03, P = .042), but became nonsignificant after considering adverse social conditions in urban neighborhoods such as low social cohesion and high neighborhood disorder (OR = 1.35, 95% CI = 0.94-1.92, P = .102). The combined association of adverse neighborhood social conditions and personal crime victimization with adolescent psychotic experiences (adjusted OR = 4.86, 95% CI = 3.28-7.20, P < .001) was substantially greater than for either exposure alone, highlighting a potential interaction between neighborhood conditions and crime victimization (interaction contrast ratio = 1.81, 95% CI = -0.03 to 3.65) that was significant at the P = .054 level.

CONCLUSIONS

Cumulative effects of adverse neighborhood social conditions and personal victimization by violent crime during upbringing partly explain why adolescents in urban settings are more likely to report psychotic experiences. Early intervention efforts for psychosis could be targeted towards victimized youth living in urban and socially adverse neighborhoods.

Protective Factors for Early Psychotic Phenomena Among Children of Mothers With Psychosis

Background: Early identification of sub-clinical psychotic experiences in at-risk individuals is vital to prevent the development of psychosis, even before prodromal symptoms emerge. A widely-replicated risk factor is having a family member with psychosis. The Environmental Risk (E-Risk) Longitudinal Twin Study has shown that better cognitive functioning, a stimulating family environment, and a cohesive community, are protective against psychotic experiences among children; while engaging in physical activity, social support, and a cohesive community are protective for adolescents. In the current study we investigate whether these factors also protect against the development of sub-clinical psychotic phenomena among children and adolescents in this cohort who are at high-risk of psychosis by having a mother with psychosis. Methods: Data were utilized from the E-Risk Longitudinal Twin Study, a nationally-representative cohort of 2,232 twin children born in England and Wales in 1994-1995 followed to age 18. Psychotic phenomena were assessed in private interviews with children at ages 12 and 18, and mothers were interviewed about their own experiences of psychosis when children were aged 10 and 12. Bivariate and multivariate logistic regression analyses explored associations between individual, family, and community-level putative protective factors and absence of age-12 psychotic symptoms and age-18 psychotic experiences in children whose mothers had a diagnosis of a psychosis-spectrum disorder and/or reported psychotic symptoms. Results: Higher IQ (OR = 0.97, 95% CI 0.94-1.00, P = 0.036) and living in a more socially cohesive neighborhood (OR = 0.88, 95% CI 0.79-0.98, P = 0.023) were independently protective against age-12 psychotic symptoms among children of mothers with psychosis. Higher levels of perceived social support were independently protective against age-18 psychotic experiences among children of mothers with psychosis (OR = 0.92, 95% CI 0.87-0.98, P = 0.006). However, there were no significant interactions between these protective factors and maternal psychosis in relation to an absence of childhood or adolescent psychotic phenomena in the full sample, indicating that protective effects were not specific to this group of high-risk children. Conclusions: These findings provide preliminary evidence that preventive interventions for early psychotic phenomena could focus on improving cognition, social support, and cohesiveness of the local community. Given scarce resources these might usefully be targeted at high-risk children.

Children seeking help for auditory verbal hallucinations; who are they?

BACKGROUND

Auditory Verbal Hallucinations (AVH) in children and adolescents are a relatively common and mostly transient feature in community samples. However, it should not be regarded as a merely benign phenomenon, as childhood AVH are associated with psychopathology. Little is known about the clinical group of children seeking help for AVH. This brings uncertainty on how to assess and treat these children.

METHODS

This study describes the characteristics of 95 help-seeking children (aged 6 to 18years) with AVH attending an outpatient clinic specifically dedicated to help youth with this complaint. We aim to provide pointers regarding diagnostic assessment and interventions.

RESULTS

Children seeking help for AVH suffered from a diversity of co morbid psychiatric diagnoses and consistently experienced high stress from AVH. When the DSM-IV-TR criteria for psychotic disorder NOS were used, all 95 children obtained this diagnosis. However, when a psychotic disorder was defined using the A-criterion of schizophrenia, only a minority of 11 cases (11.6%) was diagnosed as having a psychotic disorder. All children were in need of psycho-education and coping strategies and only the minority (11.6%) fulfilling criteria for a more narrowly defined psychotic disorder was prescribed antipsychotic medication.

CONCLUSIONS

Children seeking help for AVH form a heterogeneous group with high stress and reduced functioning. Even though only a minority (11.6%) suffers from a psychotic disorder, all children warrant clinical care due to their burden and multi morbid psychopathology.

Understanding adolescent personality pathology from growth trajectories of childhood oddity

Research on developmental trajectories of early maladaptive features for understanding later personality disorders (PDs) is increasingly recognized as an important study area. The course of early odd features is highly relevant in this regard, as only a few researchers have addressed childhood oddity in the context of emerging PDs. Using latent growth modeling, the current study explores growth parameters of odd features in a mixed sample of Flemish community and referred children (N = 485) across three measurement waves with 1-year time intervals. Personality pathology was assessed at a fourth assessment point in adolescence. Beyond a general declining trend in oddity characteristics, the results demonstrated that both an early onset and an increasing trend of oddity-related characteristics over time are independent predictors of adolescent PDs. Childhood oddity tends to be the most manifest precursor for PDs with a core oddity feature (i.e., the schizotypal and borderline PD), but also appears to predict most of the other DSM-5 PDs. Results are discussed from an overarching developmental framework on PDs (Cicchetti, 2014), specifically focusing on the principle of multifinality. From a clinical perspective, the significance of increasing or steady-high childhood oddity trajectories for adolescent PDs highlights the relevance of systematic screening processes across time.

Why Are Children in Urban Neighborhoods at Increased Risk for Psychotic Symptoms? Findings From a UK Longitudinal Cohort Study

BACKGROUND

Urban upbringing is associated with a 2-fold adulthood psychosis risk, and this association replicates for childhood psychotic symptoms. No study has investigated whether specific features of urban neighborhoods increase children's risk for psychotic symptoms, despite these early psychotic phenomena elevating risk for schizophrenia and other psychiatric disorders in adulthood.

METHODS

Analyses were conducted on over 2000 children from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of UK-born twins. Neighborhood-level characteristics were assessed for each family via: a geodemographic discriminator indexing neighborhood-level deprivation, postal surveys of over 5000 residents living alongside the children, and in-home interviews with the children's mothers. Children were interviewed about psychotic symptoms at age 12. Analyses were adjusted for important family-level confounders including socioeconomic status (SES), psychiatric history, and maternal psychosis.

RESULTS

Urban residency at age-5 (OR = 1.80, 95% CI = 1.16-2.77) and age-12 (OR = 1.76, 95% CI = 1.15-2.69) were both significantly associated with childhood psychotic symptoms, but not with age-12 anxiety, depression, or antisocial behavior. The association was not attributable to family SES, family psychiatric history, or maternal psychosis, each implicated in childhood mental health. Low social cohesion, together with crime victimization in the neighborhood explained nearly a quarter of the association between urbanicity and childhood psychotic symptoms after considering family-level confounders.

CONCLUSIONS

Low social cohesion and crime victimization in the neighborhood partly explain why children in cities have an elevated risk of developing psychotic symptoms. Greater understanding of the mechanisms leading from neighborhood-level exposures to psychotic symptoms could help target interventions for emerging childhood psychotic symptoms.

Associations between nonauditory hallucinations, dissociation, and childhood adversity in first-episode psychosis

Although repeated associations have been found between adversity exposure (particularly exposure to childhood sexual abuse), dissociation, and auditory hallucinations in the context of psychosis, there is little comparable research examining hallucinations in other modalities. This study aimed to determine whether cumulative adversity exposure influences the likelihood of experiencing visual, tactile, olfactory, and gustatory hallucinations among psychosis patients and whether measures of dissociation are significantly associated with nonauditory hallucinations when exposure to childhood adversity and psychological distress are adjusted for. Self-report measures and a retrospective case-control design were applied to assess nonauditory hallucinations, dissociation, psychological distress, and childhood adversity exposure in a sample of first-episode psychosis patients reporting nonauditory hallucinations (n = 36) and controls from the same clinical population without nonauditory hallucinations (n = 31). Case participants reported higher levels of dissociation, psychological distress, and exposure to childhood rape than the control group. Dissociation remained significantly associated with nonauditory hallucinations when we adjusted for childhood sexual abuse, other types of childhood adversity, and a combined measure of emotional distress. Indication of a dose-response relationship was detected, in that total number of adversities was significantly associated with reporting more than one modality of nonauditory hallucination. Observed associations between auditory hallucinations and dissociation in psychosis may extend to other hallucination modalities. It is suggested that more research attention be paid to the etiology and impact of nonauditory hallucinations in psychosis samples.

The Representation of Agents in Auditory Verbal Hallucinations

Current models of auditory verbal hallucinations (AVHs) tend to focus on the mechanisms underlying their occurrence, but often fail to address the content of the auditory experience. In other words, they tend to ask why there are AVHs at all, instead of asking why, given that there are AVHs, they have the properties that they have. One such property, which has been largely overlooked and which we will focus on here, is why the voices are often experienced as coming from (or being the voices of) agents, and often specific, individualised agents. In this article, we argue not only that the representation of agents is important in accurately describing many cases of AVH, but also that deeper reflection on what is involved in the representation of agents has potentially vital consequences for our aetiological understanding of AVH, namely, for understanding how and why AVHs come about.

Auditory verbal hallucinations increase the risk for suicide attempts in adolescents with suicidal ideation

OBJECTIVE

It is important to prevent patients with suicidal ideation from actually attempting suicide. A school based cohort study suggested that auditory verbal hallucinations (AVHs) might play an important role in driving young people with mental health problems to attempt suicide. However, no clinical study to date has specifically investigated the association between AVHs and suicide attempts among young patients with suicidal ideation.

METHOD

We conducted a cross-sectional study of first-visit psychiatric referrals aged 10-15years at two general child and adolescent mental health hospitals in Japan. We administered self-reported questionnaires to measure suicidal ideation and suicide attempts, AVHs, and depression in the two weeks prior to the date of first-visit.

RESULTS

Among 188 patients with suicidal ideation, the presence of AVHs was associated with increased odds of suicide attempts (OR 3.4, 95% CI 1.7-6.9; p<0.05); however, depression was not associated with a significant change of odds (OR 0.7, 95% CI 0.4-1.3; p=0.29).

CONCLUSIONS

AVHs may increase the risk of suicide attempts made by adolescents with suicidal ideation. Clinicians should consider AVHs when adolescent patients present with suicidal ideation.

Psychotic experiences and psychological distress predict contemporaneous and future non-suicidal self-injury and suicide attempts in a sample of Australian school-based adolescents

BACKGROUND

Recent cross-sectional studies have shown psychotic experiences (PEs) are associated with suicidal ideation and behaviours. We aimed to examine associations between psychotic experiences (including persistent PE), and contemporaneous and incident non-suicidal self-injury (NSSI) and suicide attempts.

METHOD

Participants were from an Australian longitudinal cohort of 1896 adolescents (12-17 years). NSSI and suicide attempts were measured using the Self-Harm Behaviour Questionnaire. Items from the Diagnostic Interview Schedule for Children were used to assess psychotic experiences, and the General Health Questionnaire-12 measured psychological distress.

RESULTS

Adolescents both psychologically distressed and endorsing psychotic experiences had increased odds of contemporaneous and incident NSSI and attempted suicide. Psychotic experiences alone did not predict future risk. Persistent psychotic experiences were associated with increased risk of NSSI and suicide attempts.

CONCLUSIONS

Psychological distress with accompanying psychotic experiences and persistent psychotic experiences are important predictors of NSSI and suicide attempts. Screening these phenotypes in adolescents will assist in discerning those adolescents most at risk, providing opportunities for targeted suicide prevention strategies.

The experience of engaging with mental health services among young people who hear voices and their families: a mixed methods exploratory study

Background

Research shows us that auditory hallucinations or ‘hearing voices’ may be more common than previously thought, particularly in childhood and adolescents. Importantly, not all individuals are affected negatively by their voice hearing experiences, yet child and adolescent mental health services (CAMHS) have traditionally understood voice hearing as a symptom of psychosis and severe mental illness, with implications for the way interventions are offered. The purpose of the present study was to gain an understanding of how young people who hear voices and their families find engaging with mental health service, and to better understand their experience of mental health professionals.

Methods

A two-stage, mixed methods study was used. In the first stage, semi-structured interviews were carried out with two young people and their parents who had engaged with mental health services, and the collected data were analysed using Interpretative Phenomenological Analysis (IPA). In the second stage, a questionnaire was designed to test the generalizability of the themes arising from the first stage, and was completed online by 32 young voice hearers and 27 parents.

Results

IPA analysis produced 4 themes: (1) The struggle to understand the hearing voices phenomenon; (2) Battle with the Mental Health Services; (3) ‘Stuck in a limbo’; and (4) The wish for a more holistic approach from mental health services and professionals. The survey partially confirmed the findings of study one, with young people and parents finding useful information difficult to come by, and many reported feeling lost in CAMHS. Additionally, young voice hearers and parents often felt not listened to, and many parents expressed the need for a holistic care, whilst young people wanted a more normalizing and less stigmatizing experience.

Conclusions

Young people and their families had varying experiences of mental health services. Whilst the survey showed that some young people and their families had more positive experiences, many expressed dissatisfaction. To fulfil the needs of young people and their families, mental health services would benefit from developing alternative approaches to voice hearing and running support groups that could form part of a ‘normalising’ and ‘holistic care’ package.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0527-z) contains supplementary material, which is available to authorized users.

Frequency and pattern of childhood symptom onset reported by first episode schizophrenia and clinical high risk youth

BACKGROUND

Psychosis prevention and early intervention efforts in schizophrenia have focused increasingly on sub-threshold psychotic symptoms in adolescents and young adults. Although many youth report symptom onset prior to adolescence, the childhood incidence of prodromal-level symptoms in those with schizophrenia or related psychoses is largely unknown.

METHODS

This study reports on the retrospective recall of prodromal-level symptoms from 40 participants in a first-episode of schizophrenia (FES) and 40 participants at "clinical high risk" (CHR) for psychosis. Onset of positive and non-specific symptoms was captured using the Structured Interview for Prodromal Syndromes. Frequencies are reported according to onset during childhood (prior to age 13), adolescence (13-17), or adulthood (18+).

RESULTS

Childhood-onset of attenuated psychotic symptoms was not rare. At least 11% of FES and 23% of CHR reported specific recall of childhood-onset of unusual or delusional ideas, suspiciousness, or perceptual abnormalities. Most recalled experiencing non-specific symptoms prior to positive symptoms. CHR and FES did not differ significantly in the timing of positive and non-specific symptom onset. Other than being younger at assessment, those with childhood onset did not differ demographically from those with later onset.

CONCLUSION

Childhood-onset of initial psychotic-like symptoms may be more common than previous research has suggested. Improved characterization of these symptoms and a focus on their predictive value for subsequent schizophrenia and other major psychoses are needed to facilitate screening of children presenting with attenuated psychotic symptoms. Accurate detection of prodromal symptoms in children might facilitate even earlier intervention and the potential to alter pre-illness trajectories.

From phenomenology to neurophysiological understanding of hallucinations in children and adolescents

Typically reported as vivid, multisensory experiences which may spontaneously resolve, hallucinations are present at high rates during childhood. The risk of associated psychopathology is a major cause of concern. On the one hand, the risk of developing further delusional ideation has been shown to be reduced by better theory of mind skills. On the other hand, ideas of reference, passivity phenomena, and misidentification syndrome have been shown to increase the risk of self-injury or heteroaggressive behaviors. Cognitive psychology and brain-imaging studies have advanced our knowledge of the mechanisms underlying these early-onset hallucinations. Notably, specific functional impairments have been associated with certain phenomenological characteristics of hallucinations in youths, including intrusiveness and the sense of reality. In this review, we provide an update of associated epidemiological and phenomenological factors (including sociocultural context, social adversity, and genetics, considered in relation to the psychosis continuum hypothesis), cognitive models, and neurophysiological findings concerning hallucinations in children and adolescents. Key issues that have interfered with progress are considered and recommendations for future studies are provided.

Assessing psychotic-like symptoms using the BASC-2: adolescent, parent and teacher agreement

AIM

The aim of the current study was to investigate the psychometric properties of the BASC-2 (Behavior Assessment System for Children, Second Edition) Atypicality subscale in a sample of adolescents receiving mental health services.

METHODS

A large sample (n = 1916) of adolescents aged 12-20 years (median = 14.7 years) completed the BASC-2. A parent and teacher also completed the measure for each child. We analyzed internal consistency and interrater reliabilities for the Atypicality subscale, as well as the Depression and Hyperactivity subscales for comparison. Further analyses explored the influence of a participant's subscale scores, gender, and quality of relationships with adults on interrater agreement.

RESULTS

All subscales demonstrated good internal consistency; however, interrater agreement was low for all subscales. Gender, Atypicality subscale score, and self-reported quality of relationships with adults could not account for poor interrater agreement.

CONCLUSIONS

The Atypicality subscale has strong internal consistency across informants. Low interrater agreement for the Atypicality subscale, as well as other scales, however, presents a challenge when interpreting multi-informant scales.

The relationship between psychotic symptoms and social functioning in a non-clinical population of 12year olds

BACKGROUND

Psychotic symptoms are common in adolescents in the general population but it is unknown whether they are associated with poor social functioning.

AIMS

To investigate whether adolescent psychotic symptoms are associated with poor social functioning measured by peer relationships.

METHOD

Data from the Avon Longitudinal Study of Parents and Children cohort was used. Logistic regression was used to explore the relationship between psychotic symptoms at 12.9years detected using a semi-structured interview and poor social functioning at 13.2years using parent-reported peer problems from the Strengths and Difficulties Questionnaire.

RESULTS

There was strong evidence (p<0.001) of an unadjusted association between psychotic symptoms and poor social functioning (OR 1.41, 95% CI 1.24-1.61). The association was attenuated after adjusting for earlier social functioning, socio-demographic variables, bullying status and IQ (OR 1.28, 95% CI 1.09-1.50). The majority of the crude association was explained by additional adjustment for emotional problems including depression at age 12, emotional symptoms, hyperactivity and conduct problems at age 11 (OR 1.07, 95% CI 0.89-1.29).

CONCLUSION

Adolescents with psychotic symptoms may be no more likely to have poor social functioning than other adolescents, once other emotional problems have been taken into account. The discussion addressed two explanations. First, emotional problems may be on the causal pathway from psychotic symptoms to poor social functioning. Alternatively, emotional symptoms may act as a confounder, suggesting that medical intervention may be inappropriate. It is the impact of psychotic symptoms on the individual that should dictate whether any intervention is required.

An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders

BACKGROUND

The psychosis-proneness-persistence-impairment model of psychotic disorder incorporates notions of both phenomenological and temporal continuity (persistence) of psychotic experiences (PE), but not structural continuity. Specific testable propositions of phenomenological continuity and persistence are identified. Method Propositions are tested by systematic reviews of the epidemiology of PE, persistence of PE and disorder outcomes, and meta-analyses (including Monte Carlo permutation sampling, MCPS) of reported rates and odds ratios (ORs).

RESULTS

Estimates of the incidence and prevalence of PE obtained from 61 cohorts revealed a median annual incidence of 2.5% and a prevalence of 7.2%. Meta-analysis of risk factors identified age, minority or migrant status, income, education, employment, marital status, alcohol use, cannabis use, stress, urbanicity and family history of mental illness as important predictors of PE. The mode of assessment accounted for significant variance in the observed rates. Across cohorts, the probability of persistence was very strongly related to the rate of PE at baseline. Of those who report PE, ∼20% go on to experience persistent PE whereas for ∼80%, PE remit over time. Of those with baseline PE, 7.4% develop a psychotic disorder outcome.

CONCLUSIONS

Compelling support is found for the phenomenological and temporal continuity between PE and psychotic disorder and for the fundamental proposition that this relationship is probabilistic. However, imprecision in epidemiological research design, measurement limitations and the epiphenomenological nature of PE invite further robust scrutiny of the continuity theory.

Classes of psychotic experiences in Kenyan children and adolescents

Psychotic-like experiences (PLEs) have been observed worldwide in both adults and children outside the context of a clinical disorder. In the current study, we investigate the prevalence and patterns of PLEs among children and adolescents in Kenya. Among 1,971 students from primary and secondary schools around Nairobi (aged 8-19), 22.1 % reported a lifetime history of a psychotic experience, and 16.3 % reported this unrelated to sleep or drugs. Psychotic experiences were more common in males compared to females. LCA resulted in a three-class model comprised of a normative class (83.3 %), a predominately hallucinatory class (Type 1 psychosis: 9.6 %), and a pan-psychotic class (Type 2 psychosis: 7.2 %). These results indicate that PLEs are prevalent in children and adolescents, and the distributions of symptom clusters are similar to that found in adulthood. The relationship of specific PLEs to the future development of psychotic disorder, functional impairment or distress will require further study.

Adolescent bullying, cannabis use and emerging psychotic experiences: a longitudinal general population study

BACKGROUND

Using longitudinal and prospective measures of psychotic experiences during adolescence, we assessed the risk of developing psychosis in three groups showing low, increasing and elevated psychotic experiences associated with bullying by peers and cannabis use in a UK sample of adolescents. Method Data were collected by self-report from 1098 adolescents (mean age 13.6 years; 60.9% boys) at five separate time points, equally separated by 6 months, across a 24-month period. General growth mixture modelling identified three distinct trajectories of adolescents reporting psychotic experiences: elevated, increasing and low.

RESULTS

Controlling for cannabis use, bullying by peers significantly predicted change in psychotic experiences between Time 2 and Time 5 in adolescents belonging to the increasing group. No effect was found for the elevated or low groups. Controlling for bullying, an earlier age of cannabis use and cannabis use more than twice significantly predicted change in psychotic experiences in adolescents belonging to the increasing group. Cannabis use at any age was significantly associated with subsequent change in psychotic experiences in the low group. Reverse causal associations were examined and there was no evidence for psychotic experiences at Time 1 predicting a subsequent change in cannabis use between Times 2 and 5 in any trajectory group.

CONCLUSIONS

Bullying by peers and cannabis use are associated with adolescents' reports of increasing psychotic experiences over time. Further research into the longitudinal development of psychosis in adolescence and the associated risk factors would allow for early intervention programmes to be targeted more precisely.

Schizotypy, psychotic-like experiences and distress: an interaction model

Psychotic-like experiences (PLEs) have been found to exist on a continuum in both general and clinical populations. Such experiences may characterize normal and abnormal variations in personality, as well as prodromal or high risk states for the development of psychotic disorders. High risk paradigms tend to emphasize distress and impairment associated with PLEs, yet the extent to which individuals find PLEs to be distressing likely depends on moderating factors. In particular, individuals high in trait schizotypy may differ in their appraisal and reaction to PLEs. The current study examines the relationship between schizotypy, PLEs, and distress associated with PLEs in a college sample. Participants (N=355) completed the Schizotypal Personality Questionnaire - Brief Version (SPQ-B), which assesses schizotypal traits, and the Prodromal Questionnaire - Brief Version (PQ-B), which assesses both PLEs and associated distress. Schizotypy was found to significantly moderate the association between PLEs and subjective distress. Individuals high in trait schizotypy reported more PLEs, yet less distress associated with PLEs, relative to individuals low in trait schizotypy. Implications for high-risk state assessment are discussed.

Psychotic symptoms and gray matter deficits in clinical pediatric populations

BACKGROUND

Neuroanatomic studies have not yet addressed how subtle phenotypic distinctions in psychosis alter the underlying brain changes, and whether there is evidence for psychosis as a dimensional construct. We explored the relationship of cortical GM thickness to psychotic phenotypes in children.

METHODS

Cross-sectional comparison of anatomic brain imaging between patients referred as childhood-onset schizophrenia (COS) but ruled out after a drug free inpatient observation. Groups included: patients with no evidence of psychosis (n=22) after drug free observation, patients with psychosis not otherwise specified (PNOS; total n=29) further divided into those without other axis I diagnoses (n=13) and those with other axis I comorbidities (n=16), age/sex matched COS patients (n=48), and 51 matched healthy controls. GM cortical thickness was compared between the groups, and regressed on patients' SAPS, SANS and GAS scores.

RESULTS

Patients with no evidence of psychosis showed no cortical GM deficits. Presence of psychosis (PNOS with or without co-morbidities) showed some areas of temporal and prefrontal deficits, more subtle compared to the extensive bilateral cortical deficits seen for COS. GAS SAPS and SANS scores showed a relationship with cortical GM thickness although it did not survive adjustment for multiple comparisons.

CONCLUSIONS

These results highlight the need for careful phenotypic characterization, as subtle diagnostic distinctions appear to reflect distinct underlying patterns of brain deficits. The incremental nature of cortical deficits from no psychosis to PNOS to COS may further support dimensional model for psychosis.

Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies

BACKGROUND

Psychotic symptoms occur more frequently in the general population than psychotic disorder and index risk for psychopathology. Multiple studies have reported on the prevalence of these symptoms using self-report questionnaires or clinical interviews but there is a lack of consensus about the prevalence of psychotic symptoms among children and adolescents.

METHOD

We conducted a systematic review of all published literature on psychotic symptom prevalence in two age groups, children aged 9-12 years and adolescents aged 13-18 years, searching through electronic databases PubMed, Ovid Medline, PsycINFO and EMBASE up to June 2011, and extracted prevalence rates.

RESULTS

We identified 19 population studies that reported on psychotic symptom prevalence among children and adolescents. The median prevalence of psychotic symptoms was 17% among children aged 9-12 years and 7.5% among adolescents aged 13-18 years.

CONCLUSIONS

Psychotic symptoms are relatively common in young people, especially in childhood. Prevalence is higher in younger (9-12 years) compared to older (13-18 years) children.

Examining the course of hallucinatory experiences in children and adolescents: a systematic review

BACKGROUND

Childhood and adolescence represent the periods during which hallucinatory experiences occur at the greatest prevalence, and also constitute a critical window of vulnerability for the pathogenesis of psychotic disorders. The longitudinal course of hallucinatory experiences during late childhood and adolescence, as well as their relationship to psychotic disorders, has never been the subject of review.

METHODS

We followed the PRISMA guidelines for conducting systematic reviews and combined the use of electronic and manual systematic search methods. Data were extracted upon pre-defined requested items and were analyzed using several epidemiological measures. The interpretation of the results was conducted in relation to the study design variables.

RESULTS

A total of 11 datasets (6 epidemiological and 5 clinical) were reviewed. The baseline prevalence of hallucinatory experiences ranged from 4.9% to 9%. Discontinuation occurred in between 58.7% and 94.5% of the cases, and person-year discontinuation rates ranged from 3% to 40.7% and appeared to be related to the duration of follow-up. Despite low person-year incidence rate, incident cases constituted between 27.7% and 83.3% of outcome samples. 2 of 3 studies showed evidence to predict transition to psychosis with likelihood ratios of 2.5 and 6.6.

CONCLUSIONS

Hallucinatory experiences are a common experience during childhood and adolescence. A review of the current literature suggests that there is a considerable turnover of incident-discontinuing cases and that most cases discontinue in the short term. A subset of the cases was at risk for persistence or transition to psychosis, probably related to indicators of severity of the hallucinatory experience.

Dissociation mediates the relationship between childhood trauma and hallucination-proneness

BACKGROUND

It has been proposed that the relationship between childhood trauma and hallucinations can be explained by dissociative processes. The present study examined whether the effect of childhood trauma on hallucination-proneness is mediated by dissociative tendencies. In addition, the influence of dissociative symptoms on a cognitive process believed to underlie hallucinatory experiences (i.e. reality discrimination; the capacity to discriminate between internal and external cognitive events) was also investigated.

METHOD

Patients with schizophrenia spectrum disorders (n=45) and healthy controls (with no history of hallucinations; n=20) completed questionnaire measures of hallucination-proneness, dissociative tendencies and childhood trauma, as well as performing an auditory signal detection task.

RESULTS

Compared to both healthy and non-hallucinating clinical controls, hallucinating patients reported both significantly higher dissociative tendencies and childhood sexual abuse. Dissociation positively mediated the effect of childhood trauma on hallucination-proneness. This mediational role was particularly robust for sexual abuse over other types of trauma. Signal detection abnormalities were evident in hallucinating patients and patients with a history of hallucinations, but were not associated with pathological dissociative symptoms.

CONCLUSIONS

These results are consistent with dissociative accounts of the trauma-hallucinations link. Dissociation, however, does not affect reality discrimination. Future research should examine whether other cognitive processes associated with both dissociative states and hallucinations (e.g. deficits in cognitive inhibition) may explain the relationship between dissociation and hallucinatory experiences.

Persistence and outcome of auditory hallucinations in adolescence: a longitudinal general population study of 1800 individuals

BACKGROUND

Auditory hallucinations are common in adolescents. However, it has been suggested that not the presence of low-grade psychotic experiences per se, but rather the level of persistence and associated clinical complications over time may lead to psychotic illness. The current paper investigated, in a large representative sample of adolescents, to what degree hallucinations persist, and whether persistence of hallucinations increases the risk of developing secondary delusional ideation and affective dysregulation.

METHODS

Data were derived from a general health screening of all 1912 adolescents living in the Maastricht area. Baseline assessment was in the second grade of secondary school (T0) and follow-up occurred 2 years later (T1). Questions included the psychosis screening questions (Poulton et al., 2000), the SDQ assessing general psychopathology and a question assessing depression.

RESULTS

Five percent of adolescents reported hallucinations at T0 and 27% of these hallucinations were still present 2 years later. Hallucinations at T0 were associated with increased levels of depressed mood and general psychopathology at T1, and the degree of persistence of hallucinations was associated with a progressively greater risk for T1 delusional ideation as well as increased levels of follow-up depressed mood and general psychopathology.

CONCLUSION

Although hallucinations in adolescents are a common and mainly transitory phenomenon, the persistence rate over time is far from negligible, and associated with clinical deterioration.

Childhood facial emotion recognition and psychosis-like symptoms in a nonclinical population at 12 years of age: results from the ALSPAC birth cohort

INTRODUCTION

Nonclinical psychotic symptoms (for example, low intensity or low frequency psychotic symptoms such as ideas of reference or single word auditory hallucinations) are common in adolescents and may be associated with an increased risk of developing a psychotic disorder in adulthood. Those at high risk of developing a psychotic disorder appear to perform poorly on facial emotion recognition tasks but the relationship between facial emotion recognition and nonclinical "psychosis like symptoms" (PLIKS) in children is unclear. We aimed to examine the association between childhood facial emotion recognition and PLIKS in adolescents.

METHODS

Longitudinal study using a large birth cohort. 6455 subjects completed a semistructured clinical assessment for psychotic symptoms (the PLIKSi) at the mean age of 12.9 (SD=0.23). Facial emotion recognition (using the DANVA) was previously assessed at the age of 8 in the cohort.

RESULTS

There was no increase in odds of reporting any PLIKS either in relation to the total score on the measure of facial emotion recognition or for the individual emotion scores of fear, sadness, anger, and happiness. Similar results were also found when examining more intense and/or more frequently experienced psychotic symptoms.

CONCLUSIONS

Deficits in facial emotion recognition in 8-year-olds do not appear to predict later reporting of nonclinical psychotic symptoms in early adolescence. The results do not support the proposal that recognition of emotion is a trait phenomenon in those individuals at increased risk for psychosis. However, further research is warranted in older children/adolescents when more subtle emotion recognition deficits can be investigated.

Are screening instruments valid for psychotic-like experiences? A validation study of screening questions for psychotic-like experiences using in-depth clinical interview

Individuals who report psychotic-like experiences are at increased risk of future clinical psychotic disorder. They constitute a unique "high-risk" group for studying the developmental trajectory to schizophrenia and related illnesses. Previous research has used screening instruments to identify this high-risk group, but the validity of these instruments has not yet been established. We administered a screening questionnaire with 7 items designed to assess psychotic-like experiences to 334 adolescents aged 11-13 years. Detailed clinical interviews were subsequently carried out with a sample of these adolescents. We calculated sensitivity and specificity and positive predictive value (PPV) and negative predictive value (NPV) for each screening question for the specific symptom it enquired about and also in relation to any psychotic-like experience. The predictive power varied substantially between items, with the question on auditory hallucinations ("Have you ever heard voices or sounds that no one else can hear?") providing the best predictive power. For interview-verified auditory hallucinations specifically, this question had a PPV of 71.4% and an NPV of 90.4%. When assessed for its predictive power for any psychotic-like experience (including, but not limited to, auditory hallucinations), it provided a PPV of 100% and an NPV of 88.4%. Two further questions-relating to visual hallucinations and paranoid thoughts-also demonstrated good predictive power for psychotic-like experiences. Our results suggest that it may be possible to screen the general adolescent population for psychotic-like experiences with a high degree of accuracy using a short self-report questionnaire.

Psychotic-like experiences and depressive symptoms in a community sample of adolescents

PURPOSE

Studies of psychotic-like experiences (PLEs) within community samples of adolescents have explored predominantly positive experiences. There is a paucity of research examining the prevalence and correlates of negative PLEs, and whether particular subtypes of negative PLEs can be identified among the general population of adolescents. This study examined the association of both positive and negative PLEs with depressive symptoms, including detailed analysis of subtypes of positive and negative psychosis dimensions.

METHOD

A community sample of 777 adolescents (50.9% girls: mean age 14.4 years) completed a questionnaire assessing positive and negative PLEs and depressive symptoms.

RESULTS

Principal component factor analysis identified four factors of positive symptoms (persecutory ideation, grandiose thinking, first-rank/hallucinatory experiences and self-referential thinking), and three factors of negative symptoms (social withdrawal, affective flattening, and avolition). Depressive symptoms were associated positively with persecutory ideation, first-rank/hallucinatory experiences, social withdrawal, and avolition, whereas grandiose thinking related negatively with depressive symptoms. Neither self-referential thinking nor affective flattening related to self-reported depression.

CONCLUSIONS

These findings support the view that not all types of positive and negative PLEs in adolescence are associated with depression and, therefore, they may not confer the same vulnerability for psychotic disorders.

Attenuated psychotic symptoms syndrome: how it may affect child and adolescent psychiatry

The DSM-5 task force on schizophrenia and psychotic disorders have recently proposed to include attenuated psychotic symptoms syndrome as a disorder not currently listed in DSM-IV-TR, either in the main manual or in an Appendix for further research. One of the potential benefits of including this diagnosis in DSM-5 is to identify persons at high risk of developing psychotic disorders to prevent the appearance of these disorders or lead to disorders with a better prognosis. One of the challenges applying the criteria proposed to the pediatric population is the difficulty in defining "attenuated" in the same way and it is done with adults. The threshold for psychosis may be lower in children and, therefore, what is attenuated in adults may be fully present, although transient, in paediatric population. Other potential risks are a lower threshold for prescribing antipsychotics without clear evidence and whether the help-seeking behaviour criterion will be applied to the patients and/or the parents.

Psychotic-like experiences in the general population: characterizing a high-risk group for psychosis

Recent research shows that psychotic symptoms, or psychotic-like experiences (PLEs), are reported not only by psychosis patients but also by healthy members of the general population. Healthy individuals who report these symptoms are considered to represent a non-clinical psychosis phenotype, and have been demonstrated to be at increased risk of schizophrenia-spectrum disorder. Converging research now shows that this non-clinical psychosis phenotype is familial, heritable and covaries with familial schizophrenia-spectrum disorder. A review of the research also shows that the non-clinical phenotype is associated extensively with schizophrenia-related risk factors, including social, environmental, substance use, obstetric, developmental, anatomical, motor, cognitive, linguistic, intellectual and psychopathological risk factors. The criterion and construct validity of the non-clinical psychosis phenotype with schizophrenia demonstrates that it is a valid population in which to study the aetiology of psychosis. Furthermore, it suggests shared genetic variation between the clinical and non-clinical phenotypes. Much remains to be learned about psychosis by broadening the scope of research to include the non-clinical psychosis phenotype.

Developmental trajectories of psychotic-like experiences across adolescence: impact of victimization and substance use

BACKGROUND

Research suggests that psychotic-like experiences (PLEs) in the general population are common, but can reflect either transitory or persistent developmental phenomena. Using a general adolescent population it was examined whether different developmental subtypes of PLEs exist and whether different trajectories of PLEs are associated with certain environmental risk factors, such as victimization and substance use.

METHOD

Self-reported PLEs were collected from 409 adolescents (mean age 14 years 7 months) at four time points, each 6 months apart. General growth mixture modelling was utilized to identify classes of adolescents who followed distinct trajectories of PLEs across this period. Predictors of class membership included demographics, personality, victimization, depression, anxiety and substance use.

RESULTS

We identified the following three developmental subgroups of PLEs: (1) persistent; (2) increasing; (3) low. Adolescents on the persistent trajectory reported frequent victimization and consistent elevated scores in depression and anxiety. Adolescents on the increasing trajectory were engaging in cigarette use prior to any increases in PLEs and were engaging in cocaine, cannabis and other drug use as PLEs increased at later time points.

CONCLUSIONS

The findings suggest that different developmental subgroups of PLEs exist in adolescence and are differentially related to victimization and substance use.

[Validation study of the French schizotypal personality questionnaire in a sample of adolescents: a confirmatory factor analysis]

AIMS

This article aims to validate the schizotypal personality questionnaire in a sample of French speaking adolescents. Because early schizotypal manifestations are predictive of psychosis-proneness, reliable self-report measures are crucial for early detection of vulnerability to schizophrenia during adolescence. Unlike most existing self-reports, the questionnaire de personnalité schizotypique (SPQ) assesses individual differences in all nine feature of DSM-IV schizotypal personality (i.e. ideas of reference, excessive social anxiety, odd beliefs, unusual perceptual experience, odd behaviour, no close friends, odd speech, constricted affect and suspiciousness). Furthermore, it yields dimensional scores concerning the main schizotypal factors, which represent valuable information for the clinician's case formulation and can be used as a screening instrument in the general population.

METHOD

Our sample consisted of 174 adolescents (98 girls) between 12 and 17 years old. All completed the SPQ 74-item self-report. Participants were recruited in secondary schools in Switzerland, and through the child and adolescent community outpatient psychiatric service (office médico-pédagogique) affiliated to the University of Geneva's Psychiatry Department and to the Canton of Geneva Education Department. A confirmatory factorial analysis was conducted on our sample to test nine competing models of SPQ. The 3-factor model of Raine et al. was compared to concurrent 2, 3, and 4-factor models. Simple structure models of Raine et al. and Stefanis et al. were also tested.

RESULTS

The following observations were highlighted in our results: (1) goodness-of-fit indices are better for structures allowing cross loadings than for simple structures; (2) amongst the simple structures, the best goodness-of-fit index was obtained for the Raine model and (3) the fit between our data and the Raine model is improved by a cross loading for suspiciousness subscale. The latter seems problematic for the global data fitting. This led us to test simple structures models of Siever and Gunderson, Raine et al., and Stefanis et al., based on eight subscales rather than nine. Without suspiciousness subscale, goodness-of-fit indices are enhanced in these three models. The 3-factor model yields the clearest and most reliable results in comparison with other competing models. In summary, the best goodness-of-fit indices were obtained for the 3-factor Raine model. Goodness-of-fit indices could be improved by the exclusion of the suspiciousness scale.

CONCLUSIONS

Consistent with earlier analyses by Raine et al. and Dumas et al., our data confirm the 3-factor model of the SPQ (cognitive-perceptive; interpersonal; disorganized) in a sample of French speaking adolescents. Our analyses confirm that two dimensions are insufficient to explain the structure of schizotypy during adolescence. These results further suggest the stability of a 3-factor structure during lifespan. We note that the inclusion of the suspiciousness subscales engenders statistical issues. Most studies to date have dealt with these issues by performing a cross-loading with this subscale, or by the inclusion of a paranoid factor which is linked with the negative and the cognitive-perceptive factors. We found that the most statistically sound strategy was reached without the inclusion of the suspiciousness subscale. Future studies with larger samples could investigate the SPQ structure at an item-level, which carries the benefit of reduced restrictions on the factorial analysis. In conclusion, the current study shows that the French version SPQ constitutes a reliable self-report questionnaire for the assessment of schizotypal trait expression during adolescence that may assist in the evaluation of psychosis proneness in youths.

Etiological and clinical features of childhood psychotic symptoms: results from a birth cohort

CONTEXT

It has been reported that childhood psychotic symptoms are common in the general population and may signal neurodevelopmental processes that lead to schizophrenia. However, it is not clear whether these symptoms are associated with the same extensive risk factors established for adult schizophrenia.

OBJECTIVE

To examine the construct validity of children's self-reported psychotic symptoms by testing whether these symptoms share the risk factors and clinical features of adult schizophrenia.

DESIGN

Prospective, longitudinal cohort study of a nationally representative birth cohort in Great Britain.

PARTICIPANTS

A total of 2232 twelve-year-old children followed up since age 5 years (retention, 96%). Main Outcome Measure Children's self-reported hallucinations and delusions.

RESULTS

Children's psychotic symptoms are familial and heritable and are associated with social risk factors (eg, urbanicity); cognitive impairments at age 5; home-rearing risk factors (eg, maternal expressed emotion); behavioral, emotional, and educational problems at age 5; and comorbid conditions, including self-harm.

CONCLUSIONS

The results provide a comprehensive picture of the construct validity of children's self-reported psychotic symptoms. For researchers, the findings indicate that children who have psychotic symptoms can be recruited for neuroscience research to determine the pathogenesis of schizophrenia. For clinicians, the findings indicate that psychotic symptoms in childhood are often a marker of an impaired developmental process and should be actively assessed.