Are there more than two syndromes in schizophrenia? A critique of the positive-negative dichotomy

Sociodemographic and clinical correlates of hallucinations in patients entering an early intervention program for first episode psychosis

Hallucinations are a core feature of psychosis, and their severity during the acute phase of illness is associated with a range of poor outcomes. Various clinical and sociodemographic factors may predict hallucinations and other positive psychotic symptoms in first episode psychosis (FEP). Despite this, the precise factors associated with hallucinations at first presentation to an early intervention service have not been extensively researched. Through detailed interviews and chart reviews, we investigated sociodemographic and clinical predictors in 636 minimally-medicated patients who entered PEPP-Montréal, an early intervention service for FEP, between 2003 and 2018. Hallucinations were measured using the Scale for the Assessment of Positive Symptoms (SAPS), while negative symptoms were assessed using the Scale for the Assessment of Negative symptoms (SANS). Depressive symptoms were evaluated through the Calgary Depression Scale for Schizophrenia (CDSS), and anxiety symptoms via the Hamilton Rating Scale for Anxiety (HAS). A majority (n = 381, 59.9 %) of the sample presented with clinically significant hallucinations (SAPS global hallucinations score ≥ 3) at program entry. These patients had an earlier age at onset, fewer years of education, and a higher severity of delusions, depression and negative symptoms than those without clinical-level hallucinations. These results suggest that individuals with clinically significant hallucinations at admission tend to be younger and have a greater overall symptom burden. This makes it especially important to monitor hallucinations alongside delusions, depression and negative symptoms in order to identify who might benefit from targeted interventions. The implications of these findings for early intervention and person-centered care are discussed.

Digital behavioural signatures reveal trans-diagnostic clusters of Schizophrenia and Alzheimer's disease patients

The current neuropsychiatric nosological categories underlie pragmatic treatment choice, regulation and clinical research but does not encompass biological rationale. However, subgroups of patients suffering from schizophrenia or Alzheimer's disease have more in common than the neuropsychiatric nature of their condition, such as the expression of social dysfunction. The PRISM project presents here initial quantitative biological insights allowing the first steps toward a novel trans-diagnostic classification of psychiatric and neurological symptomatology intended to reinvigorate drug discovery in this area. In this study, we applied spectral clustering on digital behavioural endpoints derived from passive smartphone monitoring data in a subgroup of Schizophrenia and Alzheimer's disease patients, as well as age matched healthy controls, as part of the PRISM clinical study. This analysis provided an objective social functioning characterization with three differential clusters that transcended initial diagnostic classification and was shown to be linked to quantitative neurobiological parameters assessed. This emerging quantitative framework will both offer new ways to classify individuals in biologically homogenous clusters irrespective of their initial diagnosis, and also offer insights into the pathophysiological mechanisms underlying these clusters.

Delusional content at initial presentation to a catchment-based early intervention service for psychosis

BACKGROUND

During a psychotic episode, patients frequently suffer from severe maladaptive beliefs known as delusions. Despite the abundant literature investigating the simple presence or absence of these beliefs, there exists little detailed knowledge regarding their actual content and severity at the onset of illness.

AIMS

This study reports on delusions during the initiation of indicated treatment for first-episode psychosis (FEP).

METHOD

Data were systematically collected from a sample of 636 patients entering a catchment-based early intervention service for FEP. The average severity and frequency of each delusional theme at baseline was reported with the Scale for the Assessment of Positive Symptoms. Delusional severity (globally and per theme) was examined across a number of sociodemographic and clinical variables.

RESULTS

Delusions were present in the vast majority of individuals experiencing onset of FEP (94%), with persecutory (77.7%) being the most common theme. Persecutory delusions remained consistent in severity across diagnoses, but were more severe with older age at onset of FEP. No meaningful differences in delusional severity were observed across gender, affective versus non-affective psychosis, or presence/absence of substance use disorder. Globally, delusion severity was associated with anxiety, but not depression. Delusions commonly referred to as passivity experiences were related to hallucinatory experiences.

CONCLUSIONS

This community sample offers a rare clinical lens into the severity and content of delusions in FEP. Although delusional severity was consistent across certain sociodemographic and clinical variables, this was not always the case. Future research should now consider the course of delusion themes over time.

Reprint of: A review of negative symptom assessment strategies in youth at clinical high-risk for psychosis

Studies attempting to deconstruct the heterogeneity of schizophrenia and the attenuated psychosis syndrome consistently find that negative symptoms are a core dimension that is distinct from other aspects of the illness (e.g., positive and disorganized symptoms). Negative symptoms are also highly predictive of poor community-based functional outcomes, suggesting they are a critical treatment target. Unfortunately, pharmacological and psychosocial treatments for negative symptoms have demonstrated limited effectiveness. To address this critical unmet therapeutic need, the NIMH sponsored a consensus development conference to delineate research priorities for the field and stimulate treatment development. A primary conclusion of this meeting was that next-generation negative symptom rating scales should be developed to address methodological and conceptual limitations of existing instruments. Although second-generation rating scales were developed for adults with schizophrenia, progress in this area has lagged behind for youth at clinical-high risk (CHR) for developing psychosis (i.e. those meeting criteria for a prodromal syndrome). Given that negative symptoms are highly predictive of the transition to diagnosable psychotic illness, enhancing our ability to detect negative symptoms in CHR youth is paramount. The current paper discusses conceptual and methodological limitations inherent to existing scales that assess negative symptoms in CHR youth. The theoretical and clinical implications of these limitations are evaluated. It is concluded that new scales specifically designed to assess negative symptoms in CHR youth are needed to accurately chart mental illness trajectories and determine when, where, and how to intervene. Recent efforts to develop next-generation measures designed specifically for CHR youth to meet this urgent need in the field are discussed. These new approaches offer significant progress for addressing issues inherent to earlier scales.

A review of negative symptom assessment strategies in youth at clinical high-risk for psychosis

Studies attempting to deconstruct the heterogeneity of schizophrenia and the attenuated psychosis syndrome consistently find that negative symptoms are a core dimension that is distinct from other aspects of the illness (e.g., positive and disorganized symptoms). Negative symptoms are also highly predictive of poor community-based functional outcomes, suggesting they are a critical treatment target. Unfortunately, pharmacological and psychosocial treatments for negative symptoms have demonstrated limited effectiveness. To address this critical unmet therapeutic need, the NIMH sponsored a consensus development conference to delineate research priorities for the field and stimulate treatment development. A primary conclusion of this meeting was that next-generation negative symptom rating scales should be developed to address methodological and conceptual limitations of existing instruments. Although second-generation rating scales were developed for adults with schizophrenia, progress in this area has lagged behind for youth at clinical-high risk (CHR) for developing psychosis (i.e. those meeting criteria for a prodromal syndrome). Given that negative symptoms are highly predictive of the transition to diagnosable psychotic illness, enhancing our ability to detect negative symptoms in CHR youth is paramount. The current paper discusses conceptual and methodological limitations inherent to existing scales that assess negative symptoms in CHR youth. The theoretical and clinical implications of these limitations are evaluated. It is concluded that new scales specifically designed to assess negative symptoms in CHR youth are needed to accurately chart mental illness trajectories and determine when, where, and how to intervene. Recent efforts to develop next-generation measures designed specifically for CHR youth to meet this urgent need in the field are discussed. These new approaches offer significant progress for addressing issues inherent to earlier scales.

Changes of Serum Insulin-like Growth Factor-2 Response to Negative Symptom Improvements in Schizophrenia Patients Treated with Atypical Antipsychotics

Accumulating evidence suggests that a disruption of early brain development, in which insulin-like growth factor-2 (IGF-2) has a crucial role, may underlie the pathophysiology of schizophrenia. Our previous study has shown that decreased serum IGF-2 was correlated with the severity of psychopathology in patients with schizophrenia. Here we conducted a prospective observation trial to investigate the effects of atypical antipsychotics on serum IGF-2 level and its relationship with clinical improvements in schizophrenia patients. Thirty-one schizophrenia patients with acute exacerbation and 30 healthy individuals were recruited in this study. Psychiatric symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) and serum IGF-2 levels were determined using ELISA. We found that schizophrenia patients with acute exacerbation had lower serum IGF-2 levels than control individuals at baseline (P<0.05). After 2 months of atypical antipsychotic treatment, a significant improvement in each PANSS subscore and total score was observed in patients (all P<0.01), and the serum IGF-2 levels of patients were significantly increased compared with those at baseline (203.13±64.62 vs. 426.99±124.26 ng/mL; t =-5.044, P<0.001). Correlation analysis revealed that the changes of serum IGF-2 levels in patients were significantly correlated with the improvements of negative symptoms (r=-0.522, P=0.006). Collectively, our findings demonstrated changes of serum IGF-2 response to improvements of negative symptoms in schizophrenia patients treated with atypical antipsychotics, suggesting that serum IGF-2 might be a treatment biomarker for schizophrenia.

Cerebral white matter changes in deficit and non-deficit subtypes of schizophrenia

The considerable clinical heterogeneity in schizophrenia makes elucidation of its neurobiology challenging. Subtyping the disorder is one way to reduce this heterogeneity and deficit status is one such categorization based on the prominence of negative symptoms. We aimed to utilize diffusion tensor imaging (DTI) to identify unique white matter cerebral changes in deficit schizophrenia (DS) compared with non-deficit schizophrenia (NDS) and healthy controls (HC) in an Asian sample. A total of 289 subjects (111 HC, 133 NDS and 45 DS) underwent DTI and completed rating scales which assessed the severity of psychopathology, psychosocial functioning and premorbid intelligence.We found that DS patients had fractional anisotropy (FA) reductions in the Body of the Corpus Callosum (BCC) and right Posterior Thalamic Radiation (PTR) regions relative to HCs, and FA reductions in the right PTR relative to NDS patients. NDS patients had FA reductions of the BCC and right PTR relative to HCs. Binomial logistic regression analyses revealed that FA reductions of the right PTR FA was an independent predictor of deficit status. The identified brain white matter changes especially in the PTR relate to deficits of cognitive control and emotional awareness, which may underlie psychopathology associated with deficit status like inattention and affective blunting. These potential biomarkers of DS warrant further examination to determine their utility for monitoring illness progression and intervention response in schizophrenia.

Principal-component analyses of PANSS and SANS-SAPS in schizophrenia: their stability in an acute phase

Whether studies agree or disagree on the positive-negative dichotomy in schizophrenia, the relevance of a third component, disorganization, remains a point of debate. Disorganization, as expressed by the scale for the assessment of negative symptoms and positive symptoms (SANS-SAPS) and the positive and negative syndrome scale (PANSS) principal-component analyses, could be considered as permanent and determinant a dimension as the positive and negative components. The aim of this study therefore was to determine whether this disorganization, with the negative and positive components, is stable and has the same composition in the acute and postacute phases of illness. This study was carried out in 57 patients, broadly defined by at least one of four diagnostic criteria (American Psychiatric Association, Langfeldt, Carpenter and Schneider), established with a computerized checklist, and evaluated with SANS-SAPS and PANSS. Principal component analyses (PCA) of these scales were performed at admission and discharge from hospital.

The PCA of SANS-SAPS displayed a 3-factor solution, regardless of the phase of illness (acute or postacute), showing that the negative, positive and disorganization components were stable. The PCA of PANSS yielded negative and positive components perfectly stable over time and a disorganization component whose composition varied between admission and discharge. At admission, this component included the conceptual disorganization item negatively correlated with one of depression. At discharge, this disorganization component included two additional items, autistic preoccupation and mannerisms and one depression component appeared. The instability of the PCA of PANSS could express the role played by the phase of illness; in an acute phase, this disorganization component was constituted by more “positive” items such as grandiosity, unusual thought content and active social avoidance whereas in the postacute phase, it included items that reflected more the chronicity of the illness, such as mannerisms and autistic preoccupation. Moreover, the depressive item appeared, in the postacute phase, in a specific depressive component. This result could be due to the fact that depressive symptoms cannot be expressed when positive symptoms are very severe, which explains why no depressive components were shown during the acute phase.

Rating scale for the assessment of communication disorders in schizophrenics

Taking up the Bleulerian view of a clinical description based on a pathogenic model, we propose a rating scale for the assessment of communication disorders in schizophrenic patients. The scale consists of clinical items that could be the direct expression of the three hypotheses of cognitive dysfunction which have been postulated to explain communication dysfunction in these patients. We assessed the frequency of the 16 items in the scale in a total of 80 subjects (43 schizophrenic subjects, ten manic subjects, 17 depressive subjects and ten normal control subjects). The results of this study showed that this item schedule was specific to schizophrenic patients and, in particular, could statistically significantly discriminate schizophrenic patients from psychotic patients with affective disorder. The methodological qualities of the scale were explored and proved accurate, except for the reliability which is too low for some items and the item-to-total correlation which is too low for one item of the scale.

Dimensional structure of first episode psychosis

AIM

Current diagnostic systems, DSM-5 and ICD-10, still adopt a categorical approach to classify psychotic disorders. The present study was aimed at investigating the structure of psychotic symptomatology in both affective and non-affective psychosis from a dimensional approach.

METHODS

Participants with a first episode psychosis (FEP) were recruited from a cluster-randomized controlled trial (GET-UP PIANO TRIAL), offered to all Community Mental Health Centres (CMHCs) located across two northern Italian regions. After clinical stabilization, patients were assessed with a comprehensive set of psychopathological measures including the Positive and Negative Syndrome Scale, the Hamilton Depression Rating Scale and the Bech-Rafaelsen Mania Rating Scale. A two-step cluster analysis was performed.

RESULTS

Overall, 257 FEP patients (male, n = 171, 66.5%; mean age = 24.96 ± 4.56) were included in the study. The cluster analysis revealed a robust four-cluster solution: delusional-persecutory (n = 82; 31.9%), depressed (n = 95; 37%), excited (n = 26; 10.1%) and negative-disorganized (n = 54; 21%), thus suggesting a quadripartite structure with both affective and non-affective dimensions. Among non-affective dimensions, negative and disorganization symptoms constituted a unique construct apart from positive symptoms.

CONCLUSIONS

Symptom dimensions may represent a useful tool for dissecting the indistinct and non-specific psychopathology of FEP in order to better target specific interventions.

Is there a discrete negative symptom syndrome in people who use methamphetamine?

BACKGROUND

Positive psychotic symptoms have consistently been associated with methamphetamine use but the presence of a negative symptom cluster remains unclear. We used exploratory factor analysis to examine whether a discrete negative syndrome could be delineated among methamphetamine users, and to examine the clinical correlates of this syndrome.

METHOD

Participants (N = 154) were people who used methamphetamine at least monthly and did not meet DSM-IV diagnostic criteria for lifetime schizophrenia. Scores on the Brief Psychiatric Rating Scale for the past month were subject to exploratory factor analysis. Latent class analysis was applied to resultant factor scores to determine whether negative and positive factors were experienced by the same participants. Past-month substance use measures were days of use for each drug type and methamphetamine dependence assessed using the Severity of Dependence Scale.

RESULTS

We articulated a three-factor model including 'positive/activation symptoms' (e.g. suspiciousness, hallucinations, conceptual disorganisation, tension), 'affective symptoms' (e.g. depression, anxiety) and 'negative symptoms' (e.g. blunted affect, motor retardation). Positive-activation and affective symptoms (but not negative symptoms) were positively correlated with past month days of methamphetamine use (r = 0.16; r = 0.25) and severity of dependence (r = 0.24; r = 0.41). Negative symptoms were correlated with heroin (r = 0.24) and benzodiazepine use (r = 0.21). Latent class analysis revealed a three-class model comprising a positive-symptom class (44%, high positive-activation, low negative symptoms), a negative-symptom class (31%, low positive-activation, high negative symptoms), and a low-symptom class (38%, low on all factors).

CONCLUSIONS

A negative symptom syndrome exists among people who use methamphetamine, but this appears related to polysubstance use rather than forming a part of the psychotic syndrome associated with methamphetamine use. Overlooking the role of polysubstance use on negative symptoms may conflate the profiles of methamphetamine-associated psychosis and schizophrenia.

Pharmacological treatment of negative symptoms in schizophrenia: update and proposal of a clinical algorithm

The clinical presentation of schizophrenia encompasses symptoms divided into three dimensions: positive, negative, and cognitive. Negative symptoms (NS), in particular, have a major impact on the quality of life of the affected subject, and, differing from positive symptoms, are often associated with a limited response to pharmacotherapy. To date, studies specifically investigating NS in schizophrenia are scant; therefore, proper selection of therapy for NS remains a major unmet medical need. Given the heterogeneity of the clinical presentation of schizophrenia, the treatment of NS, as well as therapy for other associated symptoms, should be largely individualized according to a patient's specific characteristics. In this paper, we review current knowledge on NS and construct a clinical algorithm for the treatment of schizophrenic conditions with pronounced NS. Overall, data from the literature suggest that second-generation antipsychotics, such as cariprazine and amisulpride, should be preferred over first-generation antipsychotics (FGAs), as they are associated with better functional outcomes and lower cognitive impairment. The combination of antipsychotics and antidepressants may also improve NS while addressing some affective disorders associated with schizophrenia; however, no clear information is available on the effects of this combination on primary NS or on the mechanism of action of the combination. In the proposed clinical algorithm, we suggest that cariprazine should be used as first-line treatment for patients with predominant NS, and that amisulpride should be considered as an alternative in cases of cariprazine failure. Further treatment lines may include the use of olanzapine and quetiapine, and add-on therapy with antidepressants.

Association of Pre-onset Subthreshold Psychotic Symptoms With Longitudinal Outcomes During Treatment of a First Episode of Psychosis

IMPORTANCE

The clinical high-risk state in psychosis is most often characterized by subthreshold psychotic symptoms (STPS) and represents a target for psychosis prevention. However, evidence suggests that between 30% and 50% of patients with a first episode of psychosis (FEP) report no prior history of STPS, indicating that not all patients with FEP experience a previous clinical high-risk phase. As with other early characteristics of illness onset, this diversity in the early course of symptoms may offer prognostic value for subsequent clinical trajectories.

OBJECTIVE

To determine whether a history of pre-onset STPS is associated with differential 1-year treatment outcomes in an early intervention service for FEP.

DESIGN, SETTING, AND PARTICIPANTS

Data on 195 patients 15 to 35 years of age who were recruited between January 17, 2003, and October 17, 2013, were collected from a catchment-based specialized early intervention service for FEP. Patients who reported experiencing at least 1 STPS prior to the onset of FEP were identified as STPS present (STPSp; n = 135); those who reported no such history were identified as STPS absent (STPSa; n = 60). Statistical analysis was conducted from December 15, 2016, to February 15, 2018.

MAIN OUTCOMES AND MEASURES

Summary scores on the Scale for the Assessment of Positive Symptoms and the Scale for the Assessment of Negative Symptoms, Calgary Depression Scale for Schizophrenia, Hamilton Anxiety Rating Scale, Global Assessment of Functioning scores, and Social and Occupational Functioning Assessment Scale scores at baseline and after 1 year of treatment were analyzed to evaluate 1-year outcomes.

RESULTS

Individuals in the STPSp group (39 female and 96 male participants; mean [SD] age, 23.4 [4.2] years) and the STPSa group (20 female and 40 male participants; mean [SD] age, 23.9 [5.1] years) did not differ in symptom severity or functioning at baseline. Although both groups improved by 1 year of treatment, mixed analyses of covariance (controlling for duration of untreated psychosis) revealed group-by-time interactions for scores on the Scale for the Assessment of Negative Symptoms (F1,192 = 6.17; P = .01), the Global Assessment of Functioning (F1,188 = 7.54; P = .006), and the Social and Occupational Functioning Assessment Scale (F1,192 = 3.79; P = .05). Mixed analyses of covariance also revealed a group effect for scores on the Scale for the Assessment of Positive Symptoms (F1,192 = 5.31; P = .02). After controlling for multiple comparisons, all significant results indicate poorer 1-year outcomes for patients with STPSp compared with patients with STPSa.

CONCLUSIONS AND RELEVANCE

A history of pre-onset STPS consistent with a prior clinical high-risk state is associated with poorer outcomes in psychotic symptoms and global functioning for patients after 1 year of treatment for FEP. The presence or absence of pre-onset STPS therefore has prognostic value for treatment outcomes, even during a later stage of psychotic illness.

The current conceptualization of negative symptoms in schizophrenia

Negative symptoms have long been conceptualized as a core aspect of schizophrenia. They play a key role in the functional outcome of the disorder, and their management represents a significant unmet need. Improvements in definition, characterization, assessment instruments and experimental models are needed in order to foster research aimed at developing effective interventions. A consensus has recently been reached on the following aspects: a) five constructs should be considered as negative symptoms, i.e. blunted affect, alogia, anhedonia, asociality and avolition; b) for each construct, symptoms due to identifiable factors, such as medication effects, psychotic symptoms or depression, should be distinguished from those regarded as primary; c) the five constructs cluster in two factors, one including blunted affect and alogia and the other consisting of anhedonia, avolition and asociality. In this paper, for each construct, we report the current definition; highlight differences among the main assessment instruments; illustrate quantitative measures, if available, and their relationship with the evaluations based on rating scales; and describe correlates as well as experimental models. We conclude that: a) the assessment of the negative symptom dimension has recently improved, but even current expert consensus-based instruments diverge on several aspects; b) the use of objective measures might contribute to overcome uncertainties about the reliability of rating scales, but these measures require further investigation and validation; c) the boundaries with other illness components, in particular neurocognition and social cognition, are not well defined; and d) without further reducing the heterogeneity within the negative symptom dimension, attempts to develop successful interventions are likely to lead to great efforts paid back by small rewards.

The current conceptualization of negative symptoms in schizophrenia

Negative symptoms have long been conceptualized as a core aspect of schizophrenia. They play a key role in the functional outcome of the disorder, and their management represents a significant unmet need. Improvements in definition, characterization, assessment instruments and experimental models are needed in order to foster research aimed at developing effective interventions. A consensus has recently been reached on the following aspects: a) five constructs should be considered as negative symptoms, i.e. blunted affect, alogia, anhedonia, asociality and avolition; b) for each construct, symptoms due to identifiable factors, such as medication effects, psychotic symptoms or depression, should be distinguished from those regarded as primary; c) the five constructs cluster in two factors, one including blunted affect and alogia and the other consisting of anhedonia, avolition and asociality. In this paper, for each construct, we report the current definition; highlight differences among the main assessment instruments; illustrate quantitative measures, if available, and their relationship with the evaluations based on rating scales; and describe correlates as well as experimental models. We conclude that: a) the assessment of the negative symptom dimension has recently improved, but even current expert consensus-based instruments diverge on several aspects; b) the use of objective measures might contribute to overcome uncertainties about the reliability of rating scales, but these measures require further investigation and validation; c) the boundaries with other illness components, in particular neurocognition and social cognition, are not well defined; and d) without further reducing the heterogeneity within the negative symptom dimension, attempts to develop successful interventions are likely to lead to great efforts paid back by small rewards.

A pilot study of bright light therapy in schizophrenia

Negative symptoms and episodes of major depressive disorder in patients with schizophrenia are common and there is an overlap in symptoms. Unfortunately, there is no effective primary treatment for negative symptoms yet. Depressive disorder in patients with schizophrenia is associated with a decreased quality of life and an increased risk of psychotic relapses. Previous research has shown that Bright Light Therapy (BLT) has a positive impact on negative symptoms of patients with schizophrenia. Our aim was to investigate the feasibility and the effect of Bright Light Therapy in a severely ill population of patients who were admitted to a closed ward. This pilot study was a single center, open label add-on trial with two control groups and included 20 patients.

RESULTS

Neither negative nor positive symptoms were affected. However, there was a trend towards increase on the general psychopathology scale of the Positive And Negative Syndrome Scale in the BLT group. BLT did not change daily mood ratings. One participant from the BLT group was withdrawn from the study due to a manic state possibly triggered by BLT. Patients participating in our study did not benefit from BLT. It was an additional burden on the participants and worsened general psychopathology at a follow-up. Based on this study, we did not find any beneficial effect of BLT for patients with schizophrenia.

Seeing more clearly through psychosis: Depth inversion illusions are normal in bipolar disorder but reduced in schizophrenia

Schizophrenia patients with more positive symptoms are less susceptible to depth inversion illusions (DIIs) in which concave objects appear as convex. It remains unclear, however, the extent to which this perceptual advantage uniquely characterizes the schizophrenia phenotype. To address the foregoing, we compared 30 bipolar disorder patients to a previously published sample of healthy controls (N=25) and schizophrenia patients (N=30). The task in all cases was to judge the apparent convexity of physically concave faces and scenes. Half of the concave objects were painted with realistic texture to enhance the convexity illusion and the remaining objects were untextured to reduce the illusion. Subjects viewed objects stereoscopically or via monocular motion parallax depth cues. For each group, DIIs were stronger with texture than without, and weaker with stereoscopic information than without, indicating a uniformly normal response to stimulus alterations across groups. Bipolar patients experienced DIIs more frequently than schizophrenia patients but as commonly as controls, irrespective of the face/scene category, texture, or viewing condition (motion/stereo). More severe positive and disorganized symptoms predicted reduced DIIs for schizophrenia patients and across all patients. These results suggest that people with schizophrenia, but not bipolar disorder, more accurately perceive object depth structure. Psychotic symptoms-or their accompanying neural dysfunction-may primarily drive the effect presumably through eroding the visual system's generalized tendency to construe unusual or ambiguous surfaces as convex. Because such symptoms are by definition more common in schizophrenia, DIIs are at once state-sensitive and diagnostically specific, offering a potential biomarker for the presence of acute psychosis.

Characterization of premorbid functioning during childhood in patients with deficit vs. non-deficit schizophrenia and in their healthy siblings

Impaired premorbid adjustment has been reported in patients with schizophrenia, generally in association with unfavorable aspects of the illness (e.g., poor outcome and severe negative symptoms). Several studies attempted to define the domains of premorbid dysfunction associated with negative symptoms and poor outcome; however, most of them assessed broadly defined negative symptoms. The present study was aimed to characterize premorbid functioning in a group of patients with deficit schizophrenia (DS), characterized by the presence of at least two primary and persistent negative symptoms (PPNS), and one of patients with a diagnosis of schizophrenia who did not meet criteria for DS (NDS). The presence of emotional/behavioral problems during childhood was investigated using the Childhood Behavior Checklist (CBCL) in both patient groups and in their respective healthy siblings. The Premorbid Adjustment Scale (PAS) was also used to assess premorbid functioning during childhood in the two patient groups. PPNS were also treated as a continuous variable and correlated with the indices of premorbid functioning regardless the DS/NDS categorization. DS patients, as compared to NDS, showed higher scores on the CBCL subscale "Withdrawn". Both DS and NDS patients showed, as compared to their healthy siblings, a greater impairment on almost all CBCL subscales. PAS findings revealed that DS patients had poorer premorbid adjustment than NDS. No significant correlation between premorbid functioning and PPNS was observed. These findings support the hypothesis that DS has a different developmental trajectory with respect to NDS, and that premorbid adjustment is one of the essential aspects of its characterization.

Paranoid Ideation and Violence: Meta-analysis of Individual Subject Data of 7 Population Surveys

There is controversy whether associations between psychosis and violence are due to coexisting substance misuse and factors increasing risk in nonpsychotic persons. Recent studies in clinical samples have implicated independent effects of paranoid delusions. Research findings suggest that individual psychotic-like-experiences on the psychosis continuum in the general population are associated with violence; it remains unclear whether this association is due to psychiatric comorbidity. We pooled data from 7 UK general population surveys (n = 23 444) and conducted a meta-analysis of individual subject data. Further meta-analyses were performed to identify heterogeneity. Main exposure variables: 5 psychotic-like-experiences and a categorical measure of psychosis. Comorbidity was established through standardized self-report instruments. Information was collected on violence, severity, victims. Paranoid ideation was associated with violence (AOR 2.26, 95% CI 1.75-2.91), severity and frequency, even when controlling for effects of other psychotic-like-experiences. Associations were not explained by comorbid conditions, including substance dependence. Psychotic disorder was associated with violence and injury to the perpetrator but associations were explained by paranoid ideation. Individual associations between hypomania, thought insertion, hallucinations, and violence were nonsignificant after adjustments, and significantly associated only when comorbid with antisocial personality disorder. Strange experiences were only associated with intimate partner violence. Paranoid ideation on a psychosis-continuum in the general population was associated with violence. All other associations were explained by comorbidity. Further investigation should determine whether paranoid ideation among persons in the community require preventive interventions, similar to those presenting to mental health services. Nevertheless, risks are considerably increased for psychotic-like-experiences with co-occurring antisocial personality disorder.

[To the question of pathophysiological fundamentals of endocrine system functioning in patients with a first psychotic episode]

OBJECTIVE

To study the characteristics of prolactin secretion in patients with a first psychotic episode (FPE) with regard to disease severity, gender and patient's neuromediator system state.

MATERIAL AND METHODS

Author studied 76 patients with schizophrenic spectrum disorders and 34 normals (control group).

RESULTS AND CONCLUSION

There was a significant negative sex-related correlation between the severity of psychopathologic symptoms and plasma prolactin levels. Based on the results author attempted to explain the hormonal disbalance in the patients with FPE taking into account the state of monoaminergic mediator systems in patients.

Multilevel ordinal factor analysis of the positive and negative syndrome scale (PANSS)

Clinical assessments of the presence and severity of psychopathology are often collected by health care professionals in mental health services or clinical researchers trained to use semi-structured interviews. Clustering by interviewer or rater needs to be considered when performing psychometric analyses such as factor analysis or item response modelling as non-independence of observations arises in these situations. We apply more suitable multilevel methods to analyse ordinally scored Positive and Negative Syndrome Scale (PANSS) items. Our aim is to highlight the differences in results that occur when the data are analysed using a hierarchically sensitive approach rather than using a traditional (aggregated) analysis. Our sample (n = 507) consisted of patients diagnosed with schizophrenia who participated in a multi-centre randomized control clinical trial, the DIALOG study. Analyses reported and compared include an exploratory factor analysis as well as several recently published multifactor models re-estimated within a confirmatory analysis framework. Our results show that the fit of the model and the parsimony of the exploratory factor analysis (EFA) models indicated by the number of factors necessary to explain the inter-correlation among PANSS items improved significantly when data clustering is taken into account through multilevel analysis. Our modeling results support the pentagonal PANSS model first proposed by White et al. (1997). Copyright © 2014 John Wiley & Sons, Ltd.

Patients With First-Episode Psychosis are Not a Homogeneous Population: Implications for Treatment

Objective: This study aimed at defining the characteristics of a population of patients diagnosed with first-episode psychosis (FEP), and accessing for the first time a center for early intervention in psychosis in the health district of Milan and its surroundings. Methods: Patients were included in the study from January 2007 to December 2008; criteria: first contact with any public mental health service of the catchment area for a first episode of schizophrenia or related syndromes according to the ICD-10 criteria. Cluster analysis was used to divide patients into groups based on the main socio-demographic and clinical characteristics at presentation. Results: Overall, 91 FEP patients were enrolled in the study. Two clusters were identified, which differed principally by symptom profile. Patients in cluster 1 (n=36) had severe agitation, and a history of alcohol and/or substance abuse at presentation more often than those in cluster 2 (n=55), who were more likely to suffer at presentation from severe depression or apathy, anxiety, poor self-care, functional or work impairment and severe social withdrawal. After six months of treatment patients improved on almost all symptomatic dimensions on the Health of the Nation Outcome Scale and the Brief Psychiatric Rating Scale, with greater improvement in cluster 1 than in cluster 2. Conclusions: The findings of this study need replication in larger samples and on a wider severity scale. Nevertheless, the heterogeneity of patients with FEP might impact on treatment. Policymakers should recognize the importance of the diagnostic and outcome assessment in the treatment of severe mental disorders.

Characterization of the deficit syndrome in drug-naive schizophrenia patients: the role of spontaneous movement disorders and neurological soft signs

This study aimed to characterize the deficit syndrome in drug-naive schizophrenia patients and to examine the relationship between deficit features and primary neurological abnormalities. Drug-naive schizophrenia patients (n = 102) were examined at baseline for demographics, premorbid functioning, duration of untreated illness (DUI), psychopathology, neurological signs, and deficit symptoms, and reassessed at 1-year follow-up. Neurological abnormalities were examined before inception of antipsychotic medication and included four domains of spontaneous movement disorders (SMD) and four domains of neurological soft signs (NSS). Patients fulfilling the deficit syndrome criteria at the two assessments (n = 20) were compared with nondeficit patients (n = 82) across demographic, clinical, and neurological variables. Deficit and nondeficit groups showed similar demographic characteristics and levels of psychotic, disorganization, and depressive symptoms. Compared with nondeficit patients, deficit patients showed poorer premorbid adjustment, higher premorbid deterioration, a lengthier DUI, and much poorer functional outcome. Relative to the nondeficit patients, those with the deficit syndrome showed higher levels of SMD--excepting akathisia--and NSS. This association pattern was also evident for deficit and neurological ratings in the whole sample of schizophrenia patients. Parkinsonism, motor sequencing, and release signs were all independently related to the deficit syndrome. These findings confirm that the deficit/nondeficit categorization is replicable and reliable in first-admission patients and raise the possibility that premorbid deterioration, deficit symptoms, and neurological abnormalities represent a triad of manifestations that share common underlying neurobiological mechanisms. More specifically, the data are consistent with a neurodevelopmental model of deficit symptoms involving basal ganglia dysfunction.

A new Integrated Negative Symptom structure of the Positive and Negative Syndrome Scale (PANSS) in schizophrenia using item response analysis

BACKGROUND

Debate persists with regard to how best to categorize the syndromal dimension of negative symptoms in schizophrenia. The aim was to first review published Principle Components Analysis (PCA) of the PANSS, and extract items most frequently included in the negative domain, and secondly, to examine the quality of items using Item Response Theory (IRT) to select items that best represent a measurable dimension (or dimensions) of negative symptoms.

METHODS

First, 22 factor analyses and PCA met were included. Second, using a large dataset (n=7187) of participants in clinical trials with chronic schizophrenia, we extracted items loading on one or more PCA. Third, items not loading with a value of ≥ 0.5, or loading on more than one component with values of ≥ 0.5 were discarded. Fourth, resulting items were included in a non-parametric IRT and retained based on Option Characteristic Curves (OCCs) and Item Characteristic Curves (ICCs).

RESULTS

15 items loaded on a negative domain in at least one study, with Emotional Withdrawal loading on all studies. Non-parametric IRT retained nine items as an Integrated Negative Factor: Emotional Withdrawal, Blunted Affect, Passive/Apathetic Social Withdrawal, Poor Rapport, Lack of Spontaneity/Conversation Flow, Active Social Avoidance, Disturbance of Volition, Stereotyped Thinking and Difficulty in Abstract Thinking.

CONCLUSIONS

This is the first study to use a psychometric IRT process to arrive at a set of negative symptom items. Future steps will include further examination of these nine items in terms of their stability, sensitivity to change, and correlations with functional and cognitive outcomes.

Factor structure of the targeted inventory on problems in schizophrenia

Objective

The aim of this study was to explore the factor structure of a novel, 10-item rating scale, the Targeted Inventory on Problems in Schizophrenia (TIP-Sz). Determining the factor structure will be useful in the brief evaluation of medication and non-medication treatment of the disease.

Methods

An exploratory factor analysis was performed on TIP-Sz scores obtained from 100 patients who met the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for schizophrenia.

Results

The factor analysis extracted four factors that were deemed clinically pertinent, which we labeled: disorganization, social cooperativeness, functional capacity, and emotional state. The items exhibited cross-loadings on the first three factors (i.e., some items loaded on more than one factor). In particular, the 'behavioral dyscontrol and disorganization,' 'insight and reality testing,' and 'overall prognostic impression' items had comparable cross-loadings on all of the first three factors. The emotional state factor was distinct from the other factors in that the items loading on it did not cross-load on other factors.

Conclusion

The TIP-Sz scale comprises factors that are associated with the psychosocial functioning and emotional state of patients, which are important outcome parameters for successful treatment of the disease.

Ketamine-enhanced immobility in forced swim test: a possible animal model for the negative symptoms of schizophrenia

Schizophrenia is a chronic and highly complex psychiatric disorder characterised by cognitive dysfunctions, negative and positive symptoms. The major challenge in schizophrenia research is lack of suitable animal models that mimic the core behavioural aspects and symptoms of this devastating psychiatric disorder. In this study, we used classical and atypical antipsychotic drugs to examine the predictive validity of ketamine-enhanced immobility in forced swim test (FST) as a possible animal model for the negative symptoms of schizophrenia. We also evaluated the effects of a selective serotonin reuptake inhibitor (SSRI) on the ketamine-enhanced immobility in FST. Repeated administration of a subanaesthetic dose of ketamine (30 mg kg(-1), i.p., daily for 5 days) enhanced the duration of immobility in FST 24 h after the final injection. The effect, which persisted for at least 21 days after withdrawal of the drug, was neither observed by single treatment with ketamine (30 mg kg(-1) i.p.) nor repeated treatment with amphetamine (1 and 2 mg kg(-1) i.p., daily for 5 days). The enhancing effects of ketamine (30 mg kg(-1) day(-1) i.p.) on the duration of immobility in the FST were attenuated by clozapine (1, 5 and 10 mg kg(-1) i.p.), risperidone (0.25 and 0.5 mg kg(-1) i.p.) and paroxetine (1 and 5 mg kg(-1) i.p.). Haloperidol (0.25 and 0.50 mg kg(-1) day(-1) i.p.) failed to attenuate the ketamine-enhanced immobility in the FST. The repeated ketamine administration neither affects locomotor activity nor motor coordination in rats under the same treatment conditions with the FST, suggesting that the effects of ketamine on the duration of immobility in this study was neither due to motor dysfunction nor peripheral neuromuscular blockade. Our results suggest that repeated treatment with subanaesthetic doses of ketamine enhance the duration of immobility in FST, which might be a useful animal model for the negative symptoms (particularly the depressive features) of schizophrenia.

Factor analysis of positive and negative syndrome scale in schizophrenia: An exploratory study

BACKGROUND

Controversy persists with regard to how best we can categorize symptomatic dimension of Schizophrenia. Aim of the study was to compute factorial dimensions in Indian subset of schizophrenic patients and to compare them with five factor pentagonal model extracted in western studies.

MATERIALS AND METHODS

150 inpatients of Schizophrenia with acute exacerbation were subjected to PANSS rating within one week of admission and statistical calculation done based on exploratory factor analysis.

RESULTS

Five factors namely negative, autistic, activation, positive and depression were extracted wherein negative factors showed highest percentage of total variance supporting five factor modal of western literature

CONCLUSION

A consensus is gradually emerging regarding symptomatic dimensions of Schizophrenia.

Prevalence and correlates of anomalous experiences in a large non-clinical sample

BACKGROUND

Anomalous experiences occur in many psychiatric conditions, but are also reported by non-patients. Given the continuum account of psychiatric symptoms and reports of dissociation between delusions and anomalous experiences, we predicted that anomalous experiences in a large non-clinical sample would (1) associate with delusion-like beliefs but not with socio-cultural beliefs and (2) that anomalous experiences would also show examples of dissociation with anomalous beliefs. A particular focus was the association between beliefs and experiences theoretically predicted to co-occur in Capgras syndrome.

METHODS

The study examined the distribution and correlates of differential levels of self-reported anomalous experience in a British sample of 1,000 individuals.

RESULTS

Anomalous experiences were found to be relatively common in the general population and were reported (occurring sometimes/often) by 48% of the sample. Being female and endorsing a non-Christian religion were the only two demographic factors related to higher experience scores. Significant relationships were found between anomalous experiences and anomalous beliefs (i.e., delusion-like and paranormal/religious), but not general societal beliefs. Dissociations between anomalous experiences and anomalous beliefs also were present but not common. No significant relationship was found between Capgras-type beliefs and experiences.

CONCLUSIONS

This large scale study demonstrated significant association between anomalous experiences and anomalous beliefs in the general population. The relationship was not, however present in all cases similar to cases reported in the clinical literature.

[Analysis of the Structure of Acute Psychotic Disorder]

INTRODUCTION

Schizophrenia is a clinically heterogeneous disorder. A multifactorial structure of this syndrome has been described in previous reports. The aim of this study was to evaluate what are the possible diagnostic categories in patients having acute psychotic symptoms, studying their clinical characteristics in a cross-sectional study.

METHODS

An instrument for measuring psychotic symptoms was created using previous scales (SANS, SAPS, BPRS, EMUN, Zung depression scale). Using as criteria statistical indexes and redundance of items, the initial instrument having 101 items has been reduced to 57 items. 232 patients with acute psychotic symptoms, in most cases schizophrenia, attending Clínica Nuestra Señora de la Paz in Bogotá and Hospital San Juan de Dios in Chía have been evaluated from April, 2008 to December, 2009. Multivariate statistical methods have been used for analyzing data.

RESULTS

A six-factor structure has been found (Deficit, paranoid-aggressive, disorganized, depressive, bizarre delusions, hallucinations). Cluster analysis showed eight subtypes that can be described as: 1) bizarre delusions-hallucinations; 2) deterioration and disorganized behavior; 3) deterioration; 4) deterioration and paranoid-aggressive behavior; 5) bizarre delusions; 6) paranoia-anxiety- aggressiveness; 7) depressive symptoms and bizarre delusions; 8) paranoia and aggressiveness with depressive symptoms

CONCLUSION

These subtypes allow a more exhaustive characterization that those included in standard classification schemes and should be validated in longitudinal studies.

Glutathione precursor N-acetyl-cysteine modulates EEG synchronization in schizophrenia patients: a double-blind, randomized, placebo-controlled trial

Glutathione (GSH) dysregulation at the gene, protein, and functional levels has been observed in schizophrenia patients. Together with disease-like anomalies in GSH deficit experimental models, it suggests that such redox dysregulation can play a critical role in altering neural connectivity and synchronization, and thus possibly causing schizophrenia symptoms. To determine whether increased GSH levels would modulate EEG synchronization, N-acetyl-cysteine (NAC), a glutathione precursor, was administered to patients in a randomized, double-blind, crossover protocol for 60 days, followed by placebo for another 60 days (or vice versa). We analyzed whole-head topography of the multivariate phase synchronization (MPS) for 128-channel resting-state EEGs that were recorded at the onset, at the point of crossover, and at the end of the protocol. In this proof of concept study, the treatment with NAC significantly increased MPS compared to placebo over the left parieto-temporal, the right temporal, and the bilateral prefrontal regions. These changes were robust both at the group and at the individual level. Although MPS increase was observed in the absence of clinical improvement at a group level, it correlated with individual change estimated by Liddle's disorganization scale. Therefore, significant changes in EEG synchronization induced by NAC administration may precede clinically detectable improvement, highlighting its possible utility as a biomarker of treatment efficacy.

Is there a continuum of psychotic experiences in the general population?

Summary

Aims - Schizophrenia is a severe mental illness that affects 1% of the population. The diagnosis is made according to current diagnostic systems of DSM-1V (American Psychiatric Association, 1994) and ICD-10 (World Health Organisation, 1992), on the basis of characteristic ‘positive’ and ‘negative’ symptoms. The traditional model assumes a categorical view of the schizophrenia syndrome and its core symptoms, in which differences between psychotic symptoms and their normal counterparts are considered to be qualitative. An alternative, dimensional approach assumes that schizophrenia is not a discrete illness entity, but that psychotic symptoms differ in quantitative ways from normal experiences and behaviours. This paper reviews evidence for the continuity of psychotic symptoms with normal experiences, focusing on the symptoms of hallucinations and delusions. Methods - A qualitative review of the relevant literature. Results - The literature suggests that although current epidemiological approaches yield substantial evidence for a continuum view, it is rarely interpreted as such. Conclusions - The traditional concept ofschizophrenia as a homogeneous disease entity has become outdated and is in dire need of a more valid and clinically useful successor.

Declaration of Interests

Support has been received in the last two years from the Dutch Research Council, The Dutch Ministry of Health, Maastricht University, The Dutch Brain Society, ZON-MW, The Province of Limburg, The Council of Maastricht, Eli Lilly, Janssen-Cilag, Pfizer, Astra-Zeneca and Bristol Meyer Squibb. None of these funding sources represents a conflict of interest in relation to this article.

Assessment of negative symptoms and depression in schizophrenia: revision of the SANS and how it relates to the PANSS and CDSS

OBJECTIVE

The Scale for the Assessment of Negative Symptoms (SANS) is the most widely used instrument for measuring negative symptoms in schizophrenia. The validity of its factor structure has not been established. Congruence of the SANS and its subscales to the negative subscale of the Positive and Negative Symptom Scale (PANSS-N) and the Calgary Depression Scale for Schizophrenia (CDSS) were never explored. The current study revised SANS's structure and examined its correlations with the PANSS and the CDSS.

METHOD

Two-hundred and forty patients with schizophrenia with predominantly negative symptoms were analyzed. A principal component analysis was conducted for SANS. Spearman's correlations were conducted for SANS and PANSS-N, and for SANS and CDSS.

RESULTS

Principal Component Analyses (PCA) of SANS revealed four factors, corresponding to the original SANS subscales with two exceptions: Item #13 (grooming and hygiene) loaded on the alogia factor rather than on its original affective flattening factor, and Item #4 (poor eye contact) did not load onto any factor. The total PANSS-N score showed a moderate correlation with the SANS and all of its subscales. The total CDSS score showed a low negative correlation with the total SANS score and with its avolition subscale.

CONCLUSIONS

Our results supported the validity of SANS's structure except for "poor eye contact" and "grooming end hygiene". The moderate correlation between SANS and PANSS-N suggests that although they are not identical, they measure similar constructs. The low negative correlation between SANS and CDSS suggests that they measure different constructs.

Variations in selective and nonselective prediction error with the negative dimension of schizotypy

Two human associative-learning experiments investigated the relationship between the negative dimension of schizotypy and selective and nonselective prediction-error learning. Experiment 1 demonstrates that individuals low, but not high, on the introvertive anhedonia dimension of schizotypy demonstrate Kamin blocking, which has been taken to reflect the operation of selective learning (Rescorla & Wagner, 1972). In complement, Experiment 2 demonstrates that individuals high, but not low, on the same dimension demonstrate asymmetrical learning about the components of a compound stimulus that differ in their associative history, which has been suggested to reflect the operation of nonselective learning (Rescorla, 2000). The implications of this double dissociation for understanding the nature of the cognitive deficit in schizophrenia and for theories of learning are considered.

Psychopathology, social adjustment and personality correlates of schizotypy clusters in a large nonclinical sample

INTRODUCTION

Correlational methods, unlike cluster analyses, cannot take into account the possibility that individuals score highly on more than one symptom dimension simultaneously. This may account for some of the inconsistency found in the literature of correlates of schizotypy dimensions. This study explored the clustering of positive and negative schizotypy dimensions in nonclinical subjects and whether schizotypy clusters have meaningful patterns of adjustment in terms of psychopathology, social functioning, and personality.

METHODS

Positive and negative schizotypy dimensional scores were derived from the Chapman Psychosis-Proneness Scales for 6137 college students and submitted to cluster analysis. Of these, 780 completed the NEO-PI-R and Social Adjustment Scale-self report version, and a further 430 were interviewed for schizophrenia-spectrum, mood, and substance use psychopathology.

RESULTS

Four clusters were obtained: low (nonschizotypic), high positive, high negative, and mixed (high positive and negative) schizotypy. The positive schizotypy cluster presented high rates of psychotic-like experiences, schizotypal and paranoid symptoms, had affective and substance abuse pathology, and was open to experience and extraverted. The negative schizotypy cluster had high rates of negative and schizoid symptoms, impaired social adjustment, high conscientiousness and low agreeableness. The mixed cluster was the most deviant on almost all aspects.

CONCLUSIONS

Our cluster solution is consistent with the limited cluster analytic studies reported in schizotypy and schizophrenia, indicating that meaningful profiles of schizotypy features can be detected in nonclinical populations. The clusters identified displayed a distinct and meaningful pattern of correlates in different domains, thus providing construct validity to the schizotypy types defined.

The effect of antipsychotic medication on neuromotor abnormalities in neuroleptic-naive nonaffective psychotic patients: a naturalistic study with haloperidol, risperidone, or olanzapine

OBJECTIVE

To examine the effect of antipsychotic medication on neuromotor abnormalities in a sample of psychotic patients never exposed to antipsychotic drugs.

METHOD

One hundred psychotic patients were assessed (from January 1998 to December 2002) using DSM-IV criteria for parkinsonism, dyskinesia, akathisia, catatonia, and dystonia at baseline and after 4 weeks of treatment with haloperidol (n = 23), risperidone (n = 52), or olanzapine (n = 25). We examined change scores in neuromotor ratings over the treatment period across treatment groups and rates of drug-responsive and drug-emergent neuromotor syndromes in patients with and without preexisting neuromotor abnormalities.

RESULTS

Overall time effects revealed a worsening of parkinsonism (P = .002) and akathisia (P = .002) ratings and an improvement of dyskinesia (P = .001) and catatonia (P < .001) ratings. Main treatment effects revealed that patients taking haloperidol had a significant mean increase in akathisia scores compared with those of patients taking risperidone (P = .002) or olanzapine (P < .001). A significantly greater percentage of olanzapine-treated patients experienced remission of preexisting parkinsonism than did the other treatment groups (P = .047). Patients without preexisting motor abnormalities were more likely to experience drug-emergent parkinsonism if they were treated with haloperidol or risperidone than with olanzapine (P = .001) and were more likely to experience drug-emergent dystonia (P = .014) and akathisia (P = .013) if they were treated with haloperidol than with risperidone or olanzapine.

CONCLUSIONS

The relationship between antipsychotic medication and neurologic abnormalities is more complex than previously acknowledged since antipsychotic drugs may both improve preexisting abnormalities and cause "de novo" neurologic syndromes. Overall, olanzapine has a more favorable neuromotor profile than risperidone, which in turn has a more favorable profile than haloperidol.

An abnormal relation between basal prolactin levels and prolactin response to 12.5 microg TRH i.v. in drug-naïve patients with first-episode schizophrenia

At doses lower than those needed to stimulate prolactin release directly, TRH almost completely antagonizes the inhibitory effect of dopamine on prolactin release. We have previously reported that prolactin response to administration of 12.5 microg TRH i.v. correlates with prolactin response to 0.5 mg i.m. haloperidol and negatively with 24-h urinary excretion of HVA in normal subjects, suggesting that the response reflects dopamine activity. An association between central dopamine hyperactivity and SANS scores relating to poverty of content of speech and inattention has been suggested by studies utilizing methylphenidate administration in patients with first-episode schizophrenia. The hypothesis that small plasma prolactin responses to administration of 12.5 microg TRH i.v. (Delta prolactin) correlate with SANS scores for these symptoms was tested in 19 drug-naïve patients with first-episode schizophrenia. Significant negative correlations were found between the response and scores relating to poverty of content of speech (r = - 0.55, p = 0.014) and inattention (r = - 0.52, p = 0.022), supporting the hypothesis of increased dopamine activity in association with disorganization symptoms. A significant positive correlation between basal prolactin levels and prolactin response to stimulation by 12.5 microg TRH was also found (r = + 0.61, p = 0.0058). Our previous study in normal subjects found a similar positive correlation between basal prolactin levels and prolactin response to stimulation by 200 microg TRH i.v., but not by 12.5 microg TRH i.v. As far as we know, this is the first study to report an abnormality in TRH-induced prolactin release in acute schizophrenia.

Relative contributions of psychotic symptoms and insight to quality of life in stable schizophrenia

The purpose of this study was to examine the relative contributions of psychotic symptomatology such as delusions and hallucinations, and insight to quality of life (QOL) in a sample of outpatients with stable schizophrenia. Eighty-three consecutive outpatients with stable schizophrenia were enrolled in a cross-sectional study. We performed a path analysis using a multiple regression technique to assess the specific effect of psychotic symptomatology on QOL and the possible mediating role of insight. Our findings suggested that (i) psychotic symptomatology was negatively correlated to both QOL and the two dimensions of insight we considered (awareness of symptoms and attribution of symptoms); (ii) the impact of insight on QOL was not uniform as attribution of symptoms positively predicted QOL, while the effect of symptom awareness was negative; (iii) when the mediation effect of insight was taken into account, psychotic symptomatology was no longer a significant predictor of QOL on its own. These results suggested a complex pattern of relationships between different dimensions of insight, QOL and psychotic symptomatology. Different dimensions of insight could be related to different aspects of outcome, and this would need to be reflected in rehabilitation programs.

Combining dimensional and categorical representation of psychosis: the way forward for DSM-V and ICD-11?

BACKGROUND

There is good evidence that psychotic symptoms segregate into symptom dimensions. However, it is still unclear how these dimensions are associated with risk indicators and other clinical variables, and whether they have advantages over categorical diagnosis in clinical practice. We investigated symptom dimensions in a first-onset psychosis sample and examined their associations with risk indicators and clinical variables. We then examined the relationship of categorical diagnoses to the same variables.

METHOD

We recruited 536 patients as part of a population-based, incidence study of psychosis. Psychopathology was assessed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). A principal axis factor analysis was performed on symptom scores. The relationship of dimension scores with risk indicators and with clinical variables was then examined employing regression analyses. Finally, regression models were compared to assess the contribution of dimensions versus diagnosis in explaining these variables.

RESULTS

Factor analysis gave rise to a five-factor solution of manic, reality distortion, negative, depressive and disorganization symptom dimensions. The scores of identified dimensions were differentially associated with specific variables. The manic dimension had the highest number of significant associations; strong correlations were observed with shorter duration of untreated psychosis, acute mode of onset and compulsory admission. Adding dimensional scores to diagnostic categories significantly increased the amount of variability explained in predicting these variables; the reverse was also true but to a lesser extent.

CONCLUSIONS

Categorical and dimensional representations of psychosis are complementary. Using both appears to be a promising strategy in conceptualising psychotic illnesses.

Deficit schizophrenia: an overview of clinical, biological and treatment aspects

The concept of deficit schizophrenia is regarded as one of the most promising attempts to reduce heterogeneity within schizophrenia. This paper summarizes the clinical, neurocognitive, brain imaging and electrophysiological correlates of this subtype of schizophrenia. Attempts to identify genetic and non-genetic risk factors are reviewed. Methodological limitations of studies supporting the efficacy of atypical antipsychotics in the treatment of the syndrome are highlighted. Two decades of research on deficit schizophrenia have failed to prove that it represents the extreme end of a severity continuum in schizophrenia, while some findings support the claim that it may be a separate disease entity.

The role of effort, cognitive expectancy appraisals and coping style in the maintenance of the negative symptoms of schizophrenia

The aim of the present study was to assess the role of psychological factors, specifically effort, coping, and negative expectancy appraisals, in addition to executive functioning and depression, in accounting for negative symptoms broadly defined. Fifty inpatients with acute schizophrenia participated in a study with a cross-sectional design. All of the psychological variables had significant partial correlations with some of the measures of negative symptoms when depression was controlled. A series of multiple regression analyses indicated that executive functioning only made a significant unique contribution to the prediction of affective flattening, whereas psychological factors made unique contributions to the variance in each of the negative symptom subscales apart from affective flattening, as well as to the negative symptom total score, accounting for 9% to 19% of the variance. These results suggest that, in addition to neuropsychological variables, psychological variables are important for understanding negative symptoms in acute schizophrenia.

Stability and relationships between trait or state anhedonia and schizophrenic symptoms in schizophrenia: a 13-year follow-up study

The aim of the present study was to explore the stability of anhedonia and its relationships with schizophrenic symptoms across a 13-year study period. We tested the hypothesis that trait anhedonia, rated by the Physical Anhedonia Scale (PAS), was stable and independent of schizophrenic symptoms across this period, while measures of state anhedonia were not. Sixty schizophrenic subjects were evaluated at two time points, at hospital admission or during an ambulatory psychiatric consultation and 13 years later. Trait anhedonia was assessed using the Chapman Physical Anhedonia Scale, while state anhedonia was assessed with a subscale extracted from the Beck Depression Inventory. The Positive and Negative Syndrome Scale (PANSS) was used to rate schizophrenic symptomatology. Unlike trait anhedonia, state anhedonia decreased significantly over time. Based on results from multiple regressions, negative and depressive dimensions were significant predictors of state anhedonia. Trait anhedonia was not associated with negative symptoms, but was associated with severity of disorganization symptoms at baseline and with our state measure of anhedonia at follow-up. In the current study, state and trait anhedonia were correlated, but depressive symptoms in general were not associated with physical anhedonia. The results indicated that trait anhedonia, in contrast to state anhedonia, had absolute stability, was independent of the negative dimension, as measured by the PANSS, of schizophrenic symptomatology and correlated with specific aspects of depressive anhedonia.

Schizotypy and false memory

Using the Deese-Roediger-McDermott (DRM) paradigm the present study examined the relationship between schizotypy and recognition memory. Participants scoring in the upper and lower quartile ranges for schizotypy (Schizotypal Personality Questionnaire brief version; SPQ-B) and on each of the SPQ-B subscales (cognitive-perceptual, interpersonal and disorganized) were compared on true and false memory performance. Participants scoring in the lower quartile range on the cognitive-perceptual subscale recognised a higher proportion of both true and false memories than those scoring in the higher quartile range. Participants scoring in the upper quartile on the interpersonal factor recognised fewer true items than those in the lower quartile range. No differences were found for overall schizotypy or on the disorganized subscale.

The causal model of insight in schizophrenia based on the Positive and Negative Syndrome Scale factors and the structural equation modeling

We used structural equation modeling to formulate a causal model of insight in schizophrenia patients that explains the inconsistent results of the studies on the relationship between insight and psychopathology. The Positive and Negative Syndrome Scale was used to assess 342 patients with acute stage schizophrenia and 5 factors were identified through factor analysis with which a causal model of insight was constructed. Our model, where positive, negative, and autistic preoccupation (cognitive) factors were the primary predictors of insight with the activation factor mediating between positive and autistic preoccupation factors and insight, was found to show a perfect fit by most goodness-of-fit indices and to be superior to other alternative models. Specifically, positive, negative, and autistic preoccupation factors each had some predictive power for insight and the activation factor played a partial mediating role for the positive factor and a moderating role for the autistic preoccupation factor.

Tricks of the Trade in Community Mental Health Research: Working With Mental Health Services and Clients

The complexities of research in the community mental health sector are seldom acknowledged in existing literature; this article attempts to address this void. It presents the methodological challenges experienced in the longitudinal evaluation of the Housing and Accommodation Support Initiative—a program that supports people with chronic mental illness toward long-term recovery. The evaluation provides a case study for understanding methodological problems in community mental health research, which include working with organizations that experience high staff turnover; staff members who have large caseloads; and clients who have chronic mental illness. Although not applicable to all research designs, the suggested strategies highlight the importance of innovation, flexibility, and balance between research theory and practical limitations when conducting community mental health research.

The relationship between dysphoria and proneness to hallucination and delusions among young adults

Previous research suggests that measures of dysphoria relate to positive schizophrenic symptoms. These relationships have rarely been studied within the dimensionality of psychopathology framework. The present study examined the relationship between 3 distinct aspects of dysphoria (depression and state and trait anxiety) and delusion and hallucination proneness in a nonclinical sample of young adults. A total of 472 participants were assessed on measures of dysphoria and delusion and hallucination proneness. Correlation analyses revealed significant associations between both anxiety and depression and hallucination and delusion proneness, suggesting that the association between dysphoria and positive symptoms is also present at a nonclinical level. Partial correlations, and hierarchical regression models, suggest an independent contribution of depression, over anxiety, in influencing hallucination and delusional proneness. The results are discussed in the framework of the cognitive account of schizophrenia and the dimensional model of psychopathology.

Ethical questions in human clinical psychopharmacology: should the focus be on placebo administration?

Of all ethical issues in clinical trial designs, only placebo use is dealt with acrimony and unwarranted, rhetoric emphasis. Many misconceptions are biased and may hamper research in the mechanisms of healing and recovery if placebo is banned from clinical trials, as some influential ethicists propose. Current treatments in psychiatry are by no means optimal and may vary in their effect across studies, rendering difficult to find the best available therapeutic method with which to compare new drugs. Because drugs possess specific mechanisms, it is not possible to compare drugs with different mechanisms as to their relevance in the pathophysiology of a given disorder. Placebo acts through non-specific mechanisms and is the ideal control for any disorder whose pathophysiology is relatively unknown and its treatment is still suboptimal. Sticking to short-term patient benefit in a trial reflects an individualistically oriented thinking in contemporary ethics and is likely to limit further research and efforts to better understand the mechanisms of disease and drug action, but also those related to general body reactance and self-healing, which are enhanced by placebo administration. Because in history ethics are swinging between two opposed views, it is possible that in the near future, the balance will move towards communitarianism, which is more likely to better serve long-term patient needs. Ethicists should also consider some other aspects of human experimentation, such as the consistency of research lines and the trend to substitute older drugs with their metabolites or enantiomers.