Identifying persistent negative symptoms in first episode psychosis

Persistent negative symptoms in young people at clinical high risk of psychosis treated with an Italian early intervention program: a longitudinal study

Negative symptoms in CHR-P people are generally not responsive to treatments and commonly related to poorer functional outcome. However, less research attention has been dedicated to Persistent Negative Symptoms (PNS), defined as clinically stable negative symptoms of moderate severity evident for at least 6 months. This study aims to (a) determine the prevalence of PNS in a sample of young people at CHR-P; (b) investigate any association of PNS with functioning and clinical features; (c) examine longitudinal course of PNS across 2 years of follow-up and changes in PNS severity levels with specialized treatments. One Hundred Eighty CHR-P participants were recruited and were divided into CHR-P/PNS + and CHR-P/PNS- subgroups. The clinical assessments were based on the PANSS and the GAF and were conducted at baseline and every 12 months during the follow-up. Twenty four participants showed PNS at entry. Of them, 21 concluded the 2-year follow-up period. At baseline, the CHR-P/PNS + participants showed more educational and employment deficits, and more social and functioning impairment. During the follow-up, the CHR-P/PNS + subgroup had a significant longitudinal decrease in negative symptoms, which was specifically related to antidepressant treatment. CHR-P/PNS + subjects also showed a higher incidence of new hospitalization and a lower functional recovery over time. Our findings support that the persistence of negative symptoms in CHR-P people is longitudinally related to worse daily functioning and more severe clinical conditions that are at higher risk of hospitalization and are less responsive to specialized treatments.

Time is the enemy: Negative symptoms are related to even slight differences in the duration of untreated psychosis

BACKGROUND

Negative symptoms (NS) represent a detrimental symptomatic domain in schizophrenia affecting social and occupational outcomes.

AIMS

We aimed to identify factors from the baseline visit (V1) - with a mean illness duration of 0.47 years (SD = 0.45) - that predict the magnitude of NS at the follow-up visit (V3), occurring 4.4 years later (mean +/- 0.45).

METHOD

Using longitudinal data from 77 first-episode schizophrenia spectrum patients, we analysed eight predictors of NS severity at V3: (1) the age at disease onset, (2) age at V1, (3) sex, (4) diagnosis, (5) NS severity at V1, (6) the dose of antipsychotic medication at V3, (7) hospitalisation days before V1 and; (8) the duration of untreated psychosis /DUP/). Secondly, using a multiple linear regression model, we studied the longitudinal relationship between such identified predictors and NS severity at V3 using a multiple linear regression model.

RESULTS

DUP (Pearson's r = 0.37, p = 0.001) and NS severity at V1 (Pearson's r = 0.49, p < 0.001) survived correction for multiple comparisons. The logarithmic-like relationship between DUP and NS was responsible for the initial stunning incremental contribution of DUP to the severity of NS. For DUP < 6 months, with the sharpest DUP/NS correlation, prolonging DUP by five days resulted in a measurable one-point increase in the 6-item negative symptoms PANSS domain assessed 4.9 (+/- 0.6) years after the illness onset. Prolongation of DUP to 14.7 days doubled this NS gain, whereas 39 days longer DUP tripled NS increase.

CONCLUSION

The results suggest the petrification of NS during the early stages of the schizophrenia spectrum and a crucial dependence of this symptom domain on DUP. These findings are clinically significant and highlight the need for primary preventive actions.

Unveiling the potential of machine learning in schizophrenia diagnosis: A meta-analytic study of task-based neuroimaging data

The emergence of machine learning (ML) techniques has opened up new avenues for identifying biomarkers associated with schizophrenia (SCZ) using task-related fMRI (t-fMRI) designs. To evaluate the effectiveness of this approach, we conducted a comprehensive meta-analysis of 31 t-fMRI studies using a bivariate model. Our findings revealed a high overall sensitivity of 0.83 and specificity of 0.82 for t-fMRI studies. Notably, neuropsychological domains modulated the classification performance, with selective attention demonstrating a significantly higher specificity than working memory (β = 0.98, z = 2.11, P = 0.04). Studies involving older, chronic patients with SCZ reported higher sensitivity (P <0.015) and specificity (P <0.001) than those involving younger, first-episode patients or high-risk individuals for psychosis. Additionally, we found that the severity of negative symptoms was positively associated with the specificity of the classification model (β = 7.19, z = 2.20, P = 0.03). Taken together, these results support the potential of using task-based fMRI data in combination with machine learning techniques to identify biomarkers related to symptom outcomes in SCZ, providing a promising avenue for improving diagnostic accuracy and treatment efficacy. Future attempts to deploy ML classification should consider the factors of algorithm choice, data quality and quantity, as well as issues related to generalization.

Dimensional characteristics of persistent negative symptoms in schizophrenia and their relationships with schizotypy in first-degree relatives

PURPOSE OF THE ARTICLE

Schizophrenia with persistent negative symptoms (PNS) may have different characteristics regarding negative symptom dimensions and heritability patterns. This study aimed to investigate the dimensional characteristics of PNS and their relationships with schizotypal features in first-degree relatives (FDRs).

MATERIALS AND METHODS

The study included 142 patients, 142 FDRs, and 71 healthy controls (HC). Patients were evaluated with the Positive and Negative Symptom Scale (PANSS), Brief Negative Symptom Scale (BNSS), Calgary Depression Scale for Schizophrenia (CDSS), and Simpson-Angus Scale (SAS). Schizotypy Personality Questionnaire was applied to FDR and HC groups. Clinical symptoms were compared between primary-PNS, secondary-PNS, and non-PNS groups. In addition, schizotypy scores were compared between FDRs and HCs. Then, the relationship between the symptoms of the patients in the PNS group and the schizotypy scores of their relatives was evaluated by multiple regression analysis.

RESULTS

All negative symptom dimension scores were similar in primary-PNS and secondary-PNS and lowest in non-PNS. PNS-FDR had higher in all schizotypy scores than non-PNS-FDR and HC, except for lack of close friends and social anxiety. In the PNS group, positive symptom severity and PANSS experiential deficit scores significantly predicted positive and negative schizotypy scores in relatives. Negative schizotypy was associated with asociality.

CONCLUSIONS

The PNS is likely a subtype in which the genetic basis of negative symptoms is stronger and is associated with genetic abnormalities shared by positive and negative schizotypy dimensions in relatives. Family-based genetic studies will be beneficial in enlightening the genetic etiology of PNS.

Identifying risk factors for predominant negative symptoms from early stages in schizophrenia: A longitudinal and sex-specific study in first-episode schizophrenia patients

BACKGROUND

People with schizophrenia and predominant negative symptoms (PNS) present a different clinical and functional profile from those without such symptomatology. Few studies have examined the risk factors and the incidence of PNS in first-episode schizophrenia patients (FES) and differentiating by sex. This study aims to assess prevalence, demographic and clinical characteristics related to PNS from early stages and to study if there are sex-specific features in terms of developing PNS.

METHODS

In a sample of 121 FES patients derived from a multicentre and naturalistic study, those who developed PNS at 12-months were identified. Environmental, clinical, functional, and cognitive ratings were examined longitudinally. Binary logistic regressions were applied to detect baseline risk factors for developing PNS at one-year follow-up.

RESULTS

In the present FES cohort, 24.8% of the patients (n=30) developed PNS (20% of the women, 27.6% of the men). Compared to non-PNS (75.2%, n=91), at baseline, PNS group had more negative (t=-6.347; p<0.001) and depressive symptoms (t=-5.026; p<0.001), poorer premorbid adjustment (t=-2.791; p=0.006) and functional outcome (t=-2.649; p<0.001), more amotivation (t=-7.333; p<0.001), more expressivity alterations (t=-4.417; p<0.001), worse cognitive reserve (t=2.581; p<0.011), a lower estimated intelligent quotient (t=2.417; p=0.017), worse verbal memory (t=2.608; p=0.011), and worse fluency (t=2.614; p=0.010). Regressions showed that the premorbid adjustment was the main predictor of PNS in females (p=0.007; Exp(B)=1.106) while in males were a worse verbal memory performance (p=0.031; Exp(B)=0.989) and more alterations in the motivation domain (p=0.001; Exp(B)=1.607).

CONCLUSIONS

A different baseline clinical profile and notable risk factors differences in the development of PNS between males and females were found. Results suggest that sex may be an important confounder in studies comparing schizophrenia patients with predominant and non-predominant negative symptomatology.

The Self-Evaluation of Negative Symptoms in Differentiating Deficit Schizophrenia: The Comparison of Sensitivity and Specificity with Other Tools

INTRODUCTION

Psychometric properties of the Self-evaluation of Negative Symptoms (SNS) in subjects with the deficit subtype of schizophrenia (SCZ-D) have not been investigated so far. This study had the following aims: (1) to assess psychometric properties of SNS in subjects with SCZ-D and (2) to explore the usefulness of SNS, in comparison with other clinical characteristics, in screening for SCZ-D.

METHODS

Participants were 82 stable outpatients with schizophrenia, including 40 individuals with SCZ-D and 42 individuals with the non-deficit subtype (SCZ-ND).

RESULTS

Internal consistency was acceptable-to-good in both groups. Factor analysis revealed two dimensions (apathy and emotional). There were significant positive correlations of the SNS total score with the subscore of negative symptoms from the Positive and Negative Syndrome Scale (PANSS) and significant negative correlations with scores of the Social and Occupational Functioning Assessment Scale (SOFAS) in both groups, indicating good convergent validity. The following measures were found to be appropriate screening tools for differentiating SCZ-D and SCZ-ND (p < 0.001): the SNS total score (area under the curve [AUC]: 0.849, cut-off ≥16, sensitivity: 80.0%, specificity: 78.6%), the PANSS subscore of negative symptoms (AUC: 0.868, cut-off ≥11, sensitivity: 90.0%, specificity: 78.6%), and the SOFAS (AUC: 0.779, cut-off ≤59, sensitivity: 69.2%, specificity: 82.5%). Also, adding the SOFAS (cut-off ≤59) to the SNS (cut-off: ≥16) further improved sensitivity and specificity (AUC: 0.898, p < 0.001, sensitivity = 87.5%, specificity = 82.2%). Cognitive performance and age of psychosis onset were not found to be suitable measures for differentiating SCZ-D and SCZ-ND.

CONCLUSION

The present findings indicate that the SNS has good psychometric properties in subjects with SCZ-D and those with SCZ-ND. Moreover, the SNS, the PANSS, and the SOFAS might be used as screening tools for SCZ-D.

Subtyping negative symptoms in first-episode psychosis: Contrasting persistent negative symptoms with a data-driven approach

Persistent negative symptoms (PNS) are linked to poor functional outcomes and may be primary or caused by secondary factors. Although several studies have examined PNS in first-episode psychosis (FEP), a comparison with a data-driven approach is lacking. Here, we compared clinically defined PNS subgroups with class trajectories identified through latent growth modeling (LGM). Patients admitted to an early intervention service (N = 392) were classified as PNS (n = 105), secondary PNS (sPNS; n = 74), or non-PNS (n = 213) based on longitudinal data collected six to twelve months after admission. LGM was used to stratify patients based on similar negative symptom course over the same time period. Using multiple linear regression, we assessed the utility of both approaches in predicting Social and Occupational Functioning Assessment Scale (SOFAS) scores at two-year follow-up. Three negative symptom trajectories were identified: low and remitting (LR; n = 158), moderate and improving (MI; n = 163) and delayed partial response (DR; n = 71). Most non-PNS patients followed the LR trajectory, while patients with PNS or sPNS were generally divided between MI and DR. Both PNS classification and trajectory membership were significant predictors of two-year functional outcomes; the DR and MI trajectories predicted greater increases in SOFAS scores (DR: b = -19.14; MI: b = -11.54) than either sPNS (b = -9.19) or PNS (b = -6.46). These findings demonstrate that combining PNS and symptom-based stratification can predict functional outcomes more accurately than either taxonomy alone. Such a combined approach could yield significant advances in developing more targeted interventions for patients at risk for poor functional outcomes.

Longitudinal persistence of negative symptoms in young individuals with first episode schizophrenia: a 24-month multi-modal program follow-up

PURPOSE

Persistent Negative Symptoms (PNS) affect real-world functioning already at the onset of schizophrenia. Longitudinal studies on beneficial effects of psychosocial treatments for PNS in First Episode Schizophrenia (FES) are still relatively scarce. The aim of the current study was to evaluate the longitudinal persistence of PNS in young FES individuals treated according to the multimodal "Early Intervention in Psychosis" (EIP) program over a 2-year follow-up period.

MATERIALS AND METHODS

133 FES subjects (aged 12-35 years) were recruited within the Italian EIP program and completed the Positive And Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF). In accordance with the PNS criteria, we dichotomized FES individuals with and without PNS. In the FES group with PNS, a multiple linear regression analysis was conducted to examine relevant associations between longitudinal PNS levels and the specialized treatment components of our EIP protocol.

RESULTS

Twenty (15%) FES participants met the PNS criteria. At baseline, PNS levels had relevant positive correlations with functioning decline and PANSS total score. At the end, the 2-years follow-up period, FES subjects with PNS showed a significant decrease in PNS levels. In our linear regression analysis, this reduction was associated with a higher number of individual psychotherapy and case management sessions delivered during our follow-up (together with a shorter DUP [Duration of Untreated Psychosis]).

CONCLUSIONS

PNS are clinically relevant in a minority of FES individuals. Our results suggest that patient-tailored psychosocial interventions can reduce clinical severity of PNS over a 2-year period.

Contrasting Frontoparietal Network Connectivity in Antipsychotic Medication-Naive First-Episode Psychosis Patients Who Do and Do Not Display Features of the Deficit Syndrome

BACKGROUND

The deficit syndrome is a clinical subtype of schizophrenia that is characterized by enduring negative symptoms. Several lines of evidence point to frontoparietal involvement, but the frontoparietal control network (FPCN) and its subsystems (FPCNA and FPCNB) proposed by Yeo et al. have not been systematically characterized at rest in patients with the deficit syndrome.

METHODS

We used resting-state fMRI to investigate the FPCN and its subnetworks in 72 healthy controls and 65 antipsychotic medication-naive, first-episode psychosis patients (22 displayed deficit syndrome features, 43 did not). To assess whole-brain FPCN connectivity, we used the right posterior parietal cortex as the seed region. We then performed region of interest analyses in FPCN subsystems.

RESULTS

We found that patterns of FPCN dysconnectivity to the whole brain differed in patients who displayed deficit syndrome features compared with those who did not. Examining the FPCN on a more granular level revealed reduced within-FPCN(A) connectivity only in patients displaying deficit features. FPCNB connectivity did not differ between patient groups.

DISCUSSION

Here, we describe a neurobiological signature of aberrant FPCN connectivity in antipsychotic-naive, first-episode patients who display clinical features of the deficit syndrome. Importantly, frontoparietal subnetwork connectivity differentiated subgroups, where the FPCNA is selectively involved in patients with deficit features. Our findings add to the growing body of literature supporting a neurobiological distinction between two clinical subtypes of schizophrenia, which has the potential to be leveraged for patient stratification in clinical trials and the development of novel treatments.

Medial temporal lobe and basal ganglia volume trajectories in persistent negative symptoms following a first episode of psychosis

BACKGROUND

Persistent negative symptoms (PNS, e.g., avolition, anhedonia, alogia) are present in up to 30% of individuals diagnosed with a first episode of psychosis and greatly impact functional outcomes. PNS and secondary PNS (sPNS: concomitant with positive, depressive, or extrapyramidal symptoms) may index distinct pathophysiologies reflected by structural brain changes, particularly in the medial temporal lobe (MTL) and basal ganglia.

AIMS

We sought to characterize dynamic brain changes related to PNS over the course of 2 years following a first episode of psychosis.

METHOD

Longitudinal volumetric trajectories within the MTL (hippocampus, parahippocampal gyrus, entorhinal cortex, perirhinal cortex) and basal ganglia (caudate, putamen, pallidum) were investigated in 98 patients with first-episode psychosis and 86 healthy controls using generalized estimating equations.

RESULTS

In left hippocampus, PNS (n = 25 at baseline) showed decreased volumes over time, sPNS (n = 26) volumes remained stable, and non-PNS (n = 47) volumes increased over time to control levels. PNS-specific changes were observed in left hippocampus and left perirhinal cortex, with the greatest decline from 12 to 24 months to levels significantly below those of non-PNS and controls. Affective/non-affective diagnosis, antipsychotic medication dosage and adherence at baseline did not significantly impact these findings. Basal ganglia volume trajectories did not distinguish between PNS and sPNS.

CONCLUSIONS

The current study highlights distinct structural brain trajectories in PNS that are prominent in the left MTL. Basal ganglia alterations may contribute to PNS irrespective of their etiology. Left MTL volume reductions were most evident after 1 year of treatment, highlighting the importance of targeted early interventions.

Updated perspectives on the clinical significance of negative symptoms in patients with schizophrenia

INTRODUCTION

Negative symptoms in schizophrenia are associated with poor response to available treatments, poor quality of life, and functional outcome. Therefore, they represent a substantial burden for people with schizophrenia, their families, and health-care systems.

AREAS COVERED

In this manuscript, we will provide an update on the conceptualization, assessment, and treatment of this complex psychopathological dimension of schizophrenia.

EXPERT OPINION

Despite the progress in the conceptualization of negative symptoms and in the development of state-of-the-art assessment instruments made in the last decades, these symptoms are still poorly recognized, and not always assessed in line with current conceptualization. Every effort should be made to disseminate the current knowledge on negative symptoms, on their assessment instruments and available treatments whose efficacy is supported by research evidence. Longitudinal studies should be promoted to evaluate the natural course of negative symptoms, improve our ability to identify the different sources of secondary negative symptoms, provide effective interventions, and target primary and persistent negative symptoms with innovative treatment strategies. Further research is needed to identify pathophysiological mechanisms of primary negative symptoms and foster the development of new treatments.

Impact of Negative Symptoms on Functioning and Quality of Life in First Psychotic Episodes of Schizophrenia

Negative symptoms are not considered a unitary construct encompassing two different domains, diminished expression, and avolition-apathy. The aim of this study was to explore the relationships between each domain and psychosocial functioning and quality of life in people with a first psychotic episode of schizophrenia. In total, 61 outpatients were assessed with the Clinical Assessment Interview for Negative Symptoms (CAINS), The Functioning Assesment Short Test (FAST) and The Quality of Life Scale (QLS). The mean global score for CAINS was 21.5 (SD: 15.6), with a CAINS Avolition-Apathy (MAP) score of 17.0 (SD: 11.8), and CAINS Diminished Expression (EXP) score of 4.5 (SD: 5.0). The mean FAST score was 31.9 (SD: 18.9), and 41.1 (SD: 17.9) for QLS. Linear regression analysis revealed a significant (F(4,53) = 15.65, p < 0.001) relationship between MAP and EXP CAINS’ score and FAST score. CAINS-MAP was more predictive of FAST scores (β = 0.44, p = 0.001) than CAINS-EXP (β = 0.37, p = 0.007). Linear regression analysis for QLS revealed a significant model (F(4,56) = 29.29, p < 0.001). The standardized regression weight for the CAINS-MAP was around three times greater (β = −0.63, p < 0.001) than for CAINS-EXP (β = −0.24, p = 0.024). The two different domains are associated differently with functionality and quality of life.

The Relationship Between the Recognition of Basic Emotions and Negative Symptoms in Individuals With Schizophrenia Spectrum Disorders - An Exploratory Study

Current research suggests that emotion recognition is impaired in individuals affected by schizophrenia spectrum disorders (SSD). However, the specific impact of negative symptoms on the ability to recognize single basic emotions has not yet been explored sufficiently and is the aim of the present study. A sample of N = 66 individuals diagnosed with SSD was recruited at the Charité - Universitätsmedizin Berlin. In a first step, correlation analyses were conducted between seven different negative symptom subdomains of the Positive and Negative Syndrome Scale (PANSS) and the accuracy and latency in recognizing the six basic emotions (anger, disgust, fear, happiness, sadness, surprise) using the Emotion Recognition Task (ERT) of the Cambridge Neuropsychological Test Automated Battery (CANTAB). The significant correlations were subjected to linear regression models that controlled for the significant covariates diagnoses, age, sex, and education. Results revealed that in individuals with SSD the negative symptom domain of blunted affect significantly predicted the accuracy of emotion recognition performance (p < 0.05), particularly, when recognizing happiness (p < 0.05). Additionally, we found that stereotyped thinking also predicted the performance of emotion recognition, especially the response latency (p < 0.05) and difficulty in abstract thinking predicted the recognition of fear (p < 0.05). However, the nominal significances did not withstand correction for multiple tests and therefore need to be followed up in further studies with a larger sample.

Proportion and predictors of remission and recovery in first-episode psychosis: Systematic review and meta-analysis

Background

To determine the proportion of patients in symptomatic remission and recovery following a first-episode of psychosis (FEP).

Methods

A multistep literature search using the Web of Science database, Cochrane Central Register of Reviews, Ovid/PsychINFO, and trial registries from database inception to November 5, 2020, was performed. Cohort studies and randomized control trials (RCT) investigating the proportion of remission and recovery following a FEP were included. Two independent researchers searched, following PRISMA and MOOSE guidelines and using a PROSPERO protocol. We performed meta-analyses regarding the proportion of remission/recovery (symptomatic plus functional outcomes). Heterogeneity was measured employing Q statistics and I² test. To identify potential predictors, meta-regression analyses were conducted, as well as qualitative reporting of studies included in a systematic review. Sensitivity analyses were performed regarding different times of follow-up and type of studies.

Results

One hundred articles (82 cohorts and 18 RCTs) were included in the meta-analysis. The pooled proportion of symptomatic remission was 54% (95%CI [30, 49–58]) over a mean follow-up period of 43.57 months (SD = 51.82) in 76 studies. After excluding RCT from the sample, the proportion of remission remained similar (55%). The pooled proportion of recovery was 32% (95%CI [27–36]) over a mean follow-up period of 71.85 months (SD = 73.54) in 40 studies. After excluding RCT from the sample, the recovery proportion remained the same. No significant effect of any sociodemographic or clinical predictor was found.

Conclusions

Half of the patients are in symptomatic remission around 4 years after the FEP, while about a third show recovery after 5.5 years.

Deficit syndrome in Chinese patients with first-episode drug naïve schizophrenia: Prevalence, demographic and clinical characteristics

BACKGROUND

Deficit syndrome (DS) is a common subgroup of schizophrenia. However, few studies have examined the prevalence and risk factors for DS in Chinese Han patients with schizophrenia. The aim of this study was to assess prevalence, demographic and clinical characteristics of DS in Chinese Han patients with first-episode drug naïve (FEDN) schizophrenia.

METHODS

In total, 235 patients with schizophrenia were recruited, and clinical and demographic data were collected. The Positive and Negative Syndrome Scale (PANSS) was utilized for the psychopathological symptoms, and the 17-item Hamilton Depression Rating Scale (HDRS-17) for depressive symptoms. The Proxy for the Deficit Syndrome (PDS) was adopted to identify DS.

RESULTS

The prevalence of DS in the cohort of first-episode schizophrenia patients was 23.0%. Compared to those patients without DS, patients with DS had younger age, lower education level, and were more likely to be single. Further, DS patients had significantly lower scores of positive symptoms, general psychopathology, and depression than non-DS patients. Patients with DS had fewer suicide attempts, but they had more severe negative symptoms and cognitive impairment (all p < 0.05). Multiple regression showed that poor cognitive functioning, lower levels of depression and younger age at onset were predictors of DS.

CONCLUSIONS

Chinese Han patients with FEDN schizophrenia have high prevalence of DS. Some demographic and clinical parameters may be associated with DS.

Dynamic Interplay Between Insight and Persistent Negative Symptoms in First Episode of Psychosis: A Longitudinal Study

Persistent negative symptoms (PNS) are an important factor of first episode of psychosis (FEP) that present early on in the course of illness and have a major impact on long-term functional outcome. Lack of clinical insight is consistently associated with negative symptoms during the course of schizophrenia, yet only a few studies have explored its evolution in FEP. We sought to explore clinical insight change over a 24-month time period in relation to PNS in a large sample of FEP patients. Clinical insight was assessed in 515 FEP patients using the Scale to assess Unawareness of Mental Disorder. Data on awareness of illness, belief in response to medication, and belief in need for medication were analyzed. Patients were divided into 3 groups based on the presence of negative symptoms: idiopathic (PNS; n = 135), secondary (sPNS; n = 98), or absence (non-PNS; n = 282). Secondary PNS were those with PNS but also had clinically relevant levels of positive, depressive, or extrapyramidal symptoms. Our results revealed that insight improved during the first 2 months for all groups. Patients with PNS and sPNS displayed poorer insight across the 24-month period compared to the non-PNS group, but these 2 groups did not significantly differ. This large longitudinal study supported the strong relationship known to exist between poor insight and negative symptoms early in the course of the disorder and probes into potential factors that transcend the distinction between idiopathic and secondary negative symptoms.

Neurocognitive functions in persistent negative symptoms following a first episode of psychosis

Negative symptoms are present at the onset of psychosis and their persistence is significantly associated with poor psychosocial functioning and lower quality of life. Persistent negative symptoms (PNS) may be idiopathic or secondary to other factors such as depression, positive symptoms, and medication side-effects. Several studies have examined neurocognitive functions in early psychosis patients with PNS relative to non-PNS, but have not systematically controlled for secondary PNS (sPNS). The latter may have a distinct neurocognitive profile that could obscure differences between PNS and non-PNS. Using a large (n = 425) sample, we examined neurocognitive functions in PNS, sPNS, and non-PNS and hypothesized that PNS would be associated with greater impairments relative to non-PNS. Following admission to an early intervention program, a neurocognitive battery was administered after at least 3 months of treatment, and symptom data collected during a subsequent 6-month period were used to classify patients as PNS, sPNS and non-PNS. At month 12, both PNS and sPNS groups had significantly lower level of functioning relative to the non-PNS group but the sPNS group experienced higher levels of depressive and positive symptoms and were on a higher dose of antipsychotics. Relative to non-PNS, PNS patients exhibited significant impairments in verbal memory and working memory, whereas sPNS patients exhibited a trend towards greater impairments in verbal memory. This study confirms that the presence of PNS or sPNS negatively influences functioning with more selective cognitive impairments found in PNS, providing evidence that these groups of patients could benefit from different personalised interventions.

White Matter Neurometabolic Signatures Support the Deficit and Nondeficit Distinction in Antipsychotic-Naïve First-Episode Psychosis Patients

The deficit syndrome is thought to be a more homogenous clinical subgroup within the syndrome of schizophrenia that is characterized by enduring negative symptoms. It is hypothesized that distinct pathophysiological processes underlie the subtypes, where the deficit syndrome reflects an early onset nonprogressive developmental process, and the nondeficit form of the illness is characterized by attenuated neuroplasticity secondary to elevated glutamate levels. We used single-voxel magnetic resonance spectroscopy (PRESS; TE: 30 ms) to measure left frontal white matter neurometabolite levels in 61 antipsychotic-naïve first-episode psychosis patients (39 who did not display deficit features, 22 who did display deficit features, assessed with the Schedule for the Deficit Syndrome) and 59 healthy controls. Metabolite levels were quantified with the LCModel. We used a MANCOVA to determine neurometabolite differences between healthy controls, deficit syndrome patients, and nondeficit patients. We report a significant group difference when all metabolites were considered jointly (F[10,208] = 2.16; P = .02). Post hoc analyses showed that patients presenting without deficit features had higher glutamate levels than patients with deficit features and controls. Patients presenting without deficit features also had significantly higher myoinositol levels than controls; myoinositol levels were trend-level higher in patients presenting with deficit features compared to controls. Our data support the idea that the pathophysiology of patients presenting without deficit features may differ from those presenting with deficit features.

Persistent negative symptoms in youth at clinical high risk for psychosis: A longitudinal study

BACKGROUND

Severity of negative symptoms has been associated with poor functioning, cognitive deficits, and defeatist beliefs in schizophrenia patients. However, one area that remains understudied is persistent negative symptoms (PNS). Negative symptoms, including PNS, have been observed in those at clinical high-risk (CHR) for psychosis. The aim of this study was to determine if PNS were associated with functioning, neurocognition, and defeatist beliefs in a CHR sample.

METHOD

CHR participants (n = 764) were recruited for the North American Prodrome Longitudinal Study. Negative symptoms were rated on the Scale of Psychosis-risk Symptoms. Generalized linear mixed models for repeated measures were used to examine changes over time between and within groups (PNS vs non-PNS).

RESULTS

The PNS group (n = 67) had significant deficits in functioning at baseline, 6, 12, 18, and 24-months compared to the non-PNS group (n = 673). Functioning improved over time in the non-PNS group, while functioning in the PNS group remained relatively stable and poor over a two-year period. A consistent trend emerged demonstrating higher defeatist beliefs in the PNS group; however, this result was lost when controlling for persistent depressive symptoms. There were no significant differences between the groups on neurocognition, social cognition, and transition to psychosis.

CONCLUSIONS

PNS exist in youth at CHR for psychosis, resulting in significant and persistent functional impairment, which remains when controlling for persistent depressive symptoms. PNS remain even in CHR youth who do not transition to psychosis. Thus, PNS may represent an unmet therapeutic need in CHR populations for which there are currently no effective treatments.

Latent Clinical-Anatomical Dimensions of Schizophrenia

Widespread structural brain abnormalities have been consistently reported in schizophrenia, but their relation to the heterogeneous clinical manifestations remains unknown. In particular, it is unclear whether anatomical abnormalities in discrete regions give rise to discrete symptoms or whether distributed abnormalities give rise to the broad clinical profile associated with schizophrenia. Here, we apply a multivariate data-driven approach to investigate covariance patterns between multiple-symptom domains and distributed brain abnormalities in schizophrenia. Structural magnetic resonance imaging and clinical data were derived from one discovery sample (133 patients and 113 controls) and one independent validation sample (108 patients and 69 controls). Disease-related voxel-wise brain abnormalities were estimated using deformation-based morphometry. Partial least-squares analysis was used to comprehensively map clinical, neuropsychological, and demographic data onto distributed deformation in a single multivariate model. The analysis identified 3 latent clinical-anatomical dimensions that collectively accounted for 55% of the covariance between clinical data and brain deformation. The first latent clinical-anatomical dimension was replicated in an independent sample, encompassing cognitive impairments, negative symptom severity, and brain abnormalities within the default mode and visual networks. This cognitive-negative dimension was associated with low socioeconomic status and was represented across multiple races. Altogether, we identified a continuous cognitive-negative dimension of schizophrenia, centered on 2 intrinsic networks. By simultaneously taking into account both clinical manifestations and neuroanatomical abnormalities, the present results open new avenues for multi-omic stratification and biotyping of individuals with schizophrenia.

Ten-year trajectory and outcomes of negative symptoms of patients with first-episode schizophrenia spectrum disorders

This study explored the 10-year trajectories and outcomes of negative symptoms in patients with first-episode schizophrenia-spectrum disorder. Patients were from the historical control study comparing 10-year outcomes between standard care and early intervention services. A total of 298 patients were identified, 214 were successfully interviewed at 10-year follow-up for clinical and functional outcomes and 209 patients were included for final analyses. Information from clinical records were obtained systematically using standardized data entry forms. These information including negative symptoms, hospitalization and employment, monthly for year 1-3 and trimonthly for the year 4-10. Hierarchical cluster analysis was used to explore the 10-year negative symptom clusters. Demographics and early clinical characteristics related to the cluster memberships and different components of negative symptom at 10-year follow-up were further explored. The cluster analysis identified three longitudinal clusters of negative symptoms and 15% of patients were in the relapsed group. There was no difference in cluster membership between the intervention groups. Male gender and duration of hospitalizations in year four were found to be significant determinants of relapse negative symptoms. Lower education level, higher year-one negative symptom score and more months of unemployment during the first 3 years predicted overall negative symptoms at 10-year follow-up. Male gender was found to be a predictor only for avolition and anhedonia and duration of untreated psychosis only predicted anhedonia. These results highlighted the heterogeneity of longitudinal outcomes and the importance of personalized interventions.

The Prevalence of Negative Symptoms Across the Stages of the Psychosis Continuum

BACKGROUND

Patients in every stage of the psychosis continuum can present with negative symptoms. While no treatment is currently available to address these symptoms, a more refined characterization of their course over the lifetime could help in elaborating interventions. Previous reports have separately investigated the prevalence of negative symptoms within each stage of the psychosis continuum. Our aim in this review is to compare those prevalences across stages, thereby disclosing the course of negative symptoms.

METHODS

We searched several databases for studies reporting prevalences of negative symptoms in each one of our predetermined stages of the psychosis continuum: clinical or ultra-high risk (UHR), first-episode of psychosis (FEP), and younger and older patients who have experienced multiple episodes of psychosis (MEP). We combined results using the definitions of negative symptoms detailed in the Brief Negative Symptom Scale, a recently developed tool. For each negative symptom, we averaged and weighted by the combined sample size the prevalences of each negative symptom at each stage.

RESULTS

We selected 47 studies totaling 1872 UHR, 2947 FEP, 5039 younger MEP, and 669 older MEP patients. For each negative symptom, the prevalences showed a comparable course. Each negative symptom decreased from the UHR to FEP stages and then increased from the FEP to MEP stages.

CONCLUSIONS

Certain psychological, environmental, and treatment-related factors may influence the cumulative impact of negative symptoms, presenting the possibility for early intervention to improve the long-term course.

Persistent negative symptoms in recent-onset psychosis: Relationship to treatment response and psychosocial functioning

Negative symptoms are associated with poor clinical and psychosocial outcome in schizophrenia. Their prevalence and identification in first-episode patients remains controversial. In a large cohort of patients in the early stage of schizophrenia, schizophreniform or schizoaffective disorder, we investigated, over the different phases of the OPTiMiSE trial (baseline, 4, 10 and 22 weeks of treatment), the prevalence of negative symptoms of moderate severity, unconfounded by depression and extrapyramidal symptoms at baseline. Moreover, we assessed symptomatic remission, attrition rate and psychosocial functioning in subjects with short-term (4 weeks) persistent unconfounded negative symptoms (PNS) and in those with negative symptoms that did not persist at follow-up and/or were confounded at baseline (N-PNS). Negative symptoms of moderate severity were observed in 59% of subjects at baseline. They were associated with worse psychosocial functioning and longer duration of psychosis at intake in the study. Eleven percent of subjects had PNS unconfounded at baseline and 7.9% had PNS unconfounded at both baseline and end of 4-week treatment. Psychosocial functioning was comparable in PNS and N-PNS subjects at baseline but it was significantly worse in the former group after 4-weeks. PNS subjects showed lower remission and higher attrition rates at the end of all treatment phases. Fifty-six percent of subjects completing phase 3 (clozapine treatment) had PNS, and 60% of them were non-remitters at the end of this phase. The presence of short-term PNS during the first phases of psychosis was associated with poor clinical outcome and resistance to antipsychotic treatment, including clozapine.

Negative Symptoms and Functioning in Youth at Risk of Psychosis: A Systematic Review and Meta-analysis

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Evaluate the relationship between negative symptoms and functioning in youth at clinical high risk for psychosis.

AIM

Youth at CHR for psychosis often demonstrate significant negative symptoms and poor functioning, though the magnitude and direction of the relationship between the two remains unknown. The objective of this systematic review is to summarize the relationship between negative symptoms and functioning in CHR samples.

METHOD

Electronic databases CINAHL, EBM, Embase, MEDLINE, and PsycINFO were searched from inception. Studies were selected if they included any study that reported a relationship between negative symptoms and functioning in youth at clinical high risk (CHR). The correlation coefficient r was converted to Cohen's d, and all random-effects meta-analyses were performed using the transformed values.

RESULTS

Forty-one studies met the inclusion criteria, including a total of 4574 individuals at CHR for psychosis. Negative symptom total scores were significantly associated with poorer global functioning (d, -1.40; 95% CI, -1.82 to -0.98; I = 79.4%; p < .001 [9 studies, n = 782]), social functioning (d, -1.10; 95% CI, -1.27 to -0.93; I = 10.40%; p < .001 [12 studies, n = 811]), and role functioning (d, -0.96; 95% CI, -1.17 to -0.76; I = 41.1%; p < .001 [9 studies, n = 881]). In addition, negative symptoms were consistently associated with poor premorbid functioning. When examining negative symptom domains, avolition, anhedonia, and blunted affect were each significantly and independently associated with poorer social functioning and role functioning. In terms of prediction models, negative symptoms contributed to the prediction of lower functioning across multiple studies.

CONCLUSION

This meta-analysis demonstrates a strong relationship between negative symptoms and functioning in youth at clinical high risk for psychosis.

Proteomics in Schizophrenia: A Gateway to Discover Potential Biomarkers of Psychoneuroimmune Pathways

Schizophrenia is a severe and disabling psychiatric disorder with a complex and multifactorial etiology. The lack of consensus regarding the multifaceted dysfunction of this ailment has increased the need to explore new research lines. This research makes use of proteomics data to discover possible analytes associated with psychoneuroimmune signaling pathways in schizophrenia. Thus, we analyze plasma of 45 patients [10 patients with first-episode schizophrenia (FES) and 35 patients with chronic schizophrenia] and 43 healthy subjects by label-free liquid chromatography-tandem mass spectrometry. The analysis revealed a significant reduction in the levels of glia maturation factor beta (GMF-β), the brain-derived neurotrophic factor (BDNF), and the 115-kDa isoform of the Rab3 GTPase-activating protein catalytic subunit (RAB3GAP1) in patients with schizophrenia as compared to healthy volunteers. In conclusion, GMF-β, BDNF, and 115-kDa isoform of RAB3GAP1 showed significantly reduced levels in plasma of patients with schizophrenia, thus making them potential biomarkers in schizophrenia.

Patterns of recovery course in early intervention for FIRST episode non-affective psychosis patients: The role of timing

BACKGROUND

Prevention of symptom relapse and promotion of functional recovery are the two main goals of early intervention following a first episode of non-affective psychosis (FEP). The identification of patterns of recovery is important in developing and implementing recovery focused interventions at set time interval.

METHOD

Patterns of recovery course, in terms of symptomatic and functional remission, were explored at 1 and 3-year follow-up in a sample of 373 consecutive FEP patients. Relapses during this period were considered.

RESULTS

Four patterns of recovery course were defined: good stable (26%), good unstable (21%), poor unstable (10%), poor stable (43%). Those who met criteria for good stable recovery were more likely have less severe baseline negative symptoms (OR = 2.092; 95% CI = 0.99-4.419) and to not be diagnosed with schizophrenia (OR = 2.242; 95% CI = 1.015-4.954). Short DUP (OR = 2.152; 95% CI = 0.879-5.27) and low premorbid IQ (OR = 2.281; 95% CI = 0.954-5.457) increased the likelihood of good unstable recovery. Less severe baseline negative symptoms (OR = 3.851; 95% CI = 1.422-10.435) and single status (OR = 4.307; 95% CI = 1.014-18.293) increased the likelihood of a poor unstable recovery. Poor unstable pattern was significantly associated with a high relapse rate (73%).

CONCLUSIONS

Our results shed light on identifying different recovery patterns in FEP. Despite evidence for early intervention effectiveness, we should explore ways to prevent relapse and improve long-term recovery, particularly in reference to the role of timing in the design of interventions.

Persistent negative symptoms in individuals at Ultra High Risk for psychosis

Persistent negative symptoms (PNS) defined as negative symptoms that persist for at least six months in the absence of high levels of positive, depressive and extrapyramidal symptoms, are evident early in the course of schizophrenia from the first episode of psychosis. However, their presence even earlier in the illness, in those at Ultra High Risk of psychosis, has not been investigated. In this study, we examined the prevalence, baseline correlates and outcome of PNS in 363 Ultra High Risk individuals. Assessments were conducted at baseline and 2-14 years later (mean follow up time 7.4 years). Baseline assessments included demographic, clinical and neurocognitive measures, which were repeated at follow up. The prevalence of PNS in the UHR group was 6.1%. Poor premorbid social adjustment, deficits in verbal fluency and childhood maltreatment, specifically emotional neglect, were evident at baseline in the PNS group compared to the group without PNS. PNS were associated with poor psychosocial functioning and deficits in processing speed at follow up. Our findings suggest that PNS can be detected early, allowing for the identification of a subset of Ultra High Risk patients who are likely to have poor outcome. These individuals could be the target for specific intervention. Further research is needed into the pathophysiology of these PNS to develop specific interventions.

Clarifying associations between cortical thickness, subcortical structures, and a comprehensive assessment of clinical insight in enduring schizophrenia

BACKGROUND

The relationship between poor insight and less favorable outcomes in schizophrenia has promoted research efforts to understand its neurobiological basis. Thus far, research on neural correlates of insight has been constrained by small samples, incomplete insight assessments, and a focus on frontal lobes. The purpose of this study was to examine associations of cortical thickness and subcortical volumes, with a comprehensive assessment of clinical insight, in a large sample of enduring schizophrenia patients.

METHODS

Two dimensions of clinical insight previously identified by a factor analysis of 4 insight assessments were used: Awareness of Illness and Need for Treatment (AINT) and Awareness of Symptoms and Consequences (ASC). T1-weighted structural images were acquired on a 3 T MRI scanner for 110 schizophrenia patients and 69 healthy controls. MR images were processed using CIVET (version 2.0) and MAGeT and quality controlled pre and post-processing. Whole-brain and region-of-interest, vertex-wise linear models were applied between cortical thickness, and levels of AINT and ASC. Partial correlations were conducted between volumes of the amygdala, thalamus, striatum, and hippocampus and insight levels.

RESULTS

No significant associations between both insight factors and cortical thickness were observed. Moreover, no significant associations emerged between subcortical volumes and both insight factors.

CONCLUSIONS

These results do not replicate previous findings obtained with smaller samples using single-item measures of insight into illness, suggesting a limited role of neurobiological factors and a greater role of psychological processes in explaining levels of clinical insight.

Progress of negative symptoms over the initial 5 years of a first episode of psychosis

BACKGROUND

Specialized early intervention (EI) following a first episode of psychosis (FEP) are effective at reducing negative symptoms, although its trajectory warrants systematic assessment. However, findings are equivocal as to whether extended gains are made post 2 years of EI and whether there is additional benefit of extending EI for an additional 3 years.

METHODS

Data on 178 FEP patients, from a randomized controlled trial of a 3-year extension of EI service v. transfer to regular care following 2 years of EI service, were used for this report. Repeated measures analysis of variance were conducted separately for the initial 2 years of treatment in an EI service, and for the 3-year post-randomization to examine trajectories of negative symptoms over the two periods in the two arms of the study.

RESULTS

There were significant improvements in total negative symptoms over the first 2 years of EI F(4.612, 797.905) = 25.263, p &lt; 0.001 and in domains of 'expressivity' and 'motivation'. In the following 3 years, there were further significant improvements in negative symptoms F(4.318, 759.908) = 4.182, p = 0.002 with no difference between groups F(4.318, 759.908) = 1.073, p = 0.371. Changes in negative symptoms over the extension period were driven by expressivity F(4.01, 674.73) = 7.19, p &lt; 0.01, but not motivation F(6.58, 1112.18) = 0.95, p = 0.46.

CONCLUSION

Negative symptoms improve significantly over the first 2 years of EI. Subsequent amelioration was largely the result of expressivity. Motivation deficits remained stable. Extended EI offered no advantage over regular care post-randomization.

Cognitive remediation can improve negative symptoms and social functioning in first-episode schizophrenia: A randomized controlled trial

BACKGROUND

Meta-analyses have reported that the effects of cognitive remediation might go beyond improvement in cognition to include unexpected benefits for schizophrenia patients such as negative symptom reduction and improvements in functioning. In addition, some evidence indicated that these potentially beneficial effects are also present in the initial course of schizophrenia, but work in this area is still developing.

METHOD

A RCT compared Cognitive Remediation (CR) to Healthy Behaviors Training (HBT) in 80 patients (78% male) with a mean age of 21.9years and mean education of 12.3years who had a first psychotic episode within two years of study entry. Participants were trained using CR programs or received HBT involving 50 sessions over 6months and then booster sessions over the next 6months. The SANS and BPRS were used to assess symptoms. The UCLA Social Attainment Survey assessed social functioning.

RESULTS

Using GLMM, improvements over 12months were found favoring CR for SANS Expressive Symptoms (p<0.01), which was composed of Affective Flattening (p<0.01) and Alogia (p=0.04), and for SANS Experiential Symptoms, composed of Avolition/Apathy (p=0.04) and Anhedonia/Asociality (p<0.01). CR was associated with improvements in social functioning (p=0.05) as compared to HBT.

CONCLUSIONS

We confirmed that the beneficial effects of CR appear to extend beyond cognition to improvements in negative symptoms and social functioning in early course schizophrenia patients. These results suggest that cognitive remediation might have an impact when the reduction of risk factors for chronicity is most critical for promoting recovery.

Revisiting the persistent negative symptoms proxy score using the Clinical Assessment Interview for Negative Symptoms

OBJECTIVE

The present study aimed to validate a severity cut-off of negative symptoms for persistent negative symptoms (PNS) identification using the Clinical Assessment Interview for Negative Symptoms (CAINS).

METHOD

A total of 206 patients with schizophrenia were recruited and divided into the PNS group (n = 57) and the Non-PNS group (n = 149) using PNS criteria based on the SANS and the SAPS. To determine the appropriate cut-offs on the CAINS in identifying PNS, Receiver Operating Characteristic (ROC) curve analysis was conducted in the PNS and Non-PNS groups.

RESULTS

Our results showed that the cutoffs for identifying PNS on the CAINS total score, the Motivation and Pleasure (MAP) subscale score and the Expression (EXP) subscale score were 25, 17, and 5 respectively. Area Under the Curve (AUC) analysis indicated excellent discrimination of the PNS group from the Non-PNS group using the cut-off for the CAINS total score. However, discrimination was somewhat better for the MAP subscale score than the EXP subscale score. The Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the MAP subscale were 81.54% and 97.16%.

CONCLUSION

We found that the cut-off scores derived from the CAINS to identify PNS are comparable to existing scales. The CAINS offers an alternative means in identifying PNS patients in clinical trials that overcomes methodological and conceptual limitations of older scales.

Cross Cultural Validation and Extension of the Clinical Assessment Interview for Negative Symptoms (CAINS) in the Chinese Context: Evidence from a Spectrum Perspective

The Clinical Assessment Interview for Negative Symptoms (CAINS) was designed in accordance with the recent theory and research in social affective neuroscience and to address the psychometric and conceptual limitations of other instruments assessing negative symptoms. The present study aimed to provide a large-scale validation of the CAINS in China and examine its applicability and validity evidence across the schizophrenia spectrum. Using confirmatory factor analysis, our results replicated the original findings in the US development samples that the CAINS possesses a stable 2-factor structure, namely "motivation/pleasure" and "expression". We also found significant correlations between the CAINS and other negative symptom measures. The CAINS demonstrated good discriminant validity in differentiating negative symptoms in people with schizophrenia, nonpsychotic first-degree relatives and people with social anhedonia. People with schizophrenia exhibited significantly higher CAINS subscale scores than first-degree relatives and healthy controls. In addition, first-degree relatives had higher "motivation/pleasure" scores than healthy controls. The "motivation/pleasure" subscale scores of individuals with social anhedonia were also significantly higher than healthy controls.

A study on negative and depressive symptom prevalence in individuals at ultra-high risk for psychosis

BACKGROUND

Negative symptoms are known to be present in the prodromal stage of psychotic disorders, yet little is known about their prevalence. Studies examining the presence of negative symptoms in ultra-high risk (UHR) populations have shown some limitations, notably failing to control depression. The objective of this study was to examine the prevalence of negative symptoms in the presence of significant levels of depression and in the absence of such symptoms (primary negative symptoms) over 1 year and to examine differences in negative symptoms in psychosis converters and non-converters.

METHODS

Participants were 123 individuals at UHR for the development of psychosis receiving follow-up for a period of 2 years. Negative symptoms and depression were measured using the Scale for the Assessment of Negative Symptoms and the Montgomery-Asberg Depression Scale at baseline, 6 and 12 months post-admission.

RESULTS

At baseline, the prevalence of negative symptoms and primary negative symptoms was 76.4% and 32.7%, respectively. Whereas the prevalence of negative symptoms was significantly decreased at 6 months, the prevalence of primary negative symptoms was similar at all time points. Negative symptoms at baseline were not different between later converters and non-converters to psychosis.

CONCLUSION

Our findings confirm the presence of secondary and primary negative symptoms in individuals at UHR, but suggest a differential trajectory of both measures over time. Future studies should include larger UHR groups and focus on the investigation of intra-individual changes in primary negative symptoms over time and further explore their potential role for psychosis conversion.

Long-term course of negative symptom subdomains and relationship with outcome in patients with a psychotic disorder

BACKGROUND

The longitudinal course of the negative symptoms subdomains social amotivation (SA) and expressive deficits (ED) remains largely unknown. We investigated i) the longitudinal course of SA and ED subdomain scores, ii) whether subgroups based on the course of SA and ED subdomain scores could be identified, iii) whether baseline SA and ED subdomain scores were related to functioning and quality of life six years later and iv) the longitudinal relationship between subgroups and outcomes.

METHODS

Measurements at baseline, three and six years from 1067 patients participating in the Genetic Risk and Outcome of Psychosis (GROUP) project were used. We applied mixed models analysis, regression analysis and trajectory analyses.

RESULTS

SA and ED subdomain scores decreased over time. Within both subdomains, four subgroups were identified: for both SA and ED a steady low course (±60%), increased (±15%) and decreased course (±15%). Within SA only, a higher level decreased course (±6%) and within ED only, a course with relatively stable high ED scores (±6%) was found. Lower symptom levels at baseline were related to better functioning (SA & ED) and quality of life (SA) at six years. Overall, low SA and low ED subgroups showed better outcomes than the other subgroups.

CONCLUSION

In many patients the course of negative symptoms is unstable and related to the course of outcome. Patients who do show steady low negative symptom levels (60%) may complicate the interpretation of treatment evaluation studies, as they may average out possible effects in subgroups with fluctuating symptom levels.

Grey matter reduction in the caudate nucleus in patients with persistent negative symptoms: An ALE meta-analysis

OBJECTIVES

In the present study, we used Activation Likelihood Estimation (ALE) meta-analysis to quantitatively examine brain grey matter reduction in schizophrenia patients with persistent negative symptoms (PNS).

METHOD

A total of 12 voxel-based morphometry (VBM) studies were included in ALE meta-analysis using more stringent criterion of PNS.

RESULTS

Significant grey matter reduction in the PNS group relative to controls was observed in the left caudate nucleus, the left precentral region, the left middle frontal region, the bilateral parahippocampal region, the left anterior cingulate region, the bilateral medial frontal gyrus, the thalamus and the insula.

CONCLUSION

Our results suggest that brain regions in the reward network may be specifically related to PNS, especially the left caudate nucleus. It is possible that abnormality in reward processing may constitute the neural basis of PNS.

Relationship Between Persistent Negative Symptoms and Findings of Neurocognition and Neuroimaging in Schizophrenia

Negative symptoms are defined as loss or reduction of otherwise present behaviors or functions in illness situation, and they have constituted an important aspect of schizophrenia. Although negative symptoms have usually been considered as a single entity, neurobiological investigations yielded discrepant results. To overcome challenges that derive from this discrepancy, researchers have proposed several approaches to structure negative symptoms into more homogenous constructs. Concept of persistent negative symptoms (PNS) is one of the proposed approaches, and includes both primary and secondary negative symptoms that persist after adequate treatment. PNS is relatively easy to assess, and by definition, more inclusive; yet it represents an unmet therapeutic need. Therefore, it is a target of several neurobiological and pharmacological studies. There are several structural and functional brain alterations associated with negative symptoms. On the other hand, neurocognitive investigations in patients with schizophrenia have revealed deficits in several domains that showed correlations with negative symptoms. There are several shared features between negative symptoms and neurocognitive deficits in schizophrenia such as prevalence rates, course through the illness, prognostic importance, and impact on social functioning. However, exact mechanisms behind the neurobiology of PNS and how it interacts with neurocognition remain to be explained. Earlier reviews on neuroimaging and neurocognitive correlates of PNS have been focused on studies with broadly defined negative symptoms that were selected by methodological closeness to PNS. In this review, we focus on neural correlates and neurocognitive associations of PNS, and we discuss PNS findings available to date.

The relative contributions of social cognition and self-reflectiveness to clinical insight in enduring schizophrenia

Poor clinical insight represents a major barrier to recovery in schizophrenia. Research suggests that higher-order social cognitive abilities such as theory of mind (TOM) and metacognition contribute to levels of clinical insight. However, few studies have examined whether social cognitive abilities other than TOM are related to clinical insight. Moreover, to date, no investigation has attempted to determine whether the contribution of metacognitive ability to clinical insight can be differentiated from the contribution of higher-order social cognition, despite their conceptual similarity. Therefore, the purpose of this study was to examine the relative contribution of different social cognitive abilities, as well as metacognition, to clinical insight in a large sample of 139 enduring schizophrenia patients, and controlling for established predictors of clinical insight. Hierarchical regression analyses were used to evaluate the portion of variance explained by 3 social cognitive abilities: emotion recognition, TOM, and affective empathy, and the metacognitive ability of self-reflectiveness. Clinical insight levels were assessed using the Schedule for the Assessment of Insight-Expanded version. Results indicated that affective empathy and self-reflectiveness are the strongest predictors of clinical insight. These results provide insights on the development of targeted interventions for improving clinical insight in this population.

The course of negative symptoms in first-episode schizophrenia and its predictors: A prospective two-year follow-up study

AIMS

This study aimed to investigate the course of negative symptoms and its stability over a two-year period following a first-episode schizophrenia (FES) and the possible predictors of higher severity in this symptomatology after this period.

METHODS

In this longitudinal two-year prospective follow-up study we included 268 patients with a FES, according to DSM-IV. Analysis of variance was conducted in patients who completed the full follow-up to study changes in negative symptoms over three visits. Regression analyses were conducted to show correlates and potential predictors of negative symptoms at two-year follow-up.

RESULTS

There was a significant effect for time in negative symptomatology, which was less severe at one-year follow-up after a FES and remained stable up to two years (Time 1>Time 2>Time 3); F(2,151)=20.45, p<0.001. Poorer premorbid adjustment (p=0.01) and higher negative symptoms at baseline (p<0.001) made a significant contribution to the changes in the negative symptoms severity at two-years after a FES (R²=0.21, p<0.001).

CONCLUSIONS

We found a reduction in the negative symptomatology at one-year after a FES. This change remained stable at two-year. Our results suggested that the presence of this symptomatology early in the course of the illness, together with a poorer premorbid adjustment, predict more severe negative symptoms at mid-term outcome.

Linking persistent negative symptoms to amygdala-hippocampus structure in first-episode psychosis

Early persistent negative symptoms (PNS) following a first episode of psychosis (FEP) are linked to poor functional outcome. Reports of reduced amygdalar and hippocampal volumes in early psychosis have not accounted for heterogeneity of symptoms. Age is also seldom considered in this population, a factor that has the potential to uncover symptom-specific maturational biomarkers pertaining to volume and shape changes within the hippocampus and amygdala. T1-weighted volumes were acquired for early (N=21), secondary (N=30), non-(N=44) PNS patients with a FEP, and controls (N=44). Amygdalar-hippocampal volumes and surface area (SA) metrics were extracted with the Multiple Automatically Generated Templates (MAGeT)-Brain algorithm. Linear mixed models were applied to test for a main effect of group and age × group interactions. Early PNS patients had significantly reduced left amygdalar and right hippocampal volumes, as well as similarly lateralized negative age × group interactions compared to secondary PNS patients (P<0.017, corrected). Morphometry revealed decreased SA in early PNS compared with other patient groups in left central amygdala, and in a posterior region when compared with controls. Early and secondary PNS patients had significantly decreased SA as a function of age compared with patients without such symptoms within the right hippocampal tail (P<0.05, corrected). Significant amygdalar-hippocampal changes with age are linked to PNS after a FEP, with converging results from volumetric and morphometric analyses. Differential age trajectories suggest an aberrant maturational process within FEP patients presenting with PNS, which could represent dynamic endophenotypes setting these patients apart from their non-symptomatic peers. Studies are encouraged to parse apart such symptom constructs when examining neuroanatomical changes emerging after a FEP.

Negative symptoms: History of the concept and their position in diagnosis of schizophrenia

Current conceptualizations of schizophrenia have been introduced over centuries and continue to progress in recent decades. Symptoms have been divided into several domains, contrasting negative and positive symptoms which are different in their nature, onset, progression and response to treatment. An account of the different historical changes of the concept – essentially nosographic – has led to models attempting to integrate findings for each dimension of the disorder. This paper reviews the history of negative symptoms in diagnosis and how different approaches have been utilised to consider negative symptoms in the concept of schizophrenia. The paper also bridges various international classifications which have evolved and modified the role of negative symptoms in their diagnostic criteria for schizophrenia, which highlights the challenge of defining this disease.

Allocating effort and anticipating pleasure in schizophrenia: Relationship with real world functioning

BACKGROUND

Poor motivation to engage in goal-oriented behavior has been recognized as a hallmark feature of schizophrenia spectrum disorders (SZ). Low drive in SZ may be related to anticipating rewards as well as to poor working memory. However, few studies to date have examined beliefs about self-efficacy and satisfaction for future rewards (anticipatory pleasure). Additionally, few studies to date have examined how these deficits may impact SZ patients' real world functioning.

METHOD

The present study examined SZ patients' (n=57) anticipatory pleasure, working memory, self-efficacy and real world functioning in relation to their negative symptom severity.

RESULTS

Results revealed that SZ patients' negative symptom severity was related to decisions in effort allocation and reward probability, working memory deficits, self-efficacy and anticipatory pleasure for future reward. Effort allocation deficits also predicted patients' daily functioning skills.

CONCLUSIONS

SZ patients with high levels of negative symptoms are not merely effort averse, but have more difficulty effectively allocating effort and anticipating pleasure engaging in effortful activities. It may be the case that continuously failing to achieve reinforcement from engagement and participation may lead SZ patients to form certain negative beliefs about their abilities which contributes to amotivation and cognitive deficits. Lastly, our findings provide further support for a link between SZ patients functional daily living skills their effort allocation.

Primary and persistent negative symptoms: Concepts, assessments and neurobiological bases

Primary and persistent negative symptoms (PPNS) represent an unmet need in the care of people with schizophrenia. They have an unfavourable impact on real-life functioning and do not respond to available treatments. Underlying etiopathogenetic mechanisms of PPNS are still unknown. The presence of primary and enduring negative symptoms characterizes deficit schizophrenia (DS), proposed as a separate disease entity with respect to non-deficit schizophrenia (NDS). More recently, to reduce the heterogeneity of negative symptoms by using criteria easily applicable in the context of clinical trials, the concept of persistent negative symptoms (PNS) was developed. Both PNS and DS constructs include enduring negative symptoms (at least 6months for PNS and 12months for DS) that do not respond to available treatments. PNS exclude secondary negative symptoms based on a cross-sectional evaluation of severity thresholds on commonly used rating scales for positive symptoms, depression and extrapyramidal side effects; the DS diagnosis, instead, excludes all potential sources of secondary negative symptoms based on a clinical longitudinal assessment. In this paper we review the evolution of concepts and assessment modalities relevant to PPNS, data on prevalence of DS and PNS, as well as studies on clinical, neuropsychological, brain imaging electrophysiological and psychosocial functioning aspects of DS and PNS.

Bipolar disorder risk gene FOXO6 modulates negative symptoms in schizophrenia: a neuroimaging genetics study

BACKGROUND

Despite being diagnostically associated uniquely with schizophrenia, negative symptoms are also observed in bipolar disorder (BD). Genome-wide association studies (GWAS) have uncovered a number of shared risk genes between schizophrenia and BD. The objectives of this study were to examine whether previously identified risk genes for BD are associated with negative symptom severity within a first-episode schizophrenia (FES) cohort and to examine whether such genes influence brain morphology.

METHODS

Patients experiencing FES were genotyped for 21 previously identified BD risk genes; a series of univariate analyses of covariance examined the association between negative symptom severity, as measured using the Scale for the Assessment of Negative Symptoms (SANS), and genotype. A subset of participants underwent a structural 1.5 T MRI T₁ scan, analyzed for surface area and cortical thickness changes via the CIVET pipeline and LPBA40 atlas.

RESULTS

We included 133 patients with FES in our analysis; 61 of them underwent structural MRI. We observed a significant association between negative symptom severity and the BD risk gene FOXO6 (rs4660531). Individuals with the CC genotype presented significantly higher negative symptoms (Cohen d = 0.46, F = 5.854, p = 0.017) and significantly smaller surface area within the right middle orbitofrontal gyrus (Cohen d = 0.69, F = 7.289, p = 0.009) than carriers of allele A.

LIMITATIONS

Limitations of this study include its modest sample size and lack of a control sample.

CONCLUSION

Lacking the FOXO6 risk allele was associated with an increase in negative symptoms and surface area reduction in the right orbitofrontal gyrus - an area previously associated with negative symptoms - suggesting that presence of the FOXO6 risk allele confers resistance against negative symptoms and associated neuroanatomical changes in individuals with FES.

Incidence of stressful life events and influence of sociodemographic and clinical variables on the onset of first-episode psychosis

This study presents a quantitative analysis of the incidence of stressful life events (SLEs) and the variables gender, age at onset, family history and psychotic symptoms in patients with first-episode psychosis (FEP). A descriptive, cross-sectional methodology was used to interview 68 patients with FEP between 13 and 47 years of age. The Psychiatric Epidemiology Research Interview Life Events Scale collected one-year period prior to onset of FEP - used to analyse the subcategories academic, work, love and marriage, children, residence, legal affairs, finances and social activities-, Positive and Negative Syndrome Scale, and Clinical Global Impression-Schizophrenia scale were used to assess the relevance of certain SLEs during adolescence. Age at onset showed a significant negative correlation with the categories academic and social activities. By contrast, it showed a positive correlation with work and children. A significant relationship was found between paternal family history and social activities and between maternal family history and academic and love and marriage. Finally, an inverse relationship was observed between negative symptoms and the categories children and finance. Depressive symptoms were significantly correlated with the category academic. Our results show the importance of SLEs during adolescence and suggest that there is a clear need to develop preventive actions that promote effective strategies for dealing with the accumulation of psychosocial stress.

Premorbid, clinical and cognitive correlates of primary negative symptoms in first-episode psychosis

Negative symptoms are a core psychopathological dimension of psychotic disorders. Previous research on primary negative symptoms (PNS) mostly focused on chronic samples. Data regarding premorbid, clinical and cognitive correlates of PNS in the early illness course are limited and inconsistent. In this study, we assessed 355 Hong Kong Chinese adult patients presenting with first-episode psychosis (FEP) to early intervention service with an aim to examine the prevalence of PNS and its relationships with premorbid adjustment, clinical and cognitive profiles. PNS was defined as the presence of clinically significant negative symptoms excluding depression, positive symptoms and extrapyramidal signs. Results showed that 14.6% of patients exhibited PNS at service entry. PNS group had poorer premorbid social functioning, lower level of insight, and worse performance in Modified Wisconsin Card Sorting and digit symbol tests than non-PNS group. Logistic regression analysis showed that premorbid social functioning and digit symbol test score were independently associated with PNS. Our findings thus indicate that PNS are frequently observed in FEP patients. Deficits in proceeding speed, alongside impaired premorbid social functioning, might be specifically related to PNS in the early illness stage.

Age-related cortical thickness trajectories in first episode psychosis patients presenting with early persistent negative symptoms

Recent work has clearly established that early persistent negative symptoms (ePNS) can be observed following a first episode of psychosis (FEP), and can negatively affect functional outcome. There is also evidence for cortical changes associated with ePNS. Given that a FEP often occurs during a period of ongoing complex brain development and maturation, neuroanatomical changes may have a specific age-related component. The current study examines cortical thickness (CT) and trajectories with age using longitudinal structural imaging. Structural T1 volumes were acquired at three time points for ePNS (N=21), PNS due to secondary factors (N=31), non-PNS (N=45) patients, and controls (N=48). Images were processed using the CIVET pipeline. Linear mixed models were applied to test for the main effects of (a) group, (b) time, and interactions between (c) time and group membership, and (d) age and group membership. Compared with the non-PNS and secondary PNS patient groups, the ePNS group showed cortical thinning over time in temporal regions and a thickening with age primarily in prefrontal areas. Early PNS patients also had significantly different linear and quadratic age relationships with CT compared with other groups within cingulate, prefrontal, and temporal cortices. The current study demonstrates that FEP patients with ePNS show significantly different CT trajectories with age. Increased CT may be indicative of disruptions in cortical maturation processes within higher-order brain regions. Individuals with ePNS underline a unique subgroup of FEP patients that are differentiated at the clinical level and who exhibit distinct neurobiological patterns compared with their non-PNS peers.

The stability of negative syndrome, persistent negative syndrome and deficit syndrome in a twenty-year follow-up study of schizophrenia patients

AIMS

To assess the prevalence and stability of negative symptoms in schizophrenia according to the BPRS-withdrawal/retardation, persistent negative symptoms and deficit syndrome over twenty years.

METHOD

Fifty people diagnosed with schizophrenia were evaluated during their first psychiatric hospitalisation and after three, seven, twelve and twenty years. the presence of negative symptoms was assumed when at least one of the BPRS-withdrawal/retardation symptoms (blunted affect, emotional withdrawal, motor retardation), equalled three or more points at the discharge from the index hospitalisation. The groups with persistent negative symptoms and deficit syndrome were identified based on two measurements taken at the index discharge and one year later. The Proxy for the Deficit Syndrome (PDS) was employed to identify deficit syndrome.

RESULTS

The prevalence of BPRS-withdrawal/retardation, persistent negative symptoms and deficit syndrome after one year was 20%, 4% and 6% respectively. Four of the ten people with BPRS-withdrawal/retardation symptoms maintained them at all follow-ups. No symptoms, however, were found in any of the members of the persistent negative symptoms and deficit syndrome group after twelve and twenty years.

CONCLUSIONS

The prevalence of primary, persistent negative symptoms after the first episode of psychosis was minimal. A long-term observation does not confirm their stability.

Conceptualization and treatment of negative symptoms in schizophrenia

Negative symptoms of schizophrenia including social withdrawal, diminished affective response, lack of interest, poor social drive, and decreased sense of purpose or goal directed activity predict poor functional outcomes for patients with schizophrenia. They may develop and be maintained as a result of structural and functional brain abnormalities, particularly associated with dopamine reward pathways and by environmental and psychosocial factors such as self-defeating cognitions and the relief from overstimulation that accompanies withdrawal from social and role functioning. Negative symptoms are more difficult to treat than the positive symptoms of schizophrenia and represent an unmet therapeutic need for large numbers of patients with schizophrenia. While antipsychotic medications to treat the symptoms of schizophrenia have been around for decades, they have done little to address the significant functional impairments in the disorder that are associated with negative symptoms. Negative symptoms and the resulting loss in productivity are responsible for much of the world-wide personal and economic burden of schizophrenia. Pharmacologic treatments may be somewhat successful in treating secondary causes of negative symptoms, such as antipsychotic side effects and depression. However, in the United States there are no currently approved treatments for severe and persistent negative symptoms (PNS) that are not responsive to treatments for secondary causes. Pharmacotherapy and psychosocial treatments are currently being developed and tested with severe and PNS as their primary targets. Academia, clinicians, the pharmaceutical industry, research funders, payers and regulators will need to work together to pursue novel treatments to address this major public health issue.