EEG abnormalities and 3-year outcome in first episode psychosis

The neurobiology of duration of untreated psychosis: a comprehensive review

Duration of untreated psychosis (DUP) is defined as the time from the onset of psychotic symptoms until the first treatment. Studies have shown that longer DUP is associated with poorer response rates to antipsychotic medications and impaired cognition, yet the neurobiologic correlates of DUP are poorly understood. Moreover, it has been hypothesized that untreated psychosis may be neurotoxic. Here, we conducted a comprehensive review of studies that have examined the neurobiology of DUP. Specifically, we included studies that evaluated DUP using a range of neurobiologic and imaging techniques and identified 83 articles that met inclusion and exclusion criteria. Overall, 27 out of the total 83 studies (32.5%) reported a significant neurobiological correlate with DUP. These results provide evidence against the notion of psychosis as structurally or functionally neurotoxic on a global scale and suggest that specific regions of the brain, such as temporal regions, may be more vulnerable to the effects of DUP. It is also possible that current methodologies lack the resolution needed to more accurately examine the effects of DUP on the brain, such as effects on synaptic density. Newer methodologies, such as MR scanners with stronger magnets, PET imaging with newer ligands capable of measuring subcellular structures (e.g., the PET ligand [11C]UCB-J) may be better able to capture these limited neuropathologic processes. Lastly, to ensure robust and replicable results, future studies of DUP should be adequately powered and specifically designed to test for the effects of DUP on localized brain structure and function with careful attention paid to potential confounds and methodological issues.

Recommendations for the medical work-up of first episode psychosis, including specific relevance to Indigenous Australians: A narrative review

AIMS

To collate existing literature for busy practicing psychiatrists about the medical work-up for first-episode psychosis (FEP). Therefore, (a) to review current guidelines for the medical work-up of first episode psychosis. (b) To examine whether any specific recommendations for Indigenous Australians exist. (c) To produce an easy reference table of evidence based investigations.

METHOD

A multi-part narrative review process was undertaken. Step 1 "Source identification and summary": identified key existing national and international guidelines and expert opinions related to the medical work-up of FEP and summarised these suggestions. Step 2 "Exploration of each investigation": examined each of the identified investigations for its importance. Step 3 "Relevance to Indigenous Australians": reviewed any particular relevance to the Indigenous Australian population. Step 4 "Clinician guide": involved presenting recommended investigations in a simple table.

RESULTS

Multiple guidelines were identified. There was clear consensus for many aspects. However, there were also differences in the approach for some investigations. Clinical reasoning for the proposed investigations was commonly absent. There were limited specific recommendations for Indigenous Australians. Evidence and importance was explored for each investigation and auseful table for the practicing psychiatrist was constructed. Investigations were stratified into those considered to be "universal," "low yield," or "unecessary."

CONCLUSION

A narrative review of multiple guidelines relating to the medical work-up of FEP identified many similarities and some differences to their approach. Little additional information exists for the Indigenous Australian context. A clinician friendly worksheet for everyday use may be helpful to busy clinicians.

First Episode Psychosis Medical Workup: Evidence-Informed Recommendations and Introduction to a Clinically Guided Approach

Evaluating the patient with first episode psychosis (FEP) requires a careful assessment that includes a thorough history, examination, and workup. This begins with a thoughtful consideration of the differential diagnoses and is followed and supported by laboratory, encephalographic, and imaging studies where appropriate. This article presents some of the diagnostic considerations for a patient presenting with psychosis with an emphasis on the secondary causes and proposes a tiered approach to the workup of FEP that is clinically guided.

Predicting Symptomatic and Functional Improvements over 1 Year in Patients with First-Episode Psychosis Using Resting-State Electroencephalography

OBJECTIVE

Although early intervention from the beginning of a psychotic episode is essential for a better prognosis, biomarkers predictive of symptomatic and functional improvement in early psychotic disorders are lacking. This study aimed to investigate whether the spectral power of resting-state electroencephalography (EEG) can be used as a predictive marker of the 1-year prognosis in patients with first-episode psychosis (FEP).

METHODS

Twenty-four patients with FEP and matched healthy control (HC) subjects were examined with resting-state EEG at baseline. The symptomatic severity and functional status of FEP patients were assessed at baseline and reassessed after 1 year of usual treatment. Repeated measures analysis of variance was conducted to compare EEG spectral powers across the groups. Multiple regression analysis revealed EEG spectral powers predictive of symptomatic and functional improvement in FEP patients at the 1-year follow-up.

RESULTS

Delta band power in the frontal and posterior regions was significantly higher in patients with FEP than in HCs. Higher delta band power in the posterior region predicted later improvement of positive symptoms and general functional status. Lower delta band power in the frontal region predicted improvement of negative symptoms and general functioning after 1 year.

CONCLUSION

These results suggest that increased delta absolute power is observed from the beginning of psychotic disorders. Furthermore, decreased delta power in the frontal region and increased delta power in the posterior region might be used as a predictive marker of a better prognosis of FEP, which would aid early intervention in clinical practice.

Neural oscillations in antipsychotic-naïve patients with a first psychotic episode

OBJECTIVES

In chronic schizophrenic psychoses, oscillatory abnormalities predominantly occur in prefrontal cortical regions and are associated with reduced communication across cortical areas. Nevertheless, it remains unclear whether similar alterations can be observed in patients with a first episode of psychosis (FEP), a state characterised by pathological features occurring in both late prodromal patients and initial phases of frank schizophrenic psychoses.

METHODS

We assessed resting-state electroencephalographic data of 31 antipsychotic-naïve FEP patients and 29 healthy controls (HC). We investigated the three-dimensional (3D) current source density (CSD) distribution and lagged phase synchronisation (LPS) of oscillations across small-scale and large-scale brain networks. We additionally investigated LPS relationships with clinical symptoms using linear mixed-effects models.

RESULTS

Compared to HC, FEP patients demonstrated abnormal CSD distributions in frontal areas of the brain; while decreased oscillations were found in the low frequencies, an increase was reported in the high frequencies (P < 0.01). Patients also exhibited deviant LPS in the high frequencies, whose dynamics changed over increasing 3D cortico-cortical distances and increasing psychotic symptoms.

CONCLUSIONS

These results indicate that in addition to prefrontal cortical abnormalities, altered synchronised neural oscillations are also present, suggesting possible disruptions in cortico-cortical communications. These findings provide new insights into the pathophysiological mechanisms of emerging schizophrenic psychoses.

The course of negative symptoms over the first five years of treatment: Data from an early intervention program for psychosis

BACKGROUND

Cross-sectional studies suggest that negative symptoms are constituted by separable domains of reduced expressiveness and reduced motivation, but there is little data on the longitudinal course of these symptoms. We examined evidence for differences in the course and correlates of these two domains in a prospective study of patients presenting with a first episode of psychosis.

METHODS

Of 132 patients who were followed up for five years, it was possible to monitor reduced expressiveness and motivation on a weekly basis for 127. Information on treatment delay, premorbid adjustment, intellectual functioning, anxiety, depression and psychosocial functioning were also collected.

RESULTS

Over the five year follow-up, symptoms of reduced motivation occurred in 95.3% of patients and reduced expressiveness in 68.5%; and deficits in motivation were more likely to be unremitting (15.7%) than expressive deficits (5.5%). There were differences in the correlates of the proportion of time each patient experienced symptoms of each domain. Depression, weeks of full time occupation and weeks on a disability pension were associated with both domains. Anxiety was associated only with diminished motivation. Lower performance IQ; extrapyramidal symptoms (EPS) and dysrhythmic EEG were associated only with proportion of time showing reduced expressiveness.

CONCLUSIONS

The prospective data support previous cross-sectional findings that, while these domains of negative symptoms are correlated, they do show differences in prevalence over time and in their correlates.

Electroencephalography Spectral Power Density in First-Episode Mania: A Comparative Study with Subsequent Remission Period

INTRODUCTION

Our aim in this study was to investigate spectral power density (PSD) in first-episode mania and subsequent remission period and to evaluate their difference.

METHODS

Sixty-nine consecutive cases referring to our hospital within the previous 1 year, who were evaluated as bipolar disorder manic episode according to The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) at the first episode and had the informed consent form signed by first degree relatives, were included in this study. Exclusion criteria included having previous depressive episode, using drugs which could influence electroencephalographic activity before electroencephalography (EEG), and having previous neurological disease, particularly epilepsy, head trauma, and/or loss of consciousness. EEG records were obtained using a digital device in 16 channels; 23 surface electrodes were placed according to the International 10-20 system. Spectral power density (dbμV/Hz) of EEG signal provided information on the power carried out by EEG waves in defined frequancy range per unit frequency in the present study.

RESULTS

A peak power value detected on the right with FP2P4 and on the left with F7T3 electrodes were found to be higher in the manic episode than in the remission period (p=0.018 and 0.025). In the remission period, in cases with psychotic symptoms during the manic period, F4C4 peak power value was found to be lower than that in cases with no psychotic findings during the manic period (p=0.027). There was no relation was found between YMRS scores and peak power scores.

CONCLUSION

Electrophysiological corollary of mood episode is present from the onset of the disease, and it differs between the manic and remission periods of bipolar disorder. In the remission period, peak power values of PSD distinguish cases with psychotic findings from cases without psychotic findings when they were manic.

The use of clinical and biological characteristics to predict outcome following First Episode Psychosis

OBJECTIVE

Psychotic illnesses such as schizophrenia and other non-affective psychoses are heterogeneous in disease course and functional outcomes. We review evidence from investigations in clinical psychiatry, neuroimaging, neurocognition, and blood biomarker research suggesting that distinct bio-psycho-social patterns exist at the onset and during the early phase of a First Episode Psychosis (FEP), which can describe the risk of individual illness progression and functional trajectories.

METHOD

A selective literature review was performed on articles drawn from Medline searches for relevant key words. A simulation model was constructed from data derived from two recent publications, selected as examples of studies that investigated multivariate predictors of long-term outcome following FEP.

RESULTS

We illustrate how illness trajectories following FEP could be described based on multimodal sociodemographic, clinical, psychological, and neurobiological information. A clinical modeling simulation shows thatrisk trajectories for achieving long-term favorable or unfavorable outcomes can differ significantly depending on baseline characteristics in combination with MRI and functional measurements within 6 months of disease onset.

CONCLUSIONS

Multimodal trajectory modeling may be useful to describe longitudinal outcomes following FEP. Richlongitudinal data on predictors and outcomes, and better integration of multimodal (sociodemographic, clinical, psychological, biological) data, are required to operationalize this approach. This technique may improve our understanding of course of illness and help to provide a more personalized approach to the assessment and treatment of people presenting with FEP.

Electroencephalographic abnormalities and 5-year outcome in first-episode psychosis

OBJECTIVE

To examine the relation of electroencephalographic abnormalities to 5-year outcomes in first-episode psychosis (FEP).

METHODS

Patients (n = 103) had their baseline electroencephalogram (EEG) classified by modified Mayo Clinic criteria. Symptoms and psychosocial functioning were rated after 5 years of treatment.

RESULTS

Dysrhythmic EEG was associated with persistence in positive and negative symptoms of psychoses and poorer psychosocial functioning at 5-year follow-up, independently of other characteristics, such as duration of untreated illness or premorbid adjustment. A higher percentage of people with comorbid substance use disorder had normal EEG.

CONCLUSIONS

Abnormal baseline EEG in FEP is associated with poorer 5-year symptomatic and functional outcome.

Electrophysiological aberrations associated with negative symptoms in schizophrenia

Clinical heterogeneity is a confound common to all of schizophrenia research. Deficit schizophrenia has been proposed as a homogeneous disease entity within the schizophrenia syndrome. The use of the Schedule for the Deficit Syndrome (SDS) has allowed the definition of a subgroup dominated by persistent and primary negative symptoms. While a number of studies have appeared over the years examining the electrophysiological correlates of the cluster of negative symptoms in schizophrenia, only a few studies have actually focused on the Deficit Syndrome (DS). In this chapter, electrophysiological investigations utilizing EEG, Evoked Potentials (EPs), polysomnography (PSG), or magnetoencephalography (MEG) to probe "negative symptoms," or "Deficit Syndrome" are reviewed. While this line of research is evidently in its infancy, two significant trends emerge. First, spectral EEG studies link increased slow wave activity during wakefulness to the prevalence of negative symptoms. Second, sleep studies point to an association between decrease in slow wave sleep and prevalence of negative symptoms. Several studies also indicate a relationship of negative symptoms with reduced alpha activity. A host of other abnormalities including sensory gating and P300 attenuation are less consistently reported. Three studies specifically addressed electrophysiology of the DS. Two of the three studies provided evidence suggesting that the DS may be a separate disease entity and not simply a severe form of schizophrenia.

Advances in electrophysiology in the diagnosis of behavioral disorders

INTRODUCTION

Diagnosis in psychiatry remains largely subjective. Developing biological observations in psychiatric disorders into laboratory-based diagnostic tests can significantly impact diagnosis and management of these disorders. Diagnostic electrophysiological techniques are non-invasive and relatively inexpensive.

AREAS COVERED

In this review, the authors propose that enough knowledge has accumulated to allow the establishment of psychiatry-based clinical electrophysiology laboratories (PCELs). A brief summary of established clinical indications for electrophysiology tests, summary of highly promising technologies and a presentation of a proposed four-step approach to facilitate the translation of promising biological observations into diagnostic tests are provided. The reader should develop an appreciation of the current status of the clinical applications of psychiatric electrophysiology. The authors propose to capitalize on the widely accepted indication to rule out medical causes of psychiatric symptoms (e.g., epileptic activity) to begin developing PCELs as the equipment and skills necessary are basic to the entire discipline. The potential impact of the growing knowledge on the practice of psychiatry is explored to update clinicians and administrators as they develop laboratory and service plans.

EXPERT OPINION

Psychiatric electrophysiology currently plays a limited role in the diagnosis and management in psychiatry. This status is not supported by the existing literature. The underutilization of electrophysiological tests in psychiatry is propagated by the fact that the laboratories providing the service are not managed by psychiatrists. The authors propose that the first steps are to establish such laboratories and train psychiatrists to competently provide the service.

Initial medical work-up of first-episode psychosis: a conceptual review

AIM

To help clinicians carry out a comprehensive, medical diagnostic assessment in first-episode patients who are suspected of developing schizophrenia.

METHODS

Conceptual review of the published work with emphasis on the diagnostic goals of excluding medical causes of psychosis and establishing a medical baseline.

RESULTS

There is no agreed-upon standard for the initial medical work-up of first-episode cases. Excluding secondary causes of schizophrenia requires consideration of likelihood of disease; laboratory test performance; and relevance of positive test results.

CONCLUSIONS

We propose a medical work-up for first-episode psychosis that combines: (i) broad screening; (ii) exclusion of specific diseases informed by treatability and epidemiology; and (iii) medical baseline measures.