Early signs in schizophrenia spectrum disorders

Examining the psychobiological response to acute social stress across clinical stages and symptom trajectories in the early psychosis continuum

The stress-vulnerability model has been repeatedly highlighted in relation to the risk, onset and course of psychosis, and has been independently studied in clinical high-risk (CHR) and first-episode psychosis (FEP) populations. Notable in this literature, however, is that there are few studies directly comparing markers of stress response across progressive stages of illness. Here we examined the psychobiological response to the Trier Social Stress Test in 28 CHR (mean age 19.1) and 61 FEP (age 23.0) patients, in order to understand the stage(s) or trajectories in which differences in subjective stress or physiological response occur. The overall clinical sample had greater perceived stress and blunted cortisol (FEP + CHR, n = 89, age 21.7) compared with healthy controls (n = 45, age 22.9). Additional analyses demonstrated elevated heart rate and systolic blood pressure in FEP compared with CHR, but there were no further differences in physiological parameters (cortisol, heart rate, or blood pressure) between stage- or trajectory-based groups. Together, this suggests that individual stress response markers may differentially emerge at particular stages en route to psychosis - and demonstrates how stage-based analyses can shed light on the emergence and evolution of neurobiological changes in mental illness.

Prodromal symptoms and the duration of untreated psychosis in first episode of psychosis patients: what differences are there between early vs. adult onset and between schizophrenia vs. bipolar disorder?

To assess the role of age (early onset psychosis-EOP < 18 years vs. adult onset psychosis-AOP) and diagnosis (schizophrenia spectrum disorders-SSD vs. bipolar disorders-BD) on the duration of untreated psychosis (DUP) and prodromal symptoms in a sample of patients with a first episode of psychosis. 331 patients with a first episode of psychosis (7-35 years old) were recruited and 174 (52.6%) diagnosed with SSD or BD at one-year follow-up through a multicenter longitudinal study. The Symptom Onset in Schizophrenia (SOS) inventory, the Positive and Negative Syndrome Scale and the structured clinical interviews for DSM-IV diagnoses were administered. Generalized linear models compared the main effects and group interaction. 273 AOP (25.2 ± 5.1 years; 66.5% male) and 58 EOP patients (15.5 ± 1.8 years; 70.7% male) were included. EOP patients had significantly more prodromal symptoms with a higher frequency of trouble with thinking, avolition and hallucinations than AOP patients, and significantly different median DUP (91 [33-177] vs. 58 [21-140] days; Z = - 2.006, p = 0.045). This was also significantly longer in SSD vs. BD patients (90 [31-155] vs. 30 [7-66] days; Z = - 2.916, p = 0.004) who, moreover had different profiles of prodromal symptoms. When assessing the interaction between age at onset (EOP/AOP) and type of diagnosis (SSD/BD), avolition was significantly higher (Wald statistic = 3.945; p = 0.047), in AOP patients with SSD compared to AOP BD patients (p = 0.004). Awareness of differences in length of DUP and prodromal symptoms in EOP vs. AOP and SSD vs. BD patients could help improve the early detection of psychosis among minors.

A novel model of divergent predictive perception

Predictive processing theories state that our subjective experience of reality is shaped by a balance of expectations based on previous knowledge about the world (i.e. priors) and confidence in sensory input from the environment. Divergent experiences (e.g. hallucinations and synaesthesia) are likely to occur when there is an imbalance between one's reliance on priors and sensory input. In a novel theoretical model, inspired by both predictive processing and psychological principles, we propose that predictable divergent experiences are associated with natural or environmentally induced prior/sensory imbalances: inappropriately strong or inflexible (i.e. maladaptive) high-level priors (beliefs) combined with low sensory confidence can result in reality discrimination issues, a characteristic of psychosis; maladaptive low-level priors (sensory expectations) combined with high sensory confidence can result in atypical sensory sensitivities and persistent divergent percepts, a characteristic of synaesthesia. Crucially, we propose that whether different divergent experiences manifest with dominantly sensory (e.g. hallucinations) or nonsensory characteristics (e.g. delusions) depends on mental imagery ability, which is a spectrum from aphantasia (absent or weak imagery) to hyperphantasia (extremely vivid imagery). We theorize that imagery is critically involved in shaping the sensory richness of divergent perceptual experience. In sum, to predict a range of divergent perceptual experiences in both clinical and general populations, three factors must be accounted for: a maladaptive use of priors, individual level of confidence in sensory input, and mental imagery ability. These ideas can be expressed formally using nonparametric regression modeling. We provide evidence for our theory from previous work and deliver predictions for future research.

What Is the Prevalence of Visual Hallucinations in a First-Episode Psychosis Population? A Systematic Review and Meta-analysis of the Literature

Background and Hypothesis

This systematic review and meta-analysis review the literature regarding the prevalence of visual hallucinations in patients with first-episode psychosis. Previous reviews have focused on the prevalence of visual hallucinations in a general psychosis population, highlighting a weighted prevalence of 27%. However, no reviews have focused specifically on the experiences of those with a first episode of psychosis. Understanding "first-episode" experiences is crucial, as intervention during this "critical period" is thought to define long-term outcome. Therefore, it is important that the prevalence of different symptoms during this period is accurately represented.

Study Design

Systematic searches yielded 15 studies to be meta-analyzed. Information to calculate event rates was extracted. Studies were rated for their methodological quality using a risk of bias tool. The quality of included studies varied; generalizability bias was the domain with the most risk of bias.

Study Results

Prevalence rates were synthesized from the 15 papers included in the final analysis, which generated a weighted prevalence estimate of 33% of people with first-episode psychosis experiencing visual hallucinations. Subgroup analyses were carried out and did not demonstrate significant associations.

Conclusions

This meta-analysis provides a robust estimate of 33% for the prevalence of visual hallucinations in first-episode psychosis; highlighting that visual hallucinations are relatively common experiences.

Do psychosis prodrome onset negative symptoms predict first presentation negative symptoms?

Background:

Negative symptoms have been previously reported during the psychosis prodrome, however our understanding of their relationship with treatment-phase negative symptoms remains unclear.

Objectives:

We report the prevalence of psychosis prodrome onset negative symptoms (PONS) and ascertain whether these predict negative symptoms at first presentation for treatment.

Methods:

Presence of expressivity or experiential negative symptom domains was established at first presentation for treatment using the Scale for Assessment of Negative Symptoms (SANS) in 373 individuals with a first episode psychosis. PONS were established using the Beiser Scale. The relationship between PONS and negative symptoms at first presentation was ascertained and regression analyses determined the relationship independent of confounding.

Results:

PONS prevalence was 50.3% in the schizophrenia spectrum group (n = 155) and 31.2% in the non-schizophrenia spectrum group (n = 218). In the schizophrenia spectrum group, PONS had a significant unadjusted (χ2 = 10.41, P < 0.001) and adjusted (OR = 2.40, 95% CI = 1.11–5.22, P = 0.027) association with first presentation experiential symptoms, however this relationship was not evident in the non-schizophrenia spectrum group. PONS did not predict expressivity symptoms in either diagnostic group.

Conclusion:

PONS are common in schizophrenia spectrum diagnoses, and predict experiential symptoms at first presentation. Further prospective research is needed to examine whether negative symptoms commence during the psychosis prodrome.

Medication adherence in first episode psychosis: the role of pre-onset subthreshold symptoms

OBJECTIVE

The experience of pre-onset subthreshold psychotic symptoms (STPS, signifying a clinical high-risk state) in first episode psychosis (FEP) predicts poorer outcomes during treatment, possibly through differential adherence to medication. We explored whether adherence differs between FEP patients with and without pre-onset STPS.

METHODS

Antipsychotic medication adherence was compared in 263 STPS+ and 158 STPS- subjects in a specialized early intervention program for FEP. Data were gathered from a larger observational study conducted between 2003 and 2016. STPS status, sociodemographic, and baseline clinical variables were tested as predictors of non-adherence using univariate and multivariate logistic regressions. Time to onset of non-adherence was analyzed using Kaplan-Meier curves. The same predictors were tested as predictors of time to onset of non-adherence using Cox regression models.

RESULTS

Medication non-adherence was higher in STPS+ participants (78.9% vs. 68.9%). STPS status (OR 1.709), substance use disorder (OR 1.767), and milder positive symptoms (OR 0.972) were significant baseline predictors of non-adherence. Substance use disorder (HR 1.410), milder positive symptoms (HR 0.990), and lack of contact between the clinical team and relatives (HR 1.356) were significant baseline predictors of time to non-adherence.

CONCLUSION

FEP patients who experience pre-onset STPS are more likely to be non-adherent to antipsychotic medication over 2 years of intervention. FEP programs should routinely evaluate pre-onset symptomatology to deliver more personalized treatments, with emphasis on engaging both patients and family members from the beginning of care.

Negative symptoms of psychosis: A life course approach and implications for prevention and treatment

AIM

Negative symptoms are a cause of enduring disability in serious mental illness. In spite of this, the development of effective treatments for negative symptoms has remained slow. The challenge of improving negative symptom outcomes is compounded by our limited understanding of their aetiology and longitudinal development.

METHODS

A literature search was conducted for life course approach of negative symptoms using PubMed. Further articles were included following manual checking of reference lists and other search strategies. The paper contains a theoretical synthesis of the literature, summarized using conceptual models.

RESULTS

Negative symptom definitions are compared and considered within a context of the life course. Previous studies suggest that several illness phases may contribute to negative symptoms, highlighting our uncertainty in relation to the origin of negative symptoms.

CONCLUSIONS

Similar to other aspects of schizophrenia, negative symptoms likely involve a complex interplay of several risk and protective factors at different life phases. Concepts suggested in this article, such as "negative symptom reserve" theory, require further research, which may inform future prevention and treatment strategies.

Gender differences in first onset Schizophrenia spectrum psychoses

BACKGROUND

Mental health profiles differ between boys and girls from puberty onwards. It is not known whether differences also extend to symptom presentation in schizophrenia spectrum disorders. It may be that girls and boys are not treated entirely equally by the professionals.

AIMS

To study gender differences in symptom profiles, family adversities, pathway to care, and characteristics of inpatient treatment at the first episode of diagnosed schizophrenia spectrum disorder (F20-29) among adolescents aged 13-17.

METHODS

A retrospective chart review of all (n = 106) consecutive adolescents diagnosed for the first time with schizophrenia spectrum disorder (F20-29) in a specified catchment area. Girls and boys were compared with regard to sociodemographics, pathways to care, living arrangements, symptom profiles, and treatment received.

RESULTS

During the study period more adolescent girls (n = 70, 66%) than boys (n = 36, 34%) were diagnosed with schizophrenia spectrum (F20-29) psychoses, most commonly F29. Girls were moreover younger (mean age = 15.46) than boys (mean age = 16.62) at admission. Girls more often displayed mood symptoms and boys aggressive behaviours, alcohol abuse problems, and isolation. Family adversities recorded as current stressors were more numerous among girls. Girls were more likely to be referred to specialized after-care than boys.

CONCLUSIONS

The gender differences observed in symptoms presentation are reminiscent of differences encountered in the general adolescent population. Prior to transition to psychosis, girls and boys are equally in contact with psychiatric services due to other (possibly prodromal) symptoms/disorders. Family adversities may be more stressful for girls vulnerable to psychosis than to boys.

Prodromal symptoms and remission following first episode psychosis

INTRODUCTION

Describing the trajectory of prodromal symptoms has obvious appeal in supporting advances towards sub-clinical intervention. Identifying clinical phenomena associated with unfavourable illness outcomes could have greater significance in explaining some heterogeneity within and between psychotic disorders and advancing understanding of pre-psychotic typologies. Few studies have assessed the continuity, if any, between prodromal phases and illness outcome one year after treatment.

METHODS

We assessed 375 people with first-episode psychosis (FEP) and 215 (57.4%) were seen approximately one year later. We performed factor analysis on prodromal symptom items obtained by interview with families and participants and identified a five-factor solution. We determined whether these factors predicted non-remission from psychosis in the presence of other factors that may predict outcome including premorbid adjustment, duration of prodrome and untreated psychosis (DUP), baseline symptoms and DSM-IV diagnoses. We used random forest classification to predict the most important variables and logistic regression to identify specific predictors.

RESULTS

We identified five prodromal symptom factors comprising Negative Symptoms, General Psychopathology, Reality Distortion, Strange Ideas and Irritability. Prodromal symptoms did not predict a greater risk of non-remission with the exception of Irritability and this factor was also associated with earlier age at onset, being male and a diagnosis of substance-induced psychosis. Being male, DUP and baseline positive symptoms predicted non-remission at one year.

CONCLUSION

Prodromal symptoms were not linked with outcome after a year of treatment which could be explained by greater heterogeneity in illness psychopathology which may be more pronounced in broad FEP diagnoses at different stages. It could also be explained by prodromal symptoms exerting greater influence earlier in the course illness.

Help-seeking and pathways to care in the early stages of psychosis

PURPOSE

Delay in the treatment of a first psychotic episode can have a negative influence on the future course of the disease. In this context, it is important to examine pathways to care to understand factors contributing to delay in access to adequate care.

METHODS

Using the Basel Interview for Psychosis, we examined the help-seeking behaviour of 61 individuals with an at-risk mental state for psychosis and 37 patients with a first episode of psychosis in a low threshold health care system as part of the Basel early detection of psychosis study.

RESULTS

The median duration of untreated illness was 3.4 years, of untreated psychosis 12 months. Eighty-six percent of all individuals sought help of some kind before reaching our specialised early detection outpatient clinic, with a mean number of help-seeking contacts of 1.5 prior to referral. The most frequent first help-seeking contacts were family members or relatives n = 24 (26.7 %), close friends n = 17 (17.9 %), psychiatrists in private practice n = 13 (14.4 %) or general practitioners n = 11 (12.2 %). Most patients consulted other health professionals in the early course of the illness before reaching our specialised service; help-seeking with non-medical institutions was rare. Women had more help-seeking contacts than men before contact with our early detection clinic.

CONCLUSIONS

Family, close friends and medical professionals play an important role in help-seeking leading to specialised psychiatric care. Men seek help less often; specific strategies for encouraging young, at-risk men to seek help should be developed.

Cannabis use and anticipatory pleasure as reported by subjects with early psychosis and community controls

BACKGROUND

There is evidence of decreased pleasure and deficits in the anticipation of reward in both psychotic illness and drug addiction. Individuals with low anticipatory pleasure may preferentially engage in behaviours associated with immediate reward such as cannabis use.

METHOD

Ninety-one psychosis patients and 91 controls without history of psychosis were administered the Temporal Experience of Pleasure Scale (TEPS), a self report which measures anticipatory and consummatory pleasure. Cannabis use diagnosis was assessed using the Structured Clinical Interview for DSM IV (SCID). Subjects reported the frequency of cannabis consumption and time since last use.

RESULTS

Patients did not show a significant deficit in anticipatory or consummatory pleasure compared to controls; however, patients with an active cannabis-use disorder tended to have lower consummatory pleasure than controls with active cannabis disorder (p<.05). Patients who continued to use cannabis during treatment of their first episode of psychosis reported significantly lower anticipatory pleasure compared to those who had a lifetime cannabis diagnosis but were able to maintain abstinence (F(1,60)=5.6, p=.021). Frequency of cannabis use was negatively correlated to anticipatory and consummatory pleasure (Pearson R=-.46, -.48 respectively) in 37 patients currently using cannabis but not in 46 cannabis-using controls (partial R=-.04, -.07 respectively).

CONCLUSION

Anticipatory pleasure may not be decreased in early psychosis patients. Lower hedonic response may be associated with persistent, heavy cannabis use in patients in the early phase of psychotic disorders.

The role of treatment delay in predicting 5-year outcomes in an early intervention program

BACKGROUND

Past research on the relationship between treatment delay and outcomes for first-episode psychosis has primarily focused on the role of duration of untreated psychosis (DUP) in predicting symptomatic outcomes up to 2 years. In the current study we examine the influence of both DUP and duration of untreated illness (DUI) on symptoms and functioning at 5 years follow-up while controlling for other early characteristics.

METHOD

A total of 132 patients with first-episode psychosis and treated in an early intervention program were prospectively followed up for 5 years. Outcomes assessed included positive and negative symptoms, overall functioning, weeks on disability pension and weeks of full-time competitive employment.

RESULTS

While DUP showed a significant correlation with level of positive symptoms at follow-up, this was not independent of pre-morbid social adjustment. DUI emerged as a more robust independent predictor of negative symptoms, social and occupational functioning and use of a disability pension.

CONCLUSIONS

Delay between onset of non-specific symptoms and treatment may be a more important influence on long-term functioning for first-episode patients than DUP. This suggests the possible value of treating such signs and symptoms as early as possible regardless of the effectiveness of such interventions in reducing likelihood or severity of psychotic symptoms.

An examination of patient-identified goals for treatment in a first-episode programme in Chennai, India

AIM

Our objective was to describe the goals identified by patients upon entering a specialized programme for treatment of first-episode psychosis (FEP) in Chennai, India.

METHODS

68 patients with FEP completed the Goal Attainment section of the Wisconsin Quality of Life-Client Questionnaire upon entry into treatment. Patients were asked to identify a maximum of three treatment goals and rate each identified goal on its importance and the extent of its achievement.

RESULTS

In the order of frequency of endorsement, the primary goals identified pertained to work, family/interpersonal relationships, education, symptom relief and psychological recovery, living condition, religion, finances, and household responsibilities. All patients identified at least one goal, 41 patients identified two goals, and 11 patients identified three goals.

CONCLUSION

Individuals with FEP in India present with a range of realistic and reasonable goals. Findings have implications for improving early intervention services in India by targeting patient-identified goals.

Preliminary findings from a study of first-episode psychosis in Montreal, Canada and Chennai, India: comparison of outcomes

BACKGROUND

This article reports preliminary findings from a multi-year investigation of onset and course of previously untreated first-episode psychosis in two similarly structured treatment programs in Canada and India. Specifically, the aim of this study was to examine whether one year clinical and functional outcomes of first-episode psychosis varied between these two programs.

METHOD

Patients with first-episode non-affective psychosis receiving similar treatment in Chennai, India (N=61) and in Montreal, Canada (N=88) were evaluated for demographic variables, duration of untreated psychosis, and baseline diagnosis, and for positive, negative, and general psychopathology symptoms and overall functioning at baseline and one year.

RESULTS

At both sites, there was a significant improvement in symptoms and functioning over the one year course of treatment. There was also a significant time-by-site interaction on negative symptoms and functioning, after controlling for age, sex, and marital status. On these domains, patients in India showed greater improvement over time than their Canadian counterparts. The time-by-site interactions were not significant for positive symptoms and general psychopathology.

CONCLUSION

First-episode patients in the Indian program demonstrated higher rates of improvement at one year in negative symptoms and functioning than patients receiving similar treatment in Canada. There was no difference in improvement between the sites on positive symptoms and general psychopathology. These results suggest that the sociocultural context of treatment can influence outcomes early in the course of psychotic disorders. Further, outcomes are not uniformly better or worse in one sociocultural context compared to another, but seem to vary from one outcome domain to another.

Probably at-risk, but certainly ill--advocating the introduction of a psychosis spectrum disorder in DSM-V

Current criteria for an increased risk of developing first-episode psychosis are associated with conversion rates many times higher than the general incidence of psychosis. Yet, non-conversions still outnumber conversions, and conversion rates across and within centres vary considerably, fueling the ongoing debate about clinical and ethical justification of indicated prevention. This debate, however, almost exclusively focuses on the predictive validity of at-risk criteria, thereby widely disregarding the main general finding: persons meeting at-risk criteria already suffer from multiple mental and functional disturbances for those they seek help. Moreover, they exhibit various psychological and cognitive deficits along with morphological and functional cerebral changes. Thereby, the majority of help-seeking at-risk persons fulfils DSM-IV's general criteria for mental disorders (defined as a clinically significant behavioural or psychological syndrome associated with disability and/or severe distress) and clearly have to be considered as 'ill', i.e., as 'patients' with a need and right for treatment. Hence, the clinical picture defined by current at-risk criteria should be more adequately perceived as not only a still insufficient attempt to define the psychotic prodrome but a psychosis spectrum disorder in its own right - akin to ICD-10's schizotypal disorder - with conversion to psychosis just being one of several outcomes. Such a disorder, whose criteria are proposed and discussed, should initially be part of DSM-V research criteria. Following from this shift in the perception of current at-risk criteria, access to standard medical care would have to be granted, and diagnosis- or symptom- rather than conversion-related interventions would have to be developed.

Early signs and symptoms of psychosis among Palauan adolescents

AIM

This study was designed to identify early symptoms associated with the occurrence of psychosis during adolescence.

METHOD

Participants were recruited in the Republic of Palau, an isolated island nation in Micronesia with a prevalence rate for schizophrenia of 1.99%. Diagnostic interviews were used to obtain reports of early and current symptoms from 112 genetically high-risk (GHR) and 208 genetically low-risk (GLR) adolescents (ages 16-23). Based on current psychotic symptoms, participants were sorted into three groups: non-clinical, at-risk/symptomatic risk and clinically symptomatic.

RESULTS

Multivariate analysis of variance revealed several between-group differences on rates of early symptoms. Most notably, youth who were in the GHR-clinically symptomatic group reported significantly higher rates of early marijuana use than GLR-clinically symptomatic youth, who were significantly more likely to report early symptoms of depression and behaviour disorders. In addition, several gender based differences in the link between early symptoms and adolescent onset psychosis were noted.

CONCLUSIONS

Findings are generally consistent with previous research on early indicators, though several unexpected findings suggest that results from this study may not be fully generalizable beyond this relatively isolated and culturally distinct Micronesian nation.

Multi-level comparison of empathy in schizophrenia: an fMRI study of a cartoon task

Empathy deficits might play a role in social dysfunction in schizophrenia. However, few studies have investigated the neuroanatomical underpinnings of the subcomponents of empathy in schizophrenia. This study investigated the hemodynamic responses to three subcomponents of empathy in patients with schizophrenia (N=15) and healthy volunteers (N=18), performing an empathy cartoon task during functional magnetic resonance imaging. The experiment used a block design with four conditions: cognitive, emotional, and inhibitory empathy, and physical causality control. Data were analyzed by comparing the blood-oxygen-level-dependent (BOLD) signal activation between the two groups. The cognitive empathy condition activated the right temporal pole to a lesser extent in the patient group than in comparison subjects. In the emotional and inhibitory conditions, the patients showed greater activation in the left insula and in the right middle/inferior frontal cortex, respectively. These findings add to our understanding of the impaired empathy in patients with schizophrenia by identifying a multi-level cortical dysfunction that underlies a deficit in each subcomponent of empathy and highlighting the importance of the fronto-temporal cortical network in ability to empathize.

Gender difference in the prodromal symptoms of first-episode schizophrenia

To investigate the gender difference of early symptoms appearing before the onset of the psychotic symptoms in patients with first-episode schizophrenia, we reviewed the medical records of 63 patients (38 males, 25 females), who were hospitalized for first-episode schizophrenia. The frequency and duration of prodromal and psychotic symptoms, Clinical Global Impression scale scores, Global Assessment of Functioning (GAF) scale scores at admission, and other clinical characteristics were recorded for all patients. Overall, the most common prodromal symptoms were attenuated positive symptoms (89%), followed by mood symptoms (86%). Negative symptoms were the most common in male patients (97.4%), whereas attenuated positive symptoms were the most common in female patients (84%). Male patients demonstrated more frequent negative, cognitive, and obsessive-compulsive symptoms than female patients did and also showed a tendency of having negative symptoms for the longer period. Correlational analysis showed a significant negative correlation between the duration of negative symptoms and GAF scores at admission in male patients. Our findings suggest that different patterns of prodromal symptoms between male and female begin before the onset of the psychosis. Further prospective studies should be needed.

Anger and functioning amongst inpatients with schizophrenia or schizoaffective disorder living in a therapeutic community

AIMS

This study explored the functional correlates of anger amongst therapeutic community inpatients.

METHODS

The sample consisted of 44 subjects diagnosed with schizophrenic/schizoaffective disorder who were involved in a community treatment program. Assessment involved administration of the Health of Nation Outcome Scales and the Global Assessment of Functioning as well as self-evaluations using the Social Adaptation Self-evaluation Scale. Psychopathology was assessed with the Positive and Negative Symptoms Scale. Angry feelings and coping skills were self-assessed with the State-Trait Anger Expression Inventory and the Symptom Checklist-90 Hostility Scale. Multiple regression analyses correlated anger with functioning, controlling for psychopathology.

RESULTS

Angry feelings related to self-harm, hyperactivity, physical problems, and to global weight independently from Positive and Negative Symptoms Scale scores. They also predicted interest and pleasure in housekeeping, quality of social relationships and relational exchanges.

CONCLUSIONS

Results showed that angry feelings were not merely derivations of schizophrenic psychopathology; rather, they were independently related to self-damaging behaviors, to attentional demands towards the staff, to agreement to community tasks and to low quality of social relationships. Indeed, anger was related to adaptation's level in a therapeutic community setting demonstrated by subjects with psychoses and it may represent an indirect measure of their experienced quality of life. Therapeutic and management approaches to anger amongst subjects with schizophrenia are discussed.

Signs and symptoms in the pre-psychotic phase: description and implications for diagnostic trajectories

BACKGROUND

Few studies have examined the underlying factor structure of signs and symptoms occurring before the first psychotic episode. Our objective was to determine whether factors derived from early signs and symptoms are differentially associated with non-affective versus affective psychosis.

METHOD

A principal components factor analysis was performed on early signs and symptoms reported by 128 individuals with first-episode psychosis. Factor scores were examined for their associations with duration of untreated illness, drug abuse prior to onset of psychosis, and diagnosis (schizophrenia versus affective psychosis).

RESULTS

Of the 27 early signs and symptoms reported by patients, depression and anxiety were the most frequent. Five factors were identified based on these early signs and symptoms: depression, disorganization/mania, positive symptoms, negative symptoms and social withdrawal. Longer duration of untreated illness was associated with higher levels of depression and social withdrawal. Individuals with a history of drug abuse prior to the onset of psychosis scored higher on pre-psychotic depression and negative symptoms. The two mood-related factors, depression and disorganization/mania, distinguished the eventual first-episode diagnosis of affective psychosis from schizophrenia. Individuals with affective psychosis were also more likely to have a 'mood-related' sign and symptom as their first psychiatric change than individuals later diagnosed with schizophrenia.

CONCLUSIONS

Factors derived from early signs and symptoms reported by a full diagnostic spectrum sample of psychosis can have implications for future diagnostic trajectories. The findings are a step forward in the process of understanding and characterizing clinically important phenomena to be observed prior to the onset of psychosis.

Predictors of acute treatment response in patients with a first episode of non-affective psychosis: sociodemographics, premorbid and clinical variables

Approximately 60% of patients with a first episode of psychosis will significantly reduce the severity of their positive symptomatology with antipsychotic drugs. The aim of this study was to investigate predictors of response to antipsychotic treatment during the first episode of non-affective psychosis. 172 patients (107 male) with a diagnosis of schizophreniform, schizophrenia, schizoaffective, brief reactive psychosis, schizotypal personality disorder or psychosis non-otherwise specified entered the study. Sociodemographic, premorbid and clinical data at baseline were evaluated. Unpaired t-test for continuous and chi2 for categorical data, respectively, were used to compare responders and non-responders selected variables. Multivariate logistic regression was used to establish a prediction model. 57.6% of study subjects (99 of 172) responded to antipsychotic treatment. The following variables were significantly associated with less likelihood of response: 1.--lower severity of general psychopathology, positive symptoms and disorganized symptoms at baseline; 2.--earlier age of onset; 3.--diagnosis of schizophrenia; 4.--longer DUP; 5.--poorer premorbid adjustment during adolescence, and 6.--hospitalization. Multivariate logistic regression demonstrated that differences between responders and non-responders were largely accounted for by BPRS total score, age of onset, premorbid adjustment at early adolescence, and diagnosis. Patients with an early age of onset of schizophrenia, a poor premorbid adolescent functioning, and with a lower severity of psychopathology at intake seem to have a decrease likelihood of responding to antipsychotic treatment. Helping clinicians to identify non-responders is meant as a first step to optimise therapeutic effort to benefit individuals in this vulnerable group.

Delay in treatment for psychosis : its relation to family history

BACKGROUND

Recent evidence that treatment delay may compromise the potential for recovery from psychotic disorders has resulted in increased interest in factors that influence help seeking. In this paper, we test the hypotheses, derived from past research, that having a positive family history of a psychotic disorder in first or second degree relatives will be associated with a shorter duration of untreated psychosis (DUP), but a longer duration of untreated illness (DUI). Data were derived from 169 patients who presented for treatment to a first episode psychotic disorders program. Information was collected concerning family history, DUP, DUI and the timing of family recognition of the need for help.

RESULTS

The findings failed to confirm a positive family history being associated with shorter DUP, but did support the prediction of such a history being related to longer DUI. Paradoxically, given the latter findings, families with a history of psychotic illness were more likely to recognize the need for help for the ill person prior to the onset of psychotic symptoms. The difference in DUI appears to reflect the presence of a longer period of early signs prior to the emergence of psychosis in those cases with a positive family history.

CONCLUSIONS

These findings suggest the importance of examining family history as a possible confound of any relationship between DUI and long-term course of illness.

First-episode psychosis, early intervention, and outcome: what have we learned?

OBJECTIVE

There has been increased interest in the potential of early intervention to positively influence outcome in first-episode psychosis (FEP) and, consequently, to influence mental health policy and practice. This study's objective was to examine the concept of early intervention and the evidence that currently exists to support such a shift in the delivery of care.

METHOD

We examined the evidence for phase-specific treatment of FEP, looking for interventions that attempt to arrest the transition from a putative prodromal state to full psychosis, as well as for interventions that attempt to reduce delay in treatment.

RESULTS

Some evidence supports specialized FEP interventions for short-term outcome in terms of symptom reduction, relapse rates, and greater adherence to and retention in treatment. As well, there is modest support for benefits to aspects of social and community functioning and satisfaction with life. Limited evidence supports a positive effect of community-wide case detection in terms of reduced delays in treatment and pharmacologic and psychological interventions in the prodromal phase.

CONCLUSIONS

The field of early intervention in psychosis is young, with encouraging preliminary results, especially for improving outcome in established FEP. It requires further study, especially of longer-term outcome. Further studies need to examine the effects of a specialized approach on longer-term outcome and to explore cost-effective methods to reduce delays in treatment and provide interventions in the prodromal phase.