The association between clinical, sociodemographic, familial, and environmental factors and treatment resistance in schizophrenia: A machine-learning-based approach

BACKGROUND

Prediction of treatment resistance in schizophrenia (TRS) would be helpful to reduce the duration of ineffective treatment and avoid delays in clozapine initiation. We applied machine learning to identify clinical, sociodemographic, familial, and environmental variables that are associated with TRS and could potentially predict TRS in the future.

STUDY DESIGN

Baseline and follow-up data on trait(-like) variables from the Genetic Risk and Outcome of Psychosis (GROUP) study were used. For the main analysis, we selected patients with non-affective psychotic disorders who met TRS (n = 200) or antipsychotic-responsive criteria (n = 423) throughout the study. For a sensitivity analysis, we only selected patients who met TRS (n = 76) or antipsychotic-responsive criteria (n = 123) at follow-up but not at baseline. Random forest models were trained to predict TRS in both datasets. SHapley Additive exPlanation values were used to examine the variables' contributions to the prediction.

STUDY RESULTS

Premorbid functioning, age at onset, and educational degree were most consistently associated with TRS across both analyses. Marital status, current household, intelligence quotient, number of moves, and family loading score for substance abuse also consistently contributed to the prediction of TRS in the main or sensitivity analysis. The diagnostic performance of our models was modest (area under the curve: 0.66-0.69).

CONCLUSIONS

We demonstrate that various clinical, sociodemographic, familial, and environmental variables are associated with TRS. Our models only showed modest performance in predicting TRS. Prospective large multi-centre studies are needed to validate our findings and investigate whether the model's performance can be improved by adding data from different modalities.

Psychosis Endophenotypes: A Gene-Set-Specific Polygenic Risk Score Analysis

BACKGROUND AND HYPOTHESIS

Endophenotypes can help to bridge the gap between psychosis and its genetic predispositions, but their underlying mechanisms remain largely unknown. This study aims to identify biological mechanisms that are relevant to the endophenotypes for psychosis, by partitioning polygenic risk scores into specific gene sets and testing their associations with endophenotypes.

STUDY DESIGN

We computed polygenic risk scores for schizophrenia and bipolar disorder restricted to brain-related gene sets retrieved from public databases and previous publications. Three hundred and seventy-eight gene-set-specific polygenic risk scores were generated for 4506 participants. Seven endophenotypes were also measured in the sample. Linear mixed-effects models were fitted to test associations between each endophenotype and each gene-set-specific polygenic risk score.

STUDY RESULTS

After correction for multiple testing, we found that a reduced P300 amplitude was associated with a higher schizophrenia polygenic risk score of the forebrain regionalization gene set (mean difference per SD increase in the polygenic risk score: -1.15 µV; 95% CI: -1.70 to -0.59 µV; P = 6 × 10-5). The schizophrenia polygenic risk score of forebrain regionalization also explained more variance of the P300 amplitude (R2 = 0.032) than other polygenic risk scores, including the genome-wide polygenic risk scores.

CONCLUSIONS

Our finding on reduced P300 amplitudes suggests that certain genetic variants alter early brain development thereby increasing schizophrenia risk years later. Gene-set-specific polygenic risk scores are a useful tool to elucidate biological mechanisms of psychosis and endophenotypes, offering leads for experimental validation in cellular and animal models.

Age-Related Social Cognitive Performance in Individuals With Psychotic Disorders and Their First-Degree Relatives

BACKGROUND

Social cognitive impairment is a recognized feature of psychotic disorders. However, potential age-related differences in social cognitive impairment have rarely been studied.

STUDY DESIGN

Data came from 905 individuals with a psychotic disorder, 966 unaffected siblings, and 544 never-psychotic controls aged 18-55 who participated in the Genetic Risk and Outcome of Psychosis (GROUP) study. Multilevel linear models were fitted to study group main effects and the interaction between group and age on emotion perception and processing (EPP; degraded facial affect recognition) and theory of mind (ToM; hinting task) performance. Age-related differences in the association between socio-demographic and clinical factors, and EPP and ToM were also explored.

STUDY RESULTS

Across groups, EPP performance was associated with age (β = -0.02, z = -7.60, 95% CI: -0.02, -0.01, P < .001), with older participants performing worse than younger ones. A significant group-by-age interaction on ToM (X2(2) = 13.15, P = .001) indicated that older patients performed better than younger ones, while no age-related difference in performance was apparent among siblings and controls. In patients, the association between negative symptoms and ToM was stronger for younger than older patients (z = 2.16, P = .03).

CONCLUSIONS

The findings point to different age-related performance patterns on tests of 2 key social cognitive domains. ToM performance was better in older individuals, although this effect was only observed for patients. EPP was less accurate in older compared with younger individuals. These findings have implications with respect to when social cognitive training should be offered to patients.

A Cross-sectional Conceptual Replication and Longitudinal Evaluation of the PANSS-Autism-Severity-Score Measure Suggests it Does Not Capture Autistic Traits in Individuals With Psychosis

BACKGROUND

Autism and psychosis co-occur at elevated rates, with implications for clinical outcomes, functioning, and suicidality. The PANSS-Autism-Severity-Score (PAUSS) is a measure of autism trait severity which has not yet been validated externally or longitudinally.

STUDY DESIGN

Participants were derived from the GROUP and SCOPE datasets. Participants included 1448 adults with schizophrenia spectrum disorder (SSD), 800 SSD-siblings, 103 adults diagnosed with an autistic spectrum condition (ASC), and 409 typically-developing controls (TC). Analyses from the original validation study were conducted with SSD participants, and extended into ASC, SSD-sibling, and TC participants. Test-retest reliability of the PAUSS at 2-weeks and long-term stability 3 and 6-years was also examined.

STUDY RESULTS

Results differed in important ways from the original validation. SSD participants reported higher PAUSS scores than other groups, with only a fraction of ASC participants scoring as "PAUSS-Autistic." Cronbach's alpha was acceptable for the SSD cohort only. Two-week stability of the PAUSS was fair to good for all PAUSS scores. Long-term stability was poor for most PAUSS items but fair for total PAUSS score.

CONCLUSIONS

Results suggest that the PAUSS does not appear appropriate for assessing autism, with the low rate of PAUSS-Autistic in the ASC population suggesting the PAUSS may not accurately reflect characteristics of autism. The relative lack of long-term stability is cause for concern and suggestive that the PAUSS is capturing features of psychosis rather than autism traits.

Risk factors for suicidality across psychosis vulnerability spectrum

BACKGROUND

Suicide is a leading cause of death in individuals with psychotic disorders. Risk factors for suicidality across the psychosis vulnerability spectrum are insufficiently known.

METHODS

For patients (n = 830), siblings (n = 664) and controls (n = 444), suicidality was assessed by the use of a clinical interview. Multilevel modelling was used to investigate risk factors of suicidality. Lastly, risk factor × familial risk interaction effects were examined.

RESULTS

Multivariable models revealed a significant relation between suicidality and depressive symptoms across all three groups, and childhood trauma in patients and siblings. The association between suicidality and psychotic-like experiences is more pronounced in siblings compared to controls.

CONCLUSION

Across the psychosis vulnerability spectrum, depressive symptoms and childhood trauma have been associated with suicidality. Clinicians should pay attention to suicidality in individuals at high familial risk for psychosis with psychotic-like experiences.

Personal recovery suits us all: A study in patients with non-affective psychosis, unaffected siblings and healthy controls

Personal recovery transcends illness and is a unifying human experience. Core elements in personal recovery are hope, meaning, and rebuilding oneself. Here we aim to investigate whether factors associated with personal recovery in patients with non-affective psychosis, unaffected siblings and healthy controls are similar. We investigated the association between personal recovery and resilience, social support, socio-demographic and illness-related variables in 580 patients, 630 siblings, and 351 healthy controls who participated in the Genetic Risk and Outcome of Psychosis (GROUP) study. Bi-variate associations between personal recovery and individual variables were assessed and multiple linear regression analyses were performed to estimate the proportion of variance in personal recovery that could be accounted for by the predictors and to investigate which predictors independently added to the model. Positive self was significantly and independently associated with personal recovery in all three groups. Pro-active action taking also seems to be important. Social functioning significantly contributed to explained variance in patients and siblings. Regarding illness-related factors, depressive symptoms had impact on personal recovery in both patients and siblings, whereas positive symptoms only did in siblings. The findings imply that not only personal recovery itself, but also some associated factors are universally human and suit us all. This means that patients and non-patients share supportive factors of personal recovery which may help to reach mutual understanding. Recovery-oriented practices and mental health services might be more effective when focusing also on improving self-image, functional coping styles and generating social interaction, next to the reduction of affective symptoms.

Delayed affective recovery to daily-life stressors signals a risk for depression

OBJECTIVE

The aim of this study is to investigate the time to affective recovery from daily-life stressors between healthy controls (HC) and two groups with an increased risk for developing depression: individuals with subclinical symptoms of depression (SSD), and individuals remitted from a depressive episode with residual symptoms of depression (RRS).

METHOD

The experience sampling method (ESM) was used to measure affective recovery to daily-life stressors. Affective recovery was defined as the moment that negative affect (NA) returned to baseline level following the first stressful event of the day. We assessed two different operationalizations of the baseline: NA at the moment before the stressful event (t_-1), and mean-person NA. The effect of stress intensity, and cumulative stress were also assessed.

RESULTS

Survival analyses showed significantly longer recovery times for the at risk groups in comparison to healthy individuals, albeit no significant difference was found between the two at risk groups (i.e. SSD and RRS). There was also an effect of cumulative stress, but not stress intensity on time to recovery in that cumulative stress resulted in significantly longer recovery times for all three groups.

LIMITATIONS

The present study is limited by the ESM sampling design, assessments take place post-stress and therefore do not capture peak stress. Additionally, we are only able to assess patterns at the group level. Finally, there is a significant age difference between groups.

CONCLUSION

Individuals at risk for depression display a delayed recovery to daily-life stressors when compared to healthy controls, which is not explained by differences in stress intensity or cumulative stress. Understanding what is driving this delay may help combat the development of depression.

Comparing psychotic experiences in low-and-middle-income-countries and high-income-countries with a focus on measurement invariance

BACKGROUND

The prevalence of psychotic experiences (PEs) is higher in low-and-middle-income-countries (LAMIC) than in high-income countries (HIC). Here, we examine whether this effect is explicable by measurement bias.

METHODS

A community sample from 13 countries (N = 7141) was used to examine the measurement invariance (MI) of a frequently used self-report measure of PEs, the Community Assessment of Psychic Experiences (CAPE), in LAMIC (n = 2472) and HIC (n = 4669). The CAPE measures positive (e.g. hallucinations), negative (e.g. avolition) and depressive symptoms. MI analyses were conducted with multiple-group confirmatory factor analyses.

RESULTS

MI analyses showed similarities in the structure and understanding of the CAPE factors between LAMIC and HIC. Partial scalar invariance was found, allowing for latent score comparisons. Residual invariance was not found, indicating that sum score comparisons are biased. A comparison of latent scores before and after MI adjustment showed both overestimation (e.g. avolition, d = 0.03 into d = -0.42) and underestimation (e.g. magical thinking, d = -0.03 into d = 0.33) of PE in LAMIC relative to HIC. After adjusting the CAPE for MI, participants from LAMIC reported significantly higher levels on most CAPE factors but a significantly lower level of avolition.

CONCLUSION

Previous studies using sum scores to compare differences across countries are likely to be biased. The direction of the bias involves both over- and underestimation of PEs in LAMIC compared to HIC. Nevertheless, the study confirms the basic finding that PEs are more frequent in LAMIC than in HIC.

The Puzzle of Functional Recovery in Schizophrenia-Spectrum Disorders-Replicating a Network Analysis Study

BACKGROUND AND HYPOTHESIS

Recovery from psychosis is a complex phenomenon determined by an array of variables mutually impacting each other in a manner that is not fully understood. The aim of this study is to perform an approximated replication of a previous network analysis study investigating how different clinical aspects-covering psychopathology, cognition, personal resources, functional capacity, and real-life functioning-are interrelated in the context of schizophrenia-spectrum disorders.

STUDY DESIGN

A sample of 843 subjects from a multisite cohort study, with the diagnosis of a schizophrenia-spectrum disorder, was used to estimate a network comprising 27 variables. The connectivity and relative importance of the variables was examined through network analysis. We used a quantitative and qualitative approach to infer replication quality.

STUDY RESULTS

Functional capacity and real-life functioning were central and bridged different domains of the network, in line with the replicated study. Neurocognition, interpersonal relationships, and avolition were also key elements of the network, in close relation to aspects of functioning. Despite significant methodological differences, the current study could substantially replicate previous findings.

CONCLUSIONS

Results solidify the network analysis approach in the context of mental disorders and further inform future studies about key variables in the context of recovery from psychotic disorders.

Impact of coping styles on substance use in persons with psychosis, siblings, and controls

BACKGROUND

Substance use is overrepresented in patients with psychosis. Maladaptive coping has been proposed as one of the mechanisms which might underlie this high prevalence. Patients are known to apply more maladaptive coping compared to the healthy population. However, it is unknown whether coping is associated with the use of different substances across those with different vulnerability for psychosis, and whether coping mediates the possible association between life events and substance use.

METHODS

In this multicenter, cohort study, 429 patients, 504 siblings, and 220 controls were included. We determined whether coping was associated with tobacco smoking, cannabis use, or alcohol consumption. Multivariable logistic regression models were applied whilst correcting for potential confounders. We performed post-hoc analyses to explore the association between negative life events, tobacco smoking, and the role of coping as a mediator in patients with psychosis.

RESULTS

A positive association was found in patients between passive coping and tobacco smoking (fully adjusted OR 1.65, 95% CI 1.18-2.31). Tobacco smoking patients experienced more negative life events compared to non-smoking patients and passive coping mediated this association. In siblings and controls, none of the coping strategies were associated with substance use.

CONCLUSIONS

The coping style of patients with psychosis is associated with tobacco smoking and mediates the association between negative events and tobacco smoking. No significant associations were found in siblings, controls or concerning other substance use. Future research is required to examine whether enhancing healthy coping strategies decreases tobacco use in patients with psychosis.

Intervention mechanisms of an experience sampling intervention for spousal carers of people with dementia: a secondary analysis using momentary data

Objectives: A psychosocial intervention for spousal carers of people with dementia promoted emotional well-being through self-monitoring and personalized feedback, as demonstrated in a previous randomized controlled trial. The mechanism behind the intervention effects is thought to lie in increased awareness of, and thus, engagement in behaviours that elicit positive emotions (PA). This secondary analysis tests the assumption by investigating momentary data on activities, affect, and stress and explores the relevance of personalized feedback compared to self-monitoring only.Methods: The intervention was based on the experience sampling method (ESM), meaning that carers self-monitored own affect and behaviours 10 times/day over 6 weeks. The experimental group received personalized feedback on behaviours that elicit PA, while the pseudo-experimental group performed self-monitoring only. A control group was also included. ESM-data of 72 carers was analysed using multilevel mixed-effects models.Results: The experimental group reported significant increases in passive relaxation activities over the 6 weeks (B = 0.28, SE = 0.12, Z = 2.43, p < .05). Passive relaxation in this group was negatively associated with negative affect (r = -0.50, p = .01) and positively associated with activity-related stress (r = 0.52, p = .007) from baseline to post-intervention. Other activities in this or the other groups did not change significantly.Conclusion: Carer's daily behaviours were only affected when self-monitoring was combined with personalized feedback. Changing one's daily behaviour while caring for a person with dementia is challenging and aligned with mixed emotions. Acknowledging simultaneously positive and negative emotions, and feelings of stress is suggested to embrace the complexity of carer's life and provide sustainable support.

The Community Assessment of Psychic Experiences: Optimal cut-off scores for detecting individuals with a psychotic disorder

OBJECTIVES

The need for a brief screening tool for psychosis is widely recognized. The Community Assessment of Psychic Experiences (CAPE) is a popular self-report measure of psychosis, but a cut-off score that can detect those most likely to fulfill diagnostic criteria for psychotic disorder is not established.

METHODS

A case-control sample from the Genetic Risk and Outcome of Psychosis Project study (N = 1375, healthy individuals, n = 507, and individuals with a psychotic disorder, n = 868), was used to examine cut-off scores of the CAPE with receiver operating curve analyses. We examined 27 possible cut-off scores computed from a combination of scores from the frequency and distress scales of the various factors of the CAPE.

RESULTS

The weighted severity positive symptom dimension was most optimal in detecting individuals with a psychotic disorder (>1.75 cut-off; area under the curve = 0.88; sensitivity, 75%; specificity, 88%), which correctly identified 80% of the sample as cases or controls with a diagnostic odds ratio of 22.69.

CONCLUSIONS

The CAPE can be used as a first screening tool to detect individuals who are likely to fulfill criteria for a psychotic disorder. The >1.75 cut-off of the weighted severity positive symptom dimension provides a better prediction than all alternatives tested so far.

Cognitive functioning throughout adulthood and illness stages in individuals with psychotic disorders and their unaffected siblings

Important questions remain about the profile of cognitive impairment in psychotic disorders across adulthood and illness stages. The age-associated profile of familial impairments also remains unclear, as well as the effect of factors, such as symptoms, functioning, and medication. Using cross-sectional data from the EU-GEI and GROUP studies, comprising 8455 participants aged 18 to 65, we examined cognitive functioning across adulthood in patients with psychotic disorders (n = 2883), and their unaffected siblings (n = 2271), compared to controls (n = 3301). An abbreviated WAIS-III measured verbal knowledge, working memory, visuospatial processing, processing speed, and IQ. Patients showed medium to large deficits across all functions (ES range = -0.45 to -0.73, p < 0.001), while siblings showed small deficits on IQ, verbal knowledge, and working memory (ES = -0.14 to -0.33, p < 0.001). Magnitude of impairment was not associated with participant age, such that the size of impairment in older and younger patients did not significantly differ. However, first-episode patients performed worse than prodromal patients (ES range = -0.88 to -0.60, p < 0.001). Adjusting for cannabis use, symptom severity, and global functioning attenuated impairments in siblings, while deficits in patients remained statistically significant, albeit reduced by half (ES range = -0.13 to -0.38, p < 0.01). Antipsychotic medication also accounted for around half of the impairment in patients (ES range = -0.21 to -0.43, p < 0.01). Deficits in verbal knowledge, and working memory may specifically index familial, i.e., shared genetic and/or shared environmental, liability for psychotic disorders. Nevertheless, potentially modifiable illness-related factors account for a significant portion of the cognitive impairment in psychotic disorders.

The jumping to conclusions reasoning bias as a cognitive factor contributing to psychosis progression and persistence: findings from NEMESIS-2

BACKGROUND

Contemporary models of psychosis implicate the importance of affective dysregulation and cognitive factors (e.g. biases and schemas) in the development and maintenance of psychotic symptoms, but studies testing proposed mechanisms remain limited. This study, uniquely using a prospective design, investigated whether the jumping to conclusions (JTC) reasoning bias contributes to psychosis progression and persistence.

METHODS

Data were derived from the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2). The Composite International Diagnostic Interview and an add-on instrument were used to assess affective dysregulation (i.e. depression, anxiety and mania) and psychotic experiences (PEs), respectively. The beads task was used to assess JTC bias. Time series analyses were conducted using data from T1 and T2 (N = 8666), excluding individuals who reported high psychosis levels at T0.

RESULTS

Although the prospective design resulted in low statistical power, the findings suggest that, compared to those without symptoms, individuals with lifetime affective dysregulation were more likely to progress from low/moderate psychosis levels (state of 'aberrant salience', one or two PEs) at T1 to high psychosis levels ('frank psychosis', three or more PEs or psychosis-related help-seeking behaviour) at T2 if the JTC bias was present [adj. relative risk ratio (RRR): 3.8, 95% confidence interval (CI) 0.8-18.6, p = 0.101]. Similarly, the JTC bias contributed to the persistence of high psychosis levels (adj. RRR: 12.7, 95% CI 0.7-239.6, p = 0.091).

CONCLUSIONS

We found some evidence that the JTC bias may contribute to psychosis progression and persistence in individuals with affective dysregulation. However, well-powered prospective studies are needed to replicate these findings.

The association between smoking behaviour, social cognition and social functioning in patients with a non-affective psychotic disorder: A prospective follow-up study

Introduction

In patients with psychotic disorders, both tobacco smoking and deficits in social cognition and social functioning are highly prevalent. However, little is known about their relationship in psychosis. The authors sought to evaluate the multi-cross-sectional and longitudinal associations between tobacco smoking, social cognition and social functioning in a large prospective study.

Methods

This study was performed within the Genetic Risk and Outcome of Psychosis (GROUP) Study, a cohort study conducted in patients with non-affective psychosis (N = 1074), their unaffected siblings (N = 1047) and healthy controls (N = 549). At baseline, three years and six years of follow-up, data on tobacco smoking (using the Composite International Diagnostic Review), social cognition (emotion processing and theory of mind) and social functioning were collected. To assess associations between tobacco smoking and social cognition or social functioning, multivariate linear mixed-effects models and multiple linear regression models were used. Bonferroni correction for multiple testing was applied.

Results

A significant positive association was found between smoking and emotion processing (as part of social cognition) in the patient group (estimate = 1.96, SE = 0.6, p = 0.003). However, smoking was significantly negatively associated with participating in pro-social activities compared with non-smoking (estimate = −2.55, SE = 0.9, p = 0.004). Change in smoking behaviour was not associated with social cognition or social functioning in the longitudinal analyses.

Conclusion

Findings indicate that smoking patients with a non-affective psychotic disorder slightly outperformed their non-smoking peers on a task on social cognition, but participated less in pro-social activities. Commencement or cessation of smoking was not related to social cognition or functioning.

Relationship between social cognition, general cognition, and risk for suicide in individuals with a psychotic disorder

OBJECTIVE

Cognitive alterations putatively contribute to the risk for suicide in individuals with psychosis. Yet, a comprehensive assessment of social- and general-cognitive abilities in a large sample is lacking.

METHODS

Seven-hundred-fifteen individuals diagnosed with a psychotic disorder performed tasks of facial emotion recognition, Theory of Mind, and general cognitive functioning (sustained attention, set-shifting, IQ-tests and verbal learning) as part of the Genetic-Risk-and-Outcome-of-Psychosis (GROUP) study. Presence of past suicide attempt/s and/or current suicidal ideation was reported by 261 individuals and 454 individuals reported no suicide attempt or ideation. We used general linear models to investigate group differences in task performance. All analysis were controlled for age, sex, education, and psychotic symptom severity.

RESULTS

Individuals with suicide attempt and/or ideation showed better performance on the facial emotion recognition task and lower performance on tasks of sustained attention and verbal learning, compared to individuals without suicide attempt and/or ideation, without a clear effect of attempt or ideation. Theory of Mind performance was also better for individuals with suicide attempt and/or ideation, with largest differences between individuals who reported both attempts and ideation compared to individuals without suicide attempt and/or ideation. No effect of suicide attempt and/or ideation was found on misperception of facial emotions, IQ and set-shifting. Overall, effect sizes were small.

CONCLUSION

Higher sensitivity to social-emotional cues together with weakened attentional control and learning capacity was observed in individuals with psychosis and suicide attempt and/or ideation. This may suggest that insufficient capacity for regulating perceived social stress contributes to suicidal thoughts and behavior.

Genetic copy number variants, cognition and psychosis: a meta-analysis and a family study

The burden of large and rare copy number genetic variants (CNVs) as well as certain specific CNVs increase the risk of developing schizophrenia. Several cognitive measures are purported schizophrenia endophenotypes and may represent an intermediate point between genetics and the illness. This paper investigates the influence of CNVs on cognition. We conducted a systematic review and meta-analysis of the literature exploring the effect of CNV burden on general intelligence. We included ten primary studies with a total of 18,847 participants and found no evidence of association. In a new psychosis family study, we investigated the effects of CNVs on specific cognitive abilities. We examined the burden of large and rare CNVs (>200 kb, <1% MAF) as well as known schizophrenia-associated CNVs in patients with psychotic disorders, their unaffected relatives and controls (N = 3428) from the Psychosis Endophenotypes International Consortium (PEIC). The carriers of specific schizophrenia-associated CNVs showed poorer performance than non-carriers in immediate (P = 0.0036) and delayed (P = 0.0115) verbal recall. We found suggestive evidence that carriers of schizophrenia-associated CNVs had poorer block design performance (P = 0.0307). We do not find any association between CNV burden and cognition. Our findings show that the known high-risk CNVs are not only associated with schizophrenia and other neurodevelopmental disorders, but are also a contributing factor to impairment in cognitive domains such as memory and perceptual reasoning, and act as intermediate biomarkers of disease risk.

Treating winter depressive episodes in bipolar disorder: an open trial of light therapy

BACKGROUND

Light therapy has been used to treat winter depression in bipolar disorder, although the dose, duration, and timing of treatment have differed. The present study is an open trial of light therapy for depressive episodes in autumn/winter using a Dutch protocol specific for patients with a bipolar disorder.

METHODS

Data were collected for the seasons September-April 2017-2018 and September-April 2018-2019. In total, 58 patients received light therapy for a minimum of 7 days and a maximum of 21 days; there was a follow-up measurement after two weeks. Outcomes were quick inventory of depressive symptomatology (QIDS) scores and side effects.

RESULTS

QIDS scores were significantly lower at the last day of therapy (B = - 6.00, p < 0.001) and 2 weeks after the end of treatment (B = - 6.55, p < 0.001) compared with pre-intervention. Remission (QIDS ≤ 5) was reached in 55% of the treatments and response (50% symptom reduction) in 57% of the treatments. Side effects were mild; two hypomanic periods occurred.

CONCLUSIONS

The Dutch light therapy protocol for patients with a bipolar disorder may be effective in treating a seasonal depression and side effects are mild. Light therapy deserves a prominent place in the treatment because effects may be large and quick.

Executive Functioning in 60+ Autistic Males: The Discrepancy Between Experienced Challenges and Cognitive Performance

As executive functioning (EF) is especially sensitive to age-related cognitive decline, EF was evaluated by using a multi-method assessment. Fifty males (60-85 years) with a late adulthood autism spectrum condition (ASC) diagnosis and 51 non-ASC males (60-83 years) were compared on cognitive tests across EF domains (cognitive flexibility, planning, processing speed, and working memory) and a self- and proxy report of the Behavior Rating Inventory of Executive Function-Adult Version. While no objective performance differences emerged, autistic males and their proxies did report more EF challenges than non-ASC males on the subjective measure. In order to know how to support the older autistic men who received their ASC diagnosis in late adulthood with their daily life EF challenges, it is important to understand what underlies these subjective EF problems.

Reasoning bias, working memory performance and a transdiagnostic phenotype of affective disturbances and psychotic experiences in the general population

BACKGROUND

The jumping to conclusions (JTC) reasoning bias and decreased working memory performance (WMP) are associated with psychosis, but associations with affective disturbances (i.e. depression, anxiety, mania) remain inconclusive. Recent findings also suggest a transdiagnostic phenotype of co-occurring affective disturbances and psychotic experiences (PEs). This study investigated whether JTC bias and decreased WMP are associated with co-occurring affective disturbances and PEs.

METHODS

Data were derived from the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2). Trained interviewers administered the Composite International Diagnostic Interview (CIDI) at three time points in a general population sample (N = 4618). The beads and digit-span task were completed to assess JTC bias and WMP, respectively. CIDI was used to measure affective disturbances and an add-on instrument to measure PEs.

RESULTS

Compared to individuals with neither affective disturbances nor PEs, the JTC bias was more likely to occur in individuals with co-occurring affective disturbances and PEs [moderate psychosis (1-2 PEs): adjusted relative risk ratio (RRR) 1.17, 95% CI 0.98-1.41; and high psychosis (3 or more PEs or psychosis-related help-seeking behaviour): adjusted RRR 1.57, 95% CI 1.19-2.08], but not with affective disturbances and PEs alone, whereas decreased WMP was more likely in all groups. There was some evidence of a dose-response relationship, as JTC bias and decreased WMP were more likely in individuals with affective disturbances as the level of PEs increased or help-seeking behaviour was reported.

CONCLUSION

The findings suggest that JTC bias and decreased WMP may contribute to a transdiagnostic phenotype of co-occurring affective disturbances and PEs.

Capturing the risk of persisting depressive symptoms: A dynamic network investigation of patients' daily symptom experiences

What drives the large differences across patients in terms of treatment efficacy of major depressive disorder (MDD) is unclear. A network approach to psychopathology may help to reveal underlying mechanisms determining patients' capacity for recovery. We used daily diary MDD symptom data and six-month follow-up data on depression to examine how dynamic associations between symptoms relate to the future course of MDD. Daily experiences of depressive symptoms of 69 participants were assessed by means of the SCL-90-R depression subscale, three days a week for a period of six weeks, as part of a larger intervention study. Multilevel vector autoregressive modelling was used to estimate networks of dynamic symptom connections. Long-term outcome was determined by the percentage change in Hamilton Depression Rating Scale (HDRS) score between pre-intervention and six-month follow-up. For patients with more persisting symptoms, the symptom 'feeling everything is an effort' most strongly predicted other symptoms. The networks of the two groups did not significantly differ in overall connectivity. Findings suggest that future research should not solely focus on the presence or intensity of individual symptoms when predicting long-term outcomes, but should also examine the role of a specific symptom in the larger network of dynamic symptom-to-symptom interactions.

Patterns of obsessive-compulsive symptoms and social functioning in schizophrenia; a replication study

Research has found that Obsessive Compulsive Symptoms (OCS) in schizophrenia are associated with either more or less negative symptoms and either better or poorer cognitive functioning. In order to explain these contradictory results, (Lysaker et al., 2004), performed a cluster analysis resulting in 2 OCS positive (OCSpos) clusters, one with higher functioning (HF) and one with poorer functioning (PF) compared to 2 OCS negative (OCSneg) clusters. The OCSpos/HF cluster had less negative symptoms compared to all other clusters, while the OCSpos/PF cluster showed poorer executive functioning. We performed a replication study, in an almost 10 times larger, representative sample, using both a longitudinal and cross-sectional design. Similar to Lysaker et al., we found a group with mild OCS and HF (OCSmild/HF) showing less negative symptoms compared to the PF groups. We also found an OCSmild/PF group, which did not significantly differ in executive functioning from the other groups. Moreover, we did not find evidence for a better prognosis in the OCSmild/HF group, and thus found no support for the assumption that for some patients OCS might be an effective coping mechanism.

Subjective quality of life in psychosis: Evidence for an association with real world functioning?

Subjective quality of life (SQOL) is an established patient-reported outcome in psychosis. However, current self-report measures of SQOL may be affected by recall bias and may not fully capture dynamic changes in SQOL over time. This study aimed to examine the ecological validity of self-reported and momentary assessment measures of SQOL, and their association with emotional experience, social interaction and activity in real life, in both patients with psychotic disorder (n = 56) and controls (n = 71). Self-reported QOL was assessed with the WHO-QOL, momentary QOL and real life experiences were assessed with the Experience Sampling Method (ESM). Results show that both measures were significantly associated in patients and controls, and associations with emotional experience were most relevant, momentary QOL being a stronger predictor than self-reported QOL. The association between momentary QOL and negative affect was stronger in patients than in controls. Overall, momentary QOL was more consistently associated with affect, social interaction and activity, while self-reported QOL displayed a more narrow association with mostly affect. Concluding, concurrent assessment of self-reported QOL and momentary QOL showed that momentary QOL may enhance the ecological validity of SQOL measurement. Experience sampling research may broaden our perspective on SQOL and its associations with real life functioning.

The role of cognitive functioning in the relationship between childhood trauma and a mixed phenotype of affective-anxious-psychotic symptoms in psychotic disorders

Cognitive impairments in patients with psychotic disorder have been associated with poor functioning and increased symptom severity. Furthermore, childhood trauma (CT) exposure has been associated with worse cognitive functioning as well as co-occurrence of affective-anxious-psychosis symptoms or a 'mixed phenotype of psychopathology' (MP), which in turn is associated with greater symptom severity, and poor functioning. This study aims to evaluate if cognition could be associated with CT/MP. 532 patients with non-affective psychotic patients were assessed on CT, symptom profile, cognition, functioning, and symptom severity at baseline and 3 and 6-year follow-up. Four subgroups were made according to trauma exposure (CT- or CT+) and presence of a mixed phenotype (MP- or MP+): CT-/MP (n=272), CT-/MP+ (n=157), CT+/MP- (n=49), and CT+/MP+ (n=54). Mixed-effects multilevel regression, linear regression, and Tobit analyses were performed. Patients with both CT and MP showed lower verbal learning and memory than CT-/MP+ individuals (p<0.001). No other significant differences were found among the 4 subgroups. No cognitive decline was found at follow-up, neither in the CT+/MP- nor in CT-/MP- group. Lower cognition was not associated with increased symptom severity or poor functioning at follow-up, neither in the CT+/MP- nor in CT-/MP- group. Although cognitive impairments and CT may be related to clinical or functional features of psychotic disorder, and cognitive functioning could be affected by CT exposure, cognition does not discriminate subgroups of patients stratified by CT exposure and MP.

Economic evaluation of an experience sampling method intervention in depression compared with treatment as usual using data from a randomized controlled trial

BACKGROUND

Experience sampling, a method for real-time self-monitoring of affective experiences, holds opportunities for person-tailored treatment. By focussing on dynamic patterns of positive affect, experience sampling method interventions (ESM-I) accommodate strategies to enhance personalized treatment of depression-at potentially low-costs. This study aimed to investigate the cost-effectiveness of an experience sampling method intervention in patients with depression, from a societal perspective.

METHODS

Participants were recruited between January 2010 and February 2012 from out-patient mental health care facilities in or near the Dutch cities of Eindhoven and Maastricht, and through local advertisements. Out-patients diagnosed with major depression (n = 101) receiving pharmacotherapy were randomized into: (i) ESM-I consisting of six weeks of ESM combined with weekly feedback regarding the individual's positive affective experiences, (ii) six weeks of ESM without feedback, or (iii) treatment as usual only. Alongside this randomised controlled trial, an economic evaluation was conducted consisting of a cost-effectiveness and a cost-utility analysis, using Hamilton Depression Rating Scale (HDRS) and quality adjusted life years (QALYs) as outcome, with willingness-to-pay threshold for a QALY set at €50,000 (based on Dutch guidelines for moderate severe to severe illnesses).

RESULTS

The economic evaluation showed that ESM-I is an optimal strategy only when willingness to pay is around €3000 per unit HDRS and around €40,500 per QALY. ESM-I was the least favourable treatment when willingness to pay was lower than €30,000 per QALY. However, at the €50,000 willingness-to-pay threshold, ESM-I was, with a 46% probability, the most favourable treatment (base-case analysis). Sensitivity analyses confirmed the robustness of these results.

CONCLUSIONS

We may tentatively conclude that ESM-I is a cost-effective add-on intervention to pharmacotherapy in outpatients with major depression.

TRIAL REGISTRATION

Netherlands Trial register, NTR1974 .

Constructing a Reward-Related Quality of Life Statistic in Daily Life-a Proof of Concept Study Using Positive Affect

Background: Mental healthcare needs person-tailored interventions. Experience Sampling Method (ESM) can provide daily life monitoring of personal experiences. This study aims to operationalize and test a measure of momentary reward-related Quality of Life (rQoL). Intuitively, quality of life improves by spending more time on rewarding experiences. ESM clinical interventions can use this information to coach patients to find a realistic, optimal balance of positive experiences (maximize reward) in daily life. rQoL combines the frequency of engaging in a relevant context (a 'behavior setting') with concurrent (positive) affect. High rQoL occurs when the most frequent behavior settings are combined with positive affect or infrequent behavior settings co-occur with low positive affect. Methods: Resampling procedures (Monte Carlo experiments) were applied to assess the reliability of rQoL using various behavior setting definitions under different sampling circumstances, for real or virtual subjects with low-, average- and high contextual variability. Furthermore, resampling was used to assess whether rQoL is a distinct concept from positive affect. Virtual ESM beep datasets were extracted from 1,058 valid ESM observations for virtual and real subjects. Results: Behavior settings defined by Who-What contextual information were most informative. Simulations of at least 100 ESM observations are needed for reliable assessment. Virtual ESM beep datasets of a real subject can be defined by Who-What-Where behavior setting combinations. Large sample sizes are necessary for reliable rQoL assessments, except for subjects with low contextual variability. rQoL is distinct from positive affect. Conclusion: rQoL is a feasible concept. Monte Carlo experiments should be used to assess the reliable implementation of an ESM statistic. Future research in ESM should asses the behavior of summary statistics under different sampling situations. This exploration is especially relevant in clinical implementation, where often only small datasets are available.

White noise speech illusion and psychosis expression: An experimental investigation of psychosis liability

Background

An association between white noise speech illusion and psychotic symptoms has been reported in patients and their relatives. This supports the theory that bottom-up and top-down perceptual processes are involved in the mechanisms underlying perceptual abnormalities. However, findings in nonclinical populations have been conflicting.

Objectives

The aim of this study was to examine the association between white noise speech illusion and subclinical expression of psychotic symptoms in a nonclinical sample. Findings were compared to previous results to investigate potential methodology dependent differences.

Methods

In a general population adolescent and young adult twin sample (n = 704), the association between white noise speech illusion and subclinical psychotic experiences, using the Structured Interview for Schizotypy—Revised (SIS-R) and the Community Assessment of Psychic Experiences (CAPE), was analyzed using multilevel logistic regression analyses.

Results

Perception of any white noise speech illusion was not associated with either positive or negative schizotypy in the general population twin sample, using the method by Galdos et al. (2011) (positive: ORadjusted: 0.82, 95% CI: 0.6–1.12, p = 0.217; negative: ORadjusted: 0.75, 95% CI: 0.56–1.02, p = 0.065) and the method by Catalan et al. (2014) (positive: ORadjusted: 1.11, 95% CI: 0.79–1.57, p = 0.557). No association was found between CAPE scores and speech illusion (ORadjusted: 1.25, 95% CI: 0.88–1.79, p = 0.220). For the Catalan et al. (2014) but not the Galdos et al. (2011) method, a negative association was apparent between positive schizotypy and speech illusion with positive or negative affective valence (ORadjusted: 0.44, 95% CI: 0.24–0.81, p = 0.008).

Conclusion

Contrary to findings in clinical populations, white noise speech illusion may not be associated with psychosis proneness in nonclinical populations.

Clinical high risk for psychosis: the association between momentary stress, affective and psychotic symptoms

OBJECTIVE

The aim of this study was to assess associations between momentary stress and both affective and psychotic symptoms in everyday life of individuals at clinical high risk (CHR), compared to chronic psychotic patients and healthy controls, in search for evidence of early stress sensitization. It also assessed whether psychotic experiences were experienced as stressful.

METHOD

The experience sampling method was used to measure affective and psychotic reactivity to everyday stressful activities, events and social situations in 22 CHR patients, 24 patients with a psychotic disorder and 26 healthy controls.

RESULTS

Multilevel models showed significantly larger associations between negative affect (NA) and activity-related stress for CHR patients than for psychotic patients (P = 0.008) and for CHR compared to controls (P < 0.001). Similarly, the association between activity-related stress and psychotic symptoms was larger in CHR than in patients (P = 0.02). Finally, the association between NA and symptoms (P < 0.001) was larger in CHR than in patients.

CONCLUSION

Stress sensitization seems to play a role particularly in the early phase of psychosis development as results suggest that CHR patients are more sensitive to daily life stressors than psychotic patients. In this early phase, psychotic experiences also contributed to the experience of stress.

Evidence That the Impact of Childhood Trauma on IQ Is Substantial in Controls, Moderate in Siblings, and Absent in Patients With Psychotic Disorder

Research suggests that childhood trauma is associated with cognitive alterations, but it is not known whether the cognitive alterations observed in patients with psychotic disorder, and their relatives, is trauma-related. Patients with a schizophrenia-spectrum diagnosis (n = 1119), siblings of patients (n = 1059) and healthy comparison subjects (HCS; n = 586) were interviewed 3 times over a period of 6 years. Repeated measures of IQ were analyzed as a function of childhood trauma and group, controlling for confounders. There were significant differences in the impact of childhood trauma on IQ across the 3 groups. Exposure in HCS was associated with a nearly 5-point reduction in IQ (-4.85; 95% confidence interval [CI]: -7.98 to -1.73, P = .002), a lesser reduction in siblings (-2.58; 95% CI: -4.69 to -0.46, P = .017) and no significant reduction in patients (-0.84; 95% CI: -2.78 to 1.10, P = .398). One-fourth of the sibling-control difference in IQ was reducible to childhood trauma, whereas for patients this was only 5%. Over the 6-year follow-up, those with trauma exposure showed significantly less learning effects with repeated cognitive assessments (b = 1.36, 95% CI: 0.80‒1.92, P < .001) than the nonexposed (b = 2.31, 95% CI: 1.92‒2.71, P < .001; P interaction = .001). Although childhood trauma impacts cognitive ability and learning in non-ill people at low and high genetic risk, its effect on the observed cognitive alterations in psychotic disorder may be minor. Twin and family studies on cognitive alterations in psychotic disorder need to take into account the differential impact of trauma on cognition across ill and non-ill, at risk groups.

Introducing the White Noise task in childhood: associations between speech illusions and psychosis vulnerability

BACKGROUND

Auditory verbal hallucinations (AVH) are common during development and may arise due to dysregulation in top-down processing of sensory input. This study was designed to examine the frequency and correlates of speech illusions measured using the White Noise (WN) task in children from the general population. Associations between speech illusions and putative risk factors for psychotic disorder and negative affect were examined.

METHOD

A total of 1486 children aged 11-12 years of the Copenhagen Child Cohort 2000 were examined with the WN task. Psychotic experiences and negative affect were determined using the Kiddie-SADS-PL. Register data described family history of mental disorders. Exaggerated Theory of Mind functioning (hyper-ToM) was measured by the ToM Storybook Frederik.

RESULTS

A total of 145 (10%) children experienced speech illusions (hearing speech in the absence of speech stimuli), of which 102 (70%) experienced illusions perceived by the child as positive or negative (affectively salient). Experiencing hallucinations during the last month was associated with affectively salient speech illusions in the WN task [general cognitive ability: adjusted odds ratio (aOR) 2.01, 95% confidence interval (CI) 1.03-3.93]. Negative affect, both last month and lifetime, was also associated with affectively salient speech illusions (aOR 2.01, 95% CI 1.05-3.83 and aOR 1.79, 95% CI 1.11-2.89, respectively). Speech illusions were not associated with delusions, hyper-ToM or family history of mental disorders.

CONCLUSIONS

Speech illusions were elicited in typically developing children in a WN-test paradigm, and point to an affective pathway to AVH mediated by dysregulation in top-down processing of sensory input.

Cognitive Performance and Long-Term Social Functioning in Psychotic Disorder: A Three-Year Follow-Up Study

Objective

Studies have linked cognitive functioning to everyday social functioning in psychotic disorders, but the nature of the relationships between cognition, social cognition, symptoms, and social functioning remains unestablished. Modelling the contributions of non-social and social cognitive ability in the prediction of social functioning may help in more clearly defining therapeutic targets to improve functioning.

Method

In a sample of 745 patients with a non-affective psychotic disorder, the associations between cognition and social cognition at baseline on the one hand, and self-reported social functioning three years later on the other, were analysed. First, case-control comparisons were conducted; associations were subsequently further explored in patients, investigating the potential mediating role of symptoms. Analyses were repeated in a subsample of 233 patients with recent-onset psychosis.

Results

Information processing speed and immediate verbal memory were stronger associated with social functioning in patients than in healthy controls. Most cognition variables significantly predicted social functioning at follow-up, whereas social cognition was not associated with social functioning. Symptoms were robustly associated with follow-up social functioning, with negative symptoms fully mediating most associations between cognition and follow-up social functioning. Illness duration did not moderate the strength of the association between cognitive functioning and follow-up social functioning. No associations were found between (social) cognition and follow-up social functioning in patients with recent-onset psychosis.

Conclusions

Although cognitive functioning is associated with later social functioning in psychotic disorder, its role in explaining social functioning outcome above negative symptoms appears only modest. In recent-onset psychosis, cognition may have a negligible role in predicting later social functioning. Moreover, social cognition tasks may not predict self-reported social functioning.

Change in daily life behaviors and depression: Within-person and between-person associations

OBJECTIVE

This study examined associations between daily physical, sedentary, social, and leisure behaviors and depressive symptoms (a) at a macrolevel, over the course of an Experience Sampling (ESM) self-monitoring intervention, and (b) at a microlevel, by examining daily within-person associations. Second, we examined the effects of the ESM self-monitoring intervention on these daily life behaviors.

METHODS

Individuals with a diagnosis of depression (N = 102) receiving pharmacological treatment were randomized to 1 of 2 six-week ESM intervention conditions or a control condition. Physical, sedentary, social, and leisure behaviors as well as depressive symptoms were assessed prospectively in every-day life at baseline, postintervention, and during the ESM interventions.

RESULTS

Change in physical activity and talking from baseline to postintervention was associated with change in depressive symptoms from baseline to postintervention. Within-person daily fluctuations in talking, physical activity, doing nothing/resting, and being alone predicted end-of-day depressive symptoms over and above depressive symptoms at the previous day. The ESM interventions contributed to change in talking, doing nothing/resting, and being alone over time in comparison with the control group. The analyses revealed individual differences in the amount of behavioral change over time and in the within-subject associations between daily behaviors and depressive symptoms.

CONCLUSIONS

The findings suggest that physical, sedentary, and social behaviors have affective implications for daily mental health of individuals with depression. Self-monitoring using ESM may be a useful add-on tool to achieve behavioral change and to gain personalized insight in behaviors that improve daily depressive symptoms.

Data Gathering Bias: Trait Vulnerability to Psychotic Symptoms?

Background

Jumping to conclusions (JTC) is associated with psychotic disorder and psychotic symptoms. If JTC represents a trait, the rate should be (i) increased in people with elevated levels of psychosis proneness such as individuals diagnosed with borderline personality disorder (BPD), and (ii) show a degree of stability over time.

Methods

The JTC rate was examined in 3 groups: patients with first episode psychosis (FEP), BPD patients and controls, using the Beads Task. PANSS, SIS-R and CAPE scales were used to assess positive psychotic symptoms. Four WAIS III subtests were used to assess IQ.

Results

A total of 61 FEP, 26 BPD and 150 controls were evaluated. 29 FEP were revaluated after one year. 44% of FEP (OR = 8.4, 95% CI: 3.9–17.9) displayed a JTC reasoning bias versus 19% of BPD (OR = 2.5, 95% CI: 0.8–7.8) and 9% of controls. JTC was not associated with level of psychotic symptoms or specifically delusionality across the different groups. Differences between FEP and controls were independent of sex, educational level, cannabis use and IQ. After one year, 47.8% of FEP with JTC at baseline again displayed JTC.

Conclusions

JTC in part reflects trait vulnerability to develop disorders with expression of psychotic symptoms.

Experience sampling-based personalized feedback and positive affect: a randomized controlled trial in depressed patients

OBJECTIVES

Positive affect (PA) plays a crucial role in the development, course, and recovery of depression. Recently, we showed that a therapeutic application of the experience sampling method (ESM), consisting of feedback focusing on PA in daily life, was associated with a decrease in depressive symptoms. The present study investigated whether the experience of PA increased during the course of this intervention.

DESIGN

Multicentre parallel randomized controlled trial. An electronic random sequence generator was used to allocate treatments.

SETTINGS

University, two local mental health care institutions, one local hospital.

PARTICIPANTS

102 pharmacologically treated outpatients with a DSM-IV diagnosis of major depressive disorder, randomized over three treatment arms.

INTERVENTION

Six weeks of ESM self-monitoring combined with weekly PA-focused feedback sessions (experimental group); six weeks of ESM self-monitoring combined with six weekly sessions without feedback (pseudo-experimental group); or treatment as usual (control group).

MAIN OUTCOME

The interaction between treatment allocation and time in predicting positive and negative affect (NA) was investigated in multilevel regression models.

RESULTS

102 patients were randomized (mean age 48.0, SD 10.2) of which 81 finished the entire study protocol. All 102 patients were included in the analyses. The experimental group did not show a significant larger increase in momentary PA during or shortly after the intervention compared to the pseudo-experimental or control groups (χ2(2) = 0.33, p = .846). The pseudo-experimental group showed a larger decrease in NA compared to the control group (χ2(1) = 6.29, p =.012).

CONCLUSION

PA-focused feedback did not significantly impact daily life PA during or shortly after the intervention. As the previously reported reduction in depressive symptoms associated with the feedback unveiled itself only after weeks, it is conceivable that the effects on daily life PA also evolve slowly and therefore were not captured by the experience sampling procedure immediately after treatment.

TRIAL REGISTRATION

Trialregister.nl/trialreg/index.asp. NTR1974.

Theory of Mind and attachment styles in people with psychotic disorders, their siblings, and controls

OBJECTIVE

Impaired Theory of Mind (ToM) and insecure (adult) attachment styles have been found in persons with schizophrenia as well as in their healthy siblings. ToM refers to the ability to infer mental states of self and others including beliefs and emotions. Insecure attachment is proposed to underlie impaired ToM, and comprises avoidant (discomfort with close relationships, high value of autonomy) and anxious (separation anxiety, dependency on others) attachment. Insight into the association between attachment style and ToM is clinically relevant, as it enhances our understanding and clinical approach to social dysfunction in schizophrenia. Therefore, we studied the association between insecure attachment styles and ToM in patients with schizophrenia, their siblings, and healthy controls.

METHODS

A total of 111 patients with a diagnosis in the schizophrenia spectrum, 106 non-affected siblings and 63 controls completed the Psychosis Attachment Measure, the Conflicting Beliefs and Emotions, a subsection of the Wechsler Adult Intelligence Scale, and the Childhood Trauma Questionnaire-Short Form. Severity of symptoms was assessed with the Community Assessment of Psychic Experiences and the Positive and Negative Syndrome Scale.

RESULTS

After controlling for sex, intelligence, history of trauma and symptom severity, avoidant attachment was significantly associated with cognitive as well as with affective ToM, showing U-shaped associations, indicating better ToM performance for patients with lower or higher levels of avoidant attachment compared to medium levels. Anxious attachment in patients was associated with more problems in cognitive ToM.

CONCLUSION

The results from this study support the idea that an anxious attachment style is associated with worse ToM performance in patients. Results also suggested a potential protective role of higher levels of avoidant attachment on ToM. These findings bear clinical relevance, as activation of (insecure) attachment mechanisms may affect interpersonal relations, as well as therapeutic working alliance. Further clarification is needed, especially on associations between ToM and avoidant attachment.

Novel evidence that attributing affectively salient signal to random noise is associated with psychosis

We wished to replicate evidence that an experimental paradigm of speech illusions is associated with psychotic experiences. Fifty-four patients with a first episode of psychosis (FEP) and 150 healthy subjects were examined in an experimental paradigm assessing the presence of speech illusion in neutral white noise. Socio-demographic, cognitive function and family history data were collected. The Positive and Negative Syndrome Scale (PANSS) was administered in the patient group and the Structured Interview for Schizotypy-Revised (SIS-R), and the Community Assessment of Psychic Experiences (CAPE) in the control group. Patients had a much higher rate of speech illusions (33.3% versus 8.7%, OR_adjusted: 5.1, 95% CI: 2.3–11.5), which was only partly explained by differences in IQ (OR_adjusted: 3.4, 95% CI: 1.4–8.3). Differences were particularly marked for signals in random noise that were perceived as affectively salient (OR_adjusted: 9.7, 95% CI: 1.8–53.9). Speech illusion tended to be associated with positive symptoms in patients (OR_adjusted: 3.3, 95% CI: 0.9–11.6), particularly affectively salient illusions (OR_adjusted: 8.3, 95% CI: 0.7–100.3). In controls, speech illusions were not associated with positive schizotypy (OR_adjusted: 1.1, 95% CI: 0.3–3.4) or self-reported psychotic experiences (OR_adjusted: 1.4, 95% CI: 0.4–4.6). Experimental paradigms indexing the tendency to detect affectively salient signals in noise may be used to identify liability to psychosis.

The serotonin transporter 5-HTTLPR polymorphism in the association between sleep quality and affect

A link between sleep and affect is well-known. Serotonin (5-HT) is associated with the regulation of affective as well as sleep-related processes. A functional polymorphism in the serotonin transporter gene (5-HTTLPR) has been associated with serotonergic functioning. The present study investigated whether allelic variation of this gene moderates the association between nighttime subjective sleep quality and affect the following day. A population-based sample of 361 ethnically homogenous adult female twins underwent a five day protocol based on the experience sampling method (ESM), assessing momentary negative affect, positive affect, and subjective sleep quality repeatedly and prospectively. There was a significant interaction between sleep quality and genotype in predicting positive affect the next day: carriers of one (n=167) or two S-alleles (n=78) had a significantly steeper slope compared to LL carriers (n=116) (χ(2)=4.16, p=.042 and χ(2)=3.90, p=.048 respectively). The association between subjective sleep quality and positive affect the next day varied as a function of 5-HTTLPR: it was stronger in carriers of at least one copy of the S-allele compared to homozygous L-carriers, supporting a link between sleep and affect regulation, in which serotonin may play a role. However, these results are preliminary and require replication.

Time-lagged moment-to-moment interplay between negative affect and paranoia: new insights in the affective pathway to psychosis

Evidence suggests that affect plays a role in the development of psychosis but the underlying mechanism requires further investigation. This study examines the moment-to-moment dynamics between negative affect (NA) and paranoia prospectively in daily life. A female general population sample (n = 515) participated in an experience sampling study. Time-lagged analyses between increases in momentary NA and subsequent momentary paranoia were examined. The impact of childhood adversity, stress sensitivity (impact of momentary stress on momentary NA), and depressive symptoms on these time-lagged associations, as well as associations with follow-up self-reported psychotic symptoms (Community Assessment of Psychic Experiences and the Symptom Checklist-90-Revised) were investigated. Moments of NA increase resulted in a significant increase in paranoia over 180 subsequent minutes. Both stress sensitivity and depressive symptoms impacted on the transfer of NA to paranoia. Stress sensitivity moderated the level of increase in paranoia during the initial NA increase, while depressive symptoms increased persistence of paranoid feelings from moment to moment. Momentary paranoia responses to NA increases were associated with follow-up psychotic symptoms. Examination of microlevel momentary experience may thus yield new insights into the mechanism underlying co-occurrence of altered mood states and psychosis. Knowledge of the underlying mechanism is required in order to determine source and place where remediation should occur.

Intermediate phenotype analysis of patients, unaffected siblings, and healthy controls identifies VMAT2 as a candidate gene for psychotic disorder and neurocognition

Psychotic disorders are associated with neurocognitive alterations that aggregate in unaffected family members, suggesting that genetic vulnerability to psychotic disorder impacts neurocognition. The aim of the present study was to investigate whether selected schizophrenia candidate single nucleotide polymorphisms (SNPs) are associated with (1) neurocognitive functioning across populations at different genetic risk for psychosis (2) and psychotic disorder. The association between 152 SNPs in 43 candidate genes and a composite measure of neurocognitive functioning was examined in 718 patients with psychotic disorder. Follow-up analyses were carried out in 750 unaffected siblings and 389 healthy comparison subjects. In the patients, 13 associations between SNPs and cognitive functioning were significant at P < .05, situated in DRD1, DRD3, SLC6A3, BDNF, FGF2, SLC18A2, FKBP5, and DNMT3B. Follow-up of these SNPs revealed a significant and directionally similar association for SLC18A2 (alternatively VMAT2) rs363227 in siblings (B = -0.13, P = .04) and a trend association in control subjects (B = -0.10, P = .12). This association was accompanied by a significantly increased risk for psychotic disorder associated with the T allele (linear OR = 1.51, 95% CI 1.10-2.07, P = .01), which was reduced when covarying for cognitive performance (OR = 1.29, 95% CI 0.92-1.81, P = .14), suggesting mediation. Genetic variation in VMAT2 may be linked to alterations in cognitive functioning underlying psychotic disorder, possibly through altered transport of monoamines into synaptic vesicles.

Day-to-day associations between subjective sleep and affect in regard to future depression in a female population-based sample

BACKGROUND

Poor sleep is a risk factor for depression, but little is known about the underlying mechanisms.

AIMS

Disentangling potential mechanisms by which sleep may be related to depression by zooming down to the 'micro-level' of within-person daily life patterns of subjective sleep and affect using the experience sampling method (ESM).

METHOD

A population-based twin sample consisting of 553 women underwent a 5-day baseline ESM protocol assessing subjective sleep and affect together with four follow-up assessments of depression.

RESULTS

Sleep was associated with affect during the next day, especially positive affect. Daytime negative affect was not associated with subsequent night-time sleep. Baseline sleep predicted depressive symptoms across the follow-up period.

CONCLUSIONS

The subtle, repetitive impact of sleep on affect on a daily basis, rather than the subtle repetitive impact of affect on sleep, may be one of the factors on the pathway to depression in women.

Emotion recognition in psychosis: no evidence for an association with real world social functioning

BACKGROUND

Patients with psychotic disorders show impairments in the recognition of emotions in other people. These impairments have been associated with poor social functioning as measured by self-report questionnaires, clinical interviews and laboratory-based tests of social skills. The ecological validity of these tests, however, is low. Associations were examined between emotion recognition and daily life social interactions in 50 patients diagnosed with a non-affective psychotic disorder and 67 healthy controls.

METHODS

All participants were assessed with the Degraded Facial Affect Recognition Task (DFAR), a computer test measuring the recognition of emotional facial expressions. Social functioning in daily life was assessed using the Experience Sampling Method (a random time sampling technique) with focus on measures of social context and appraisal of the social situation.

RESULTS

Groups differed significantly in the recognition of angry faces, whereas no differences existed for other emotions. There were no associations between emotion recognition and social functioning in daily life and there was no evidence for differential associations in patients as compared to controls.

DISCUSSION

Social functioning, when assessed in an ecologically valid fashion, is not sensitive to variation in the traditional experimental assessment of emotion recognition. Real life measures of functioning should guide research linking the handicaps associated with psychosis to underlying cognitive and emotional dysregulation.

Genetic Risk and Outcome of Psychosis (GROUP), a multi-site longitudinal cohort study focused on gene-environment interaction: objectives, sample characteristics, recruitment and assessment methods

OBJECTIVE

A longitudinal focus on gene-environment vulnerability and resilience in both patients, their unaffected family members and non-related controls offers the opportunity to elucidate etiological and pathogenetic factors influencing the onset and course of psychotic disorders. The current paper delineates the objectives, sample characteristics, recruitment and assessment procedures of the Genetic Risk and Outcome of Psychoses (GROUP) study.

METHODS

A naturalistic longitudinal cohort study with assessments at baseline, after three and six years of follow-up. The study is conducted by a consortium of four university psychiatric centres, with their affiliated mental health care institutions in the Netherlands covering more than 7.5 million inhabitants. Extensive assessment of genetic factors, environmental factors, (endo)phenotypes, and outcome.

RESULTS

At baseline, 1120 patients, 1057 siblings, 919 parents and 590 healthy controls were included.

CONCLUSION

The GROUP study will contribute to insight in risk and protective factors in the aetiology of non-affective psychotic disorders, and in the variation in their course and outcome.

Evidence that genes for depression impact on the pathway from trauma to psychotic-like symptoms by occasioning emotional dysregulation

BACKGROUND

Genes for depression may act by making individuals more sensitive to childhood trauma. Given that childhood adversity is a risk factor for adult psychosis and symptoms of depression and psychosis tend to cluster within individuals and families, the aim was to examine whether the association between childhood adversity and psychotic-like symptoms is moderated by genetic liability for depression. A secondary aim was to determine to what degree a depression-related increase in stress sensitivity or depressive symptoms themselves occasioned the moderating effect.

METHOD

Female twins (n=508) completed both prospective and retrospective questionnaires regarding childhood adversity [the Symptom Checklist-90 - Revised (SCL-90-R) and SCID-I (psychotic symptoms)] and psychotic trait liability [the Community Assessment of Psychic Experiences (CAPE)]. Stress sensitivity was indexed by appraisals of event-related stress and negative affect (NA) in the flow of daily life, assessed with momentary assessment technology for five consecutive days. Multilevel regression analyses were used to examine moderation of childhood adversity by genetic liability for depression in the prediction of follow-up psychotic experiences.

RESULTS

The effect of childhood adversity was significantly moderated by genetic vulnerability for depression in the model of both follow-up psychotic experiences (SCL-90-R) and follow-up psychotic trait liability (CAPE). The moderation by genetic liability was mediated by depressive experience but not by stress sensitivity.

CONCLUSIONS

Genetic liability for depression may potentiate the pathway from childhood adversity to psychotic-like symptoms through dysfunctional emotional processing of anomalous experiences associated with childhood trauma.

Cognitive alterations in patients with non-affective psychotic disorder and their unaffected siblings and parents

OBJECTIVE

The purpose of this study was to examine a range of cognitive measures as candidate phenotypic liability markers for psychosis in a uniquely large sample of patients with psychosis, their unaffected relatives and control subjects.

METHOD

Patients with non-affective psychosis (n = 1093), their unaffected siblings (n = 1044), parents (n = 911), and controls (n = 587) completed a comprehensive cognitive test battery. Cognitive functioning was compared using tests of verbal learning and memory, attention/vigilance, working memory, processing speed, reasoning and problem solving, acquired knowledge, and social cognition. Age- and gender-adjusted z-scores were compared between groups using mixed-model analyses of covariance. Clinically relevant impairment (-1 and -2 SD from control mean) was compared between subject groups.

RESULTS

Patients performed significantly worse than controls in all cognitive domains (z-range -0.26 to -1.34). Siblings and parents showed alterations for immediate verbal learning, processing speed, reasoning and problem solving, acquired knowledge, and working memory (z-range -0.22 to -0.98). Parents showed additional alterations for social cognition. Prevalence of clinically relevant impairment in relatives ranged from 50% (-1 SD criterion) to 10% (-2 SD criterion).

CONCLUSION

Cognitive functioning is a candidate intermediate phenotype given significant small to large alterations in patients and intermediate alterations in first-degree relatives.

Momentary assessment technology as a tool to help patients with depression help themselves

OBJECTIVE

Given high relapse rates and residual symptoms in depression, new strategies to increase treatment effectiveness are required. A promising avenue is to investigate how electronic momentary assessment technology may contribute to clinical assessment and interventions in depression.

METHOD

A literature search was conducted focusing on the potential contribution of momentary assessments to clinical applications in depression.

RESULTS

Momentary assessments are able to reveal subtle, small but repetitive and relevant patterns of emotional expression that predict future course of depression. A momentary assessment tool may expose manageable pieces of daily life behaviour contributing to the depressive experience that patients can influence. The use of this explicit knowledge of daily life experience is understudied with regard to its contribution to diagnostic assessment, monitoring of treatment effects and feedback interventions in depressed patients. The clinical application of momentary assessments may stimulate a shift from passive consumption of treatment to an active role for patients in their recovery and increased patient ownership.

CONCLUSION

The precise, prospective and fine-grained information that momentary assessment technology provides may contribute to clinical practice in various ways. Future studies should examine the clinical impact of its use and the feasibility of its implementation in mental health care.

The dynamic interplay between negative and positive emotions in daily life predicts response to treatment in depression: a momentary assessment study

OBJECTIVES

Although the treatment of depressive illness aims to restore the imbalance between an excess of negative affect (NA) and a shortage of positive affect (PA), no study has examined how NA and PA may influence each other in depression. This study examines how NA and PA dynamically influence each other in depression and how this may impact on treatment response.

DESIGN

Depressed help-seeking individuals participated in the Experience Sampling Method (ESM), which enables visualization of subtle dynamic alterations of momentary affective states over time. Thereafter, participants received a combination of antidepressant treatment and psychotherapy, and were followed up each month.

METHODS

NA and PA were assessed during ESM at 10 random moments per day for 6 days. Depressive symptoms were assessed at baseline and at monthly intervals during treatment.

RESULTS

Future response to treatment was associated with altered baseline NA-PA dynamics in individuals with previous depressive episodes. Their daily life boosts of PA were followed by a stronger suppression of NA over subsequent hours than in other depressed groups or controls.

CONCLUSIONS

Subtle individual differences in daily life emotional dynamics predict future treatment outcome in depression.

Unveiling patterns of affective responses in daily life may improve outcome prediction in depression: a momentary assessment study

OBJECTIVE

Daily life affective responses are closely linked to vulnerability and resilience in depression. Prediction of future clinical course may be improved if information on daily life emotional response patterns is taken into account.

METHOD

Female subjects with a history of major depression (n=83), recruited from a population twin register, participated in a longitudinal study using momentary assessment technology with 4 follow-up measurements. The effect of baseline daily life emotional response patterns (affect variability, stress-sensitivity and reward experience) on follow-up depressive symptomatology was examined.

RESULTS

Both reward experience (B=-0.30, p=0.001) and negative affect variability (B=0.46, p=0.001) predicted future negative affective symptoms independent of all other dynamic emotional patterns and conventional predictors.

CONCLUSION

Daily life information on dynamic emotional patterns adds to the prediction of future clinical course, independent of severity of symptoms and neuroticism score. Better prediction of course may improve decision-making regarding quantitative and qualitative aspects of treatment.