Community Psychosis Risk Screening: An Instrument Development Investigation

Identification of Psychosis Risk and Diagnosis of First-Episode Psychosis: Advice for Clinicians

Early detection of psychotic-spectrum disorders among adolescents and young adults is crucial, as the initial years after psychotic symptom onset encompass a critical period in which psychosocial and pharmacological interventions are most effective. Moreover, clinicians and researchers in recent decades have thoroughly characterized psychosis-risk syndromes, in which youth are experiencing early warning signs indicative of heightened risk for developing a psychotic disorder. These insights have created opportunities for intervention even earlier in the illness course, ideally culminating in the prevention or mitigation of psychosis onset. However, identification and diagnosis of early signs of psychosis can be complex, as clinical presentations are heterogeneous, and psychotic symptoms exist on a continuum. When a young person presents to a clinic, it may be unclear whether they are experiencing common, mild psychotic-like symptoms, early warning signs of psychosis, overt psychotic symptoms, or symptoms better accounted for by a non-psychotic disorder. Therefore, the purpose of this review is to provide a framework for clinicians, including those who treat non-psychotic disorders and those in primary care settings, for guiding identification and diagnosis of early psychosis within the presenting clinic or via referral to a specialty clinic. We first provide descriptions and examples of first-episode psychosis (FEP) and psychosis-risk syndromes, as well as assessment tools used to diagnose these conditions. Next, we provide guidance as to the differential diagnosis of conditions which have phenotypic overlap with psychotic disorders, while considering the possibility of co-occurring symptoms in which case transdiagnostic treatments are encouraged. Finally, we conclude with an overview of early detection screening and outreach campaigns, which should be further optimized to reduce the duration of untreated psychosis among youth.

Mapping Psychosis Risk States onto the Hierarchical Taxonomy of Psychopathology Using Hierarchical Symptom Dimensions

Clinical high risk for psychosis (CHR) is a transdiagnostic risk state. However, it is unclear how risk states such as CHR fit within broad transdiagnostic models such as the Hierarchical Taxonomy of Psychopathology (HiTOP). In this study, a hierarchical dimensional symptom structure was defined by unfolding factor analysis of self-report data from 3,460 young adults (mage=20.3). A subsample (n=436) completed clinical interviews, 85 of whom met CHR criteria. Regression models examined relationships between symptom dimensions, CHR status, and clinician-rated symptoms. CHR status was best explained by a reality distortion dimension, with contributions from internalizing dimensions. Positive and negative attenuated psychotic symptoms were best explained by multiple psychotic and nonpsychotic symptom dimensions including reality distortion, distress, fear, detachment, and mania. Attenuated psychotic symptoms are a complex presenting problem warranting comprehensive assessment. HiTOP can provide both diagnostic precision and broad transdiagnostic coverage, making it a valuable resource for use with at-risk individuals.

Review of factors resulting in systemic biases in the screening, assessment, and treatment of individuals at clinical high-risk for psychosis in the United States

Background

Since its inception, research in the clinical high-risk (CHR) phase of psychosis has included identifying and exploring the impact of relevant socio-demographic factors. Employing a narrative review approach and highlighting work from the United States, sociocultural and contextual factors potentially affecting the screening, assessment, and service utilization of youth at CHR were reviewed from the current literature.

Results

Existing literature suggests that contextual factors impact the predictive performance of widely used psychosis-risk screening tools and may introduce systemic bias and challenges to differential diagnosis in clinical assessment. Factors reviewed include racialized identity, discrimination, neighborhood context, trauma, immigration status, gender identity, sexual orientation, and age. Furthermore, racialized identity and traumatic experiences appear related to symptom severity and service utilization among this population.

Conclusions

Collectively, a growing body of research from the United States and beyond suggests that considering context in psychosis-risk assessment can provide a more accurate appraisal of the nature of risk for psychosis, render more accurate results improving the field's prediction of conversion to psychosis, and enhance our understanding of psychosis-risk trajectories. More work is needed in the U.S. and across the globe to uncover how structural racism and systemic biases impact screening, assessment, treatment, and clinical and functional outcomes for those at CHR.

Prevalence of Individuals at Clinical High-Risk of Psychosis in the General Population and Clinical Samples: Systematic Review and Meta-Analysis

(1) The consistency and magnitude of the prevalence of Clinical High-Risk for Psychosis (CHR-P) individuals are undetermined, limiting efficient detection of cases. We aimed to evaluate the prevalence of CHR-P individuals systematically assessed in the general population or clinical samples. (2) PRISMA/MOOSE-compliant (PROSPERO: CRD42020168672) meta-analysis of multiple databases until 21/01/21: a random-effects model meta-analysis, heterogeneity analysis, publication bias and quality assessment, sensitivity analysis—according to the gold-standard CHR-P and pre-screening instruments—leave-one-study-out analyses, and meta-regressions were conducted. (3) 35 studies were included, with 37,135 individuals tested and 1554 CHR-P individuals identified (median age = 19.3 years, Interquartile range (IQR) = 15.8–22.1; 52.2% females, IQR = 38.7–64.4). In the general population (k = 13, n = 26,835 individuals evaluated), the prevalence of the CHR-P state was 1.7% (95% Confidence Interval (CI) = 1.0–2.9%). In clinical samples (k = 22, n = 10,300 individuals evaluated), the prevalence of the CHR-P state was 19.2% (95% CI = 12.9–27.7%). Using a pre-screening instrument was associated with false negatives (5.6%, 95% CI = 2.2–13.3%) and a lower CHR-P prevalence (11.5%, 95% CI = 6.2–20.5%) compared to using CHR-P instruments only (28.5%, 95% CI = 23.0–34.7%, p = 0.003). (4) The prevalence of the CHR-P state is low in the general population and ten times higher in clinical samples. The prevalence of CHR-P may increase with a higher proportion of females in the general population and with a younger population in clinical samples. The CHR-P state may be unrecognized in routine clinical practice. These findings can refine detection and preventive strategies.

The COVID-19 Pandemic Introduces Diagnostic and Treatment Planning Complexity for Individuals at Clinical High Risk for Psychosis

COVID-19 has led to a great deal of general suffering and an increased prevalence of psychiatric illness worldwide. Within the area of psychosis-risk syndromes, a highly heterogeneous clinical population, the picture is quite nuanced as the social restrictions resulting from the pandemic have reduced stress for some and increased it for others. Further, a number of pandemic-related societal and cultural changes have obfuscated the diagnostic and treatment landscape in this area as well. In this opinion article, we describe several prototypical cases, representative of presentations seen in our clinical high-risk (CHR) research programs. The cases highlight considerable clinical variability and, in addition, speak to the current complexities faced by diagnosticians and treatment providers. In addition to discussing these issues, this piece introduces potential solutions highlighting the promise of incorporating data-driven strategies to identify more homogenous CHR subtypes and employ precision medicine.

Prevalence and Functional Consequences of Social Anxiety in Individuals at Clinical High-Risk for Psychosis: Perspective From a Community Sample Comparison

Background

Social anxiety disorder (SAD) commonly occurs among individuals at clinical high-risk (CHR) for psychosis. Extant research has yet to examine the prevalence and clinical/functional correlates of SAD in this population compared to a community control (CC) sample. This comparison may improve the generalizability that traditional nonpsychiatric control samples cannot provide. Additionally, it remains unknown how SAD contributes to symptom severity and social impairments in individuals at CHR for psychosis.

Methods

Both CHR and CC groups were recruited from general community sources; CC participants were not excluded in this analysis on the basis of any psychopathology except psychosis. A total of 245 adolescents and young adults (CHR = 81; CC = 164) were administered the Social Phobia Scale, the Structured Interview for Psychosis-risk Syndromes, Structured Clinical Interview for DSM-5 Research Version, and the Social Functioning Scale.

Results

The CHR group was at increased risk for having SAD relative to CC (42% CHR; 13% CC; RR = 3.28) and, to a lesser degree, a non-SAD anxiety disorder (41% CHR; 29% CC; RR = 1.42). Greater social anxiety was related to higher levels of negative (r = 0.29) but not positive (r = 0.05) symptoms within the CHR group. Furthermore, elevated social anxiety was found to be linked with poor social functioning in the CHR group (r = -0.31).

Conclusions

These findings demonstrate the specificity of SAD over and above other anxiety disorders in individuals at CHR for psychosis and the critical target of SAD to treat subclinical psychotic symptoms and social functioning.

Sensorimotor and Activity Psychosis-Risk (SMAP-R) Scale: An Exploration of Scale Structure With Replication and Validation

BACKGROUND

Sensorimotor abnormalities precede and predict the onset of psychosis. Despite the practical utility of sensorimotor abnormalities for early identification, prediction, and individualized medicine applications, there is currently no dedicated self-report instrument designed to capture these important behaviors. The current study assessed and validated a questionnaire designed for use in individuals at clinical high-risk for psychosis (CHR).

METHODS

The current study included both exploratory (n = 3009) and validation (n = 439) analytic datasets-that included individuals identified as meeting criteria for a CHR syndrome (n = 84)-who completed the novel Sensorimotor Abnormalities and Psychosis-Risk (SMAP-R) Scale, clinical interviews and a finger-tapping task. The structure of the scale and reliability of items were consistent across 2 analytic datasets. The resulting scales were assessed for discriminant validity across CHR, community sample non-psychiatric volunteer, and clinical groups.

RESULTS

The scale showed a consistent structure across 2 analytic datasets subscale structure. The resultant subscale structure was consistent with conceptual models of sensorimotor pathology in psychosis (coordination and dyskinesia) in both the exploratory and the validation analytic dataset. Further, these subscales showed discriminant, predictive, and convergent validity. The sensorimotor abnormality scales discriminated CHR from community sample non-psychiatric controls and clinical samples. Finally, these subscales predicted to risk calculator scores and showed convergent validity with sensorimotor performance on a finger-tapping task.

CONCLUSION

The SMAP-R scale demonstrated good internal, discriminant, predictive, and convergent validity, and subscales mapped on to conceptually relevant sensorimotor circuits. Features of the scale may facilitate widespread incorporation of sensorimotor screening into psychosis-risk research and practice.