Early and broadly defined psychosis risk mental states

TechCare: mobile assessment and therapy for psychosis - an intervention for clients in the Early Intervention Service: A feasibility study protocol

Objectives:

Technological advances in healthcare have shown promise when delivering interventions for mental health problems such as psychosis. The aim of this project is to develop a mobile phone intervention for people with psychosis and to conduct a feasibility study of the TechCare App.

Methods:

The TechCare App will assess participant’s symptoms and respond with a personalised guided self-help-based psychological intervention with the aim of exploring feasibility and acceptability. The project will recruit 16 service users and 8–10 health professionals from the Lancashire Care NHS Foundation Trust Early Intervention Service.

Results:

In strand 1 of the study, we will invite people to discuss their experience of psychosis and give their opinions on the existing evidence-based treatment (cognitive behavioural therapy) and how the mobile app can be developed. In strand 2, we will complete a test run with a small number of participants (n = 4) to refine the mobile intervention (TechCare). Finally, in strand 3 of the study, the TechCare App will be examined in a feasibility study with 12 participants.

Conclusion:

It has been suggested that there is a need for a rapid increase in the efforts to develop the evidence base for the clinical effectiveness of digital technologies, considering mHealth research can potentially be helpful in addressing the demand on mental health services globally.

Assessing self-reported clinical high risk symptoms in community-derived adolescents: A psychometric evaluation of the Prodromal Questionnaire-Brief

BACKGROUND

The reliable early identification of individuals at risk for psychosis requires well-validated screening measures. To date, there is little information about the psychometric properties of the screening measures for psychosis risk in nonclinical adolescents. The main purpose of the present study was to validate the Prodromal Questionnaire-Brief (PQ-B) in a community sample of non-clinical Spanish adolescents. We also analyzed the prevalence, factorial validity, and reliability of the PQ-B scores as well as the relationship between self-reported clinical high risk symptoms and schizotypal traits.

METHOD

Four hundred and forty-nine high-school students participated in a cross-sectional survey. The PQ-B and the Oviedo Schizotypy Assessment Questionnaire (ESQUIZO-Q) were used.

RESULTS

Although 85.1% of the total sample reported at least one clinical high risk symptom, only 16% of the adolescents scored above the standardized cut-off. The PQ-B revealed an essentially unidimensional structure. The internal consistency of the PQ-B total score was 0.93. Pearson correlation coefficients indicated a high degree of overlap between self-reported clinical high risk symptoms and Positive and Disorganized schizotypal traits. A Canonical correlation between the PQ-B total score and ESQUIZO-Q dimensions showed that the associated variance between both sets of variables was 45.4% (adjusted R(2)=0.45).

CONCLUSIONS

The PQ-B is a brief, easy, and reliable tool for screening self-reported clinical high risk symptoms in adolescents from the general population. These results also indicated that self-reported clinical high risk symptoms and schizotypal traits are closely associated at the subclinical level. The assessment of psychosis risk symptoms and their relationship with other distal risk factors, in a close-in strategy, may enhance the early identification of individuals at heightened risk for psychosis spectrum disorders.

Reciprocal causation models of cognitive vs volumetric cerebral intermediate phenotypes for schizophrenia in a pan-European twin cohort

In aetiologically complex illnesses such as schizophrenia, there is no direct link between genotype and phenotype. Intermediate phenotypes could help clarify the underlying biology and assist in the hunt for genetic vulnerability variants. We have previously shown that cognition shares substantial genetic variance with schizophrenia; however, it is unknown if this reflects pleiotropic effects, direct causality or some shared third factor that links both, for example, brain volume (BV) changes. We quantified the degree of net genetic overlap and tested the direction of causation between schizophrenia liability, brain structure and cognition in a pan-European schizophrenia twin cohort consisting of 1243 members from 626 pairs. Cognitive deficits lie upstream of the liability for schizophrenia with about a quarter of the variance in liability to schizophrenia explained by variation in cognitive function. BV changes lay downstream of schizophrenia liability, with 4% of BV variation explained directly by variation in liability. However, our power to determine the nature of the relationship between BV deviation and schizophrenia liability was more limited. Thus, while there was strong evidence that cognitive impairment is causal to schizophrenia liability, we are not in a position to make a similar statement about the relationship between liability and BV. This is the first study to demonstrate that schizophrenia liability is expressed partially through cognitive deficits. One prediction of the finding that BV changes lie downstream of the disease liability is that the risk loci that influence schizophrenia liability will thereafter influence BV and to a lesser extent. By way of contrast, cognitive function lies upstream of schizophrenia, thus the relevant loci will actually have a larger effect size on cognitive function than on schizophrenia. These are testable predictions.

Subtyping Schizophrenia by Treatment Response: Antipsychotic Development and the Central Role of Positive Symptoms

We have recently proposed a model for subtyping schizophrenia based on antipsychotic (AP) treatment response. Evidence suggests that APs, both old and new, are comparable in terms of efficacy; however, one AP, clozapine, is uniquely effective in one subgroup of patients (that is, those with treatment-resistant schizophrenia [TRS]). This permits us to subdivide schizophrenia into 3 specific groups: AP responsive, clozapine responsive, and clozapine resistant. Here, we integrate this model with current criteria related to TRS and ultraresistant schizophrenia, the latter referred to in our model as clozapine resistant. We suggest several modifications to existing criteria, in line with current evidence and practice patterns, particularly emphasizing the need to focus on positive symptoms. While APs can favourably impact numerous dimensions related to schizophrenia, it is their effect on positive symptoms that distinguishes them from other psychotropics. Further, it is positive symptoms that are central to AP and clozapine resistance, and it is these people that place the greatest demands on acute and long-term inpatient resources. In moving AP development forward, we advocate specifically focusing on positive symptoms and capitalizing on the evidence we have of 3 subtypes of psychosis (that is, positive symptoms) based on treatment response, implicating 3 distinguishable forms of underlying pathophysiology. Conversely, pooling these groups risks obfuscating potentially identifiable differences. Such a position does not challenge the importance of dopamine D2 receptor blockade, but rather highlights the need to better isolate those other subgroups that require something more or entirely different.

Pituitary volume and clinical trajectory in young relatives at risk for schizophrenia

BACKGROUND

Stress and vulnerability likely interact to play a major role in psychosis. While much has been written about the neural diathesis-stress model in psychosis and its clinical risk states, little is known about HPA axis biomarkers in non-help-seeking individuals at familial high risk (FHR). We sought to prospectively measure pituitary volume (PV) in adolescents and young adults at FHR for schizophrenia and to follow their emerging sub-clinical psychotic symptoms and clinical trajectories.

METHOD

Forty healthy controls and 38 relatives of patients with schizophrenia or schizoaffective disorder were identified in Pittsburgh, USA. PV was derived from baseline 1.5 T magnetic resonance imaging. Chapman's schizotypy scales were acquired at baseline, and structured clinical interviews for DSM-IV-TR Axis I diagnoses were attempted annually for up to 3 years.

RESULTS

Seven individuals converted to psychosis. PV did not differ between FHR and control groups overall. Within the FHR group, PV was positively correlated with Chapman's positive schizotypy (Magical Ideation and Perceptual Aberration) scores, and there was a significant group × PV interaction with schizotypy. PV was significantly higher in FHR subjects carrying any baseline Axis I diagnosis (p = 0.004), and higher still in individuals who went on to convert to psychosis (p = 0.0007).

CONCLUSIONS

Increased PV is a correlate of early positive schizotypy, and may predict trait vulnerability to subsequent psychosis in FHR relatives. These preliminary findings support a model of stress-vulnerability and HPA axis activation in the early phases of psychosis.

Changes in neurocognitive functioning during transition to manifest disease: comparison of individuals at risk for schizophrenic and bipolar affective psychoses

BACKGROUND

Neurocognitive deficits are important aspects of schizophrenic disorder because they have a strong impact on social and vocational outcomes. Previously it was assumed that cognitive abilities progressively deteriorate with illness onset. However, recent research results have contradicted this with observations of continuous or even improved performance in individuals at risk for psychosis or manifest schizophrenia. The objective of our longitudinal study was to examine neurocognitive functioning in help-seeking individuals meeting basic symptoms or ultra-high-risk criteria for schizophrenic psychosis (HRSchiz) or risk criteria for affective psychosis (HRBip). The progression of cognitive functioning in individuals converting to psychosis was compared with that of at-risk individuals who did not convert during the follow-up period.

METHOD

Data were available from 86 study participants who completed neurocognitive and clinical assessments at baseline and, on average, 12.8 (s.d. = 1.5) months later. Neurocognitive measures were grouped according to their load in factor analysis to five cognitive domains: speed, attention, fluency, learning and memory, and working memory.

RESULTS

Neurocognitive functioning in HRSchiz and HRBip individuals generally improved over time. Subjects converting to manifest psychosis displayed a stable neurocognitive profile from baseline to follow-up. Compared with non-converters, they had already demonstrated a significantly lower level of performance during their baseline examinations.

CONCLUSIONS

Our data provide no evidence for a progressive cognitive decline in individuals at risk of psychosis. In line with the neurodevelopmental model, our findings suggest that cognitive deficits are already present very early, before or during the prodromal stage of the illness.

New Targets for Prevention of Schizophrenia: Is It Time for Interventions in the Premorbid Phase?

A number of influences have converged that make this Special Theme Issue timely: "A New Direction: Considering Developmentally Sensitive Targets for Very Early Intervention in Schizophrenia". These factors include: 1. the substantial knowledge about premorbid developmental vulnerabilities to psychosis, especially regarding schizophrenia; 2. the promising results emerging from interventions during the clinical high-risk (CHR) phase of psychosis and; 3. the recognition that the CHR period is a relatively late phase of developmental derailment. These factors have together led to a perspective that even earlier intervention is warranted. This paper briefly summarizes the articles comprising the Special Theme including new data on early neurocognitive development, proposed potential targets for psychosocial and psychopharmacological interventions during the premorbid period as early as pregnancy, and ethical challenges. These thought experiments must be empirically tested, and the ethical challenges overcome as posed by the various interventions, which range from relatively low risk, supportive, psychosocial to higher risk, experimental, pharmacological interventions. All of the interventions proposed require careful study of ethics, safety, potential stigma, feasibility, efficacy and tolerability, and the meaning to the people involved.

Neurocognitive functioning of subjects with putative pre-psychotic states and early psychosis

BACKGROUND

The neurocognitive functioning of patients with schizophrenia is likely to decline at the early stage of the illness. More evidence is needed to determine whether deficits in certain domains of neurocognition precede the onset of illness and can predict the onset of psychosis.

METHODS

Subjects were recruited from the SOPRES study in Taiwan. A neuropsychological battery including the continuous performance test, Wisconsin Card Sorting Test, Wechsler Adult Intelligence Scale-Third Edition, Trail Making Tests, Mandarin version of the Verbal Fluency Test, and Wechsler Memory Scale-Third Edition, was applied at baseline and 1-year follow-up. Neurocognitive profiles derived from these tests were categorized into 9 domains for comparisons among subjects with different levels of clinical severity.

RESULTS

A total of 324 participants, including 49 with first episode psychosis (FEP), 53 with ultra-high risk (UHR), 42 with intermediate risk (IR), 43 with marginal risk (MR), and 137 normal controls completed a baseline assessment and 71% of the participants completed a 1-year follow-up assessment. The profiles of the UHR and IR groups were identical at baseline. Those who converted to FEP later on (UHR+) showed relatively poorer performance than non-converters (UHR-) at baseline. At follow-up the performance of UHR+ was compatible to that of FEP, while UHR- generally improved.

CONCLUSIONS

By including subjects with early putative pre-psychotic states, our study clarifies some inconsistencies about the timing and stability of changes in neurocognitive functioning that occur at the start of psychosis; it also raises questions regarding the feasibility of using neurocognitive deficits to predict the risks of transition to psychosis.

Mismatch negativity (MMN) deficiency: a break-through biomarker in predicting psychosis onset

Currently, the mismatch negativity (MMN) deficit is one of the most robust and replicable findings in schizophrenia, reflecting cognitive and functional decline, psychosocial and socio-occupational impairment, and executive dysfunction in these patients. An important break-through has very recently taken place here in the prediction of conversion to psychosis when the MMN in particular to change in tone duration was recorded in clinically at risk-mental state (ARMS) individuals. Attenuations in the MMN in these patients may be very useful in helping clinicians determine who are most likely to develop a psychotic disorder, as we will review in the present article.

Intervention précoce pour la psychose : concepts, connaissances actuelles et orientations futures

Cet article fournit un survol de la logique de l’intervention précoce pour psychose, de ses fondements théoriques et de la littérature essentielle sur le concept. L’intervention précoce repose sur l’hypothèse de la période critique, qui vient accentuer l’importance des premiers stades de la maladie, et sur les résultats d’études dans le domaine, qui suggère que la durée d’une psychose non traitée en influence le pronostic. L’intervention précoce facilite l’accès à un traitement spécialisé adapté à la phase de la maladie par un processus de recommandations médicales plus ouvert, des délais rapides et l’éducation du public et des praticiens sur la psychose. L’intervention précoce, qui dure généralement deux ans à partir du dépistage, comprend une prise en charge intensive et des médicaments antipsychotiques à faible dose. L’accent est mis sur le fonctionnement social, l’intervention familiale, l’attention précoce aux troubles connexes ainsi qu’une alliance thérapeutique entre le jeune et sa famille. Selon les données scientifiques disponibles, une telle intervention donne de meilleurs résultats que les soins typiquement offerts. Les critiques du concept visent la qualité des études en sa faveur, sa mise en oeuvre, la répartition des ressources en intervention précoce et son utilité pour les personnes présentant un risque élevé de psychose. En termes de disponibilité et d’élaboration de politiques en intervention précoce, le Royaume-Uni détient une avance certaine, alors que le Canada se situe au milieu, et les États-Unis au bas de l’échelle. Au Québec, les résultats varient et d’autres études et investissements sont nécessaires. Récemment, le concept d’intervention précoce a servi d’exemple à des mesures plus importantes visant la transformation des soins de santé mentale des jeunes, ce qui constitue une toute nouvelle percée au Canada.

Neurocognitive profiles in help-seeking individuals: comparison of risk for psychosis and bipolar disorder criteria

BACKGROUND

Neurocognitive deficits are important aspects of the schizophrenic disorders because they have a strong impact on social and vocational outcomes. We expanded on previous research by focusing on the neurocognitive profiles of persons at high risk (HR) or ultra-high risk (UHR) for schizophrenic and affective psychoses. Our main aim was to determine whether neurocognitive measures are sufficiently sensitive to predict a group affiliation based on deficits in functional domains.

METHOD

This study included 207 help-seeking individuals identified as HR (n = 75), UHR (n = 102) or at high risk for bipolar disorder (HRBip; n = 30), who were compared with persons comprising a matched, healthy control group (CG; n = 50). Neuropsychological variables were sorted according to their load in a factor analysis and were compared among groups. In addition, the likelihood of group membership was estimated using logistic regression analyses.

RESULTS

The performance of HR and HRBip participants was comparable, and intermediate between the controls and UHR. The domain of processing speed was most sensitive in discriminating HR and UHR [odds ratio (OR) 0.48, 95% confidence interval (CI) 0.28-0.78, p = 0.004] whereas learning and memory deficits predicted a conversion to schizophrenic psychosis (OR 0.47, 95% CI 0.25-0.87, p = 0.01).

CONCLUSIONS

Performances on neurocognitive tests differed among our three at-risk groups and may therefore be useful in predicting psychosis. Overall, cognition had a profound effect on the extent of general functioning and satisfaction with life for subjects at risk of psychosis. Thus, this factor should become a treatment target in itself.

The WERCAP Screen and the WERC Stress Screen: psychometrics of self-rated instruments for assessing bipolar and psychotic disorder risk and perceived stress burden

BACKGROUND

Identification of individuals in the prodromal phase of bipolar disorder and schizophrenia facilitates early intervention and promises an improved prognosis. There are no current assessment tools for clinical risk symptoms of bipolar disorder, and psychosis-risk assessment generally involves semi-structured interviews, which are time consuming and rater dependent. We present psychometric data on two novel quantitative questionnaires: the Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen for assessing bipolar and psychotic disorder risk traits, and the accompanying WERC Stress Screen for assessing individual and total psychosocial stressor severities.

METHODS

Prevalence rates of the WERCAP Screen were evaluated among 171 community youth (aged 13-24 years); internal consistency was assessed and k-means cluster analysis was used to identify symptom groups. In 33 participants, test-retest reliability coefficients were assessed, and ROC curve analysis was used to determine the validity of the psychosis section of the WERCAP Screen (pWERCAP) against the Structured Interview of Psychosis-Risk Symptoms (SIPS). Correlations of the pWERCAP, the affectivity section of the WERCAP Screen (aWERCAP) and the WERC Stress Screen were examined to determine the relatedness of scores with cognition and clinical measures.

RESULTS

Cluster analysis identified three groups of participants: a normative (47%), a psychosis-affectivity (18%) and an affectivity only (35%) group. Internal consistency of the aWERCAP and pWERCAP resulted in alphas of 0.87 and 0.92, and test-retest reliabilities resulted in intraclass correlation coefficients of 0.76 and 0.86 respectively. ROC curve analysis showed the optimal cut-point on the pWERCAP as a score of >30 (sensitivity: 0.89; specificity: 1.0). There was a significant negative correlation between aWERCAP scores and total cognition (R=-0.42), and between pWERCAP scores and sensorimotor processing speed. Total stress scores correlated significantly with scores on the aWERCAP (R=0.88), pWERCAP (R=0.62) and total cognition (R=-0.44).

CONCLUSIONS

Our results show that the WERCAP Screen and the WERC Stress Screen are easy to administer and derived scores are related to cognitive and clinical traits. This suggests that their use could have particular benefits for epidemiologic studies and in busy clinical settings. Longitudinal studies would be required to evaluate clinical outcomes with high questionnaire scores.

Is prophylactic psychiatry around the corner? combating adolescent oxidative stress for adult psychosis and schizophrenia

Early detection and intervention are key principles in clinical medicine and psychiatry. In this issue of Neuron, Cabungcal et al. (2014) demonstrate that prophylactic treatment with antioxidants in adolescence prevents adult deficits in a rat model relevant to schizophrenia.

Psychotic symptoms, functioning and coping in adolescents with mental illness

BACKGROUND

Psychotic symptoms in the context of psychiatric disorders are associated with poor functional outcomes. Environmental stressors are important in the development of psychosis; however, distress may only be pathogenic when it exceeds an individual's ability to cope with it. Therefore, one interesting factor regarding poor functional outcomes in patients with psychotic symptoms may be poor coping. This paper aimed to address the question whether 1) psychotic symptoms are associated with poorer functioning and 2) whether poor coping moderated the association.

METHODS

In a clinical case-clinical control study of 106 newly-referred adolescent patients with non-psychotic psychiatric disorders, coping was investigated using the Adolescents Coping Scale. Severity of impairment in socio-occupational functioning was assessed with the Children's Global Assessment Scale.

RESULTS

Patients with non-psychotic psychiatric disorders and additional psychotic symptoms (N = 50) had poorer functioning and were more likely to use avoidance-oriented coping compared to patients with non-psychotic psychiatric disorders without psychotic symptoms (N = 56). No differences were found with respect to approach-oriented coping. When stratifying for poor/good coping, only those adolescent patients with psychotic symptoms who applied poor coping (i.e. less use of approach-oriented coping styles [OR 0.24, p < 0.015] and more use of avoidance-oriented coping [OR 0.23, p < 0.034]) had poorer functioning. However, these interactions were not significant.

CONCLUSIONS

Non-adaptive coping and poorer functioning were more often present in adolescents with non-psychotic psychiatric disorders and additional psychotic symptoms. Due to small subgroups, our analyses could not give definitive conclusions about the question whether coping moderated the association between psychotic symptoms and functioning. Improvement of coping skills may form an important target for intervention that may contribute to better clinical and functional outcomes in patients with psychotic symptoms.

Altered autonomic arousal in psychosis: an analysis of vulnerability and specificity

Vulnerability-stress models implicate that alterations of the autonomous nervous system contribute to the development of psychosis. Previous research has found autonomic arousal alterations in psychotic disorders and at-risk individuals that are not explained by medication alone. To test whether these alterations are associated with the extent of an individual's vulnerability and whether they are specific to psychosis, we compared participants with psychosis (n=23), first-degree relatives of individuals with psychosis (n=21), and healthy participants with attenuated positive symptoms (n=23) to participants with depression (n=24) and healthy controls (n=24). At rest, skin conductance level was assessed and photoplethysmography was applied to measure time- and frequency-domain heart rate variability (HRV). Univariate and multivariate analyses of covariance with perceived stress and psychophysiological values as dependent variables showed significant between-group differences for perceived stress (p=.010), heart rate (p=.022), time-domain HRV indices (all ps≤.027), and vagal activity (p=.017). Group differences in sympathetic activity were nonsignificant (p=.069). In an additional analysis with medication as a second between-group factor, the physiological between-group differences remained significant or trend significant (all ps≤.060). With the exception of sympathetic activity, participants with psychosis exhibited more extreme arousal than the control groups. First-degree relatives and participants with attenuated symptoms showed comparable autonomic activity to healthy controls. Thus, the hypothesized association of an alteration of arousal and vulnerability to psychosis was not confirmed. However, particularly low time-domain HRV was found for psychosis, with significant differences to healthy controls (all ps≤.007) and to depression (all ps≤.004), with the latter indicating a specificity to psychosis.

Shades of vulnerability: latent structures of clinical caseness in prodromal and early phases of schizophrenia

The underlying structures of clinical caseness and need of care in prodromal (i.e., at-risk) and early phases of schizophrenia remain poorly characterized in their essential psycho-behavioral coherence. To identify the schizophrenia proneness-related subtypes within a population of young help-seekers referred to a dedicated, community-based early detection program (Programma 2000). A sample of consecutive referrals (n = 168) for suspected psychosis or first-episode schizophrenia spectrum psychosis received a detailed clinical assessment, including the early recognition inventory for the retrospective assessment of the onset of schizophrenia checklist. We used exploratory factor analysis (EFA) to determine the underlying dimensional structure and latent class analysis (LCA) to identify putative vulnerability subtypes. EFA identified four factors: dysphoria (irritability tension), paranoid autocentrism, introversive withdrawal, and disturbed subjective experience. LCA distinguished three classes, interpretable as carrying different degrees of "proneness to schizophrenia psychosis," which best captured the underlying continuum of clinical severity. The validity of the three classes was supported by distinct patterns of association with major clinical variables (i.e., diagnostic staging at referral). Vulnerability to schizophrenia psychosis in young help-seekers may manifest in three major clinical prototypes, presenting common levels of dysphoria and social withdrawal but different degrees of paranoid autocentrism and disturbed subjective experience. Overall, the results provide the empirical background to dissect shared features of clinical caseness from more schizophrenia-specific vulnerability components. This is of value for the refinement of the clinical staging model as well as for the pragmatic implementation of multiple-gate screening programs.

Resting-state connectivity in the prodromal phase of schizophrenia: insights from EEG microstates

INTRODUCTION

Resting-state EEG microstates are thought to reflect the momentary local states and interactions of distributed neural networks in the brain. Several changes in resting-state EEG microstates have been described in acutely ill patients with schizophrenia, but it is not known whether these represent trait or state abnormalities. The present study aimed to investigate this issue by assessing EEG microstate characteristics in high-risk individuals (HR) and clinically stable first-episode patients with schizophrenia (SZ) with low symptom levels, compared to each other and healthy controls (HC).

METHOD

Participants were 18 HR, 18 SZ, and 22 HC subjects. 64-channel resting-state EEG recordings were used for microstate analyses. Microstates were clustered into four classes (A-D) according to their topography. Temporal parameters and topographies of microstates were compared among groups.

RESULTS

Microstate class A displayed higher coverage and occurrence in HR than SZ and HC, while microstate class B covered significantly more time in SZ compared to both HR and HC. Microstate class B displayed an aberrant spatial configuration in SZ, and to a lesser extent also in HR, compared to HC, with patients exhibiting significantly higher activity in the vicinity of the left posterior cingulate.

DISCUSSION

Microstate abnormalities observed in HR were similar to those previously reported in acutely ill patients with schizophrenia. Moreover, there was evidence that HR and SZ might share specific disturbances in brain functional connectivity. These findings raise the possibility that certain abnormalities in resting-state EEG microstates might be associated with an increased risk for psychosis.

Temporal lobe volume abnormalities precede the prodrome: a study of children presenting antecedents of schizophrenia

Distributed abnormalities of gray matter (GM) and white matter (WM) volume characterize individuals experiencing their first episode of schizophrenia. Regions of abnormality are present already, albeit less extensively, during the prodromal phase of illness. This study aimed to determine whether putatively at-risk children, aged 9-12 years, who present multiple antecedents of schizophrenia (ASz), display GM and WM volume abnormalities relative to typically developing (TD) children presenting no antecedents. Structural magnetic resonance images were acquired for 20 ASz children and 20 TD children matched on age, sex, and IQ. Whole-brain differences in GM and WM volume were determined using voxel-based morphometry. Relative to the TD group, ASz children showed significantly decreased GM volume in the right middle temporal gyrus (MTG) and increased GM volume in the left superior-middle temporal gyri (P < 0.05, cluster correction). WM volume was significantly increased in ASz children relative to TD children in a cluster encompassing the left inferior parietal lobe, occipital lobe, and superior temporal gyrus. Post-hoc analyses indicated that these abnormalities were not limited to ASz children who self-reported auditory hallucinations on questionnaire. Our findings suggest that children aged 9-12 years who present multiple ASz are characterized by abnormalities of GM and WM volume in the temporal lobes, comprising a subset of the regions affected in first-episode schizophrenia and in the prodromal phase of illness. These preliminary findings indicate that structural brain abnormalities associated with schizophrenia may be detected in putatively at-risk, preprodromal children. Prospective studies following the brain development of at-risk children are needed.

Psychosis prediction and clinical utility in familial high-risk studies: selective review, synthesis, and implications for early detection and intervention

AIM

Accurate prediction of which high-risk individuals will go on to develop psychosis would assist early intervention and prevention paradigms. We sought to review investigations of prospective psychosis prediction based on markers and variables examined in longitudinal familial high-risk (FHR) studies.

METHODS

We performed literature searches in MedLine, PubMed and PsycINFO for articles assessing performance characteristics of predictive clinical tests in FHR studies of psychosis. Studies were included if they reported on one or more predictive variables in subjects at FHR for psychosis. We complemented this search strategy with references drawn from articles, reviews, book chapters and monographs.

RESULTS

Across generations of FHR projects, predictive studies have investigated behavioural, cognitive, psychometric, clinical, neuroimaging and other markers. Recent analyses have incorporated multivariate and multi-domain approaches to risk ascertainment, with generally modest results.

CONCLUSIONS

Although a broad range of risk factors has been identified, no individual marker or combination of markers can at this time enable accurate prospective prediction of emerging psychosis for individuals at FHR. We outline the complex and multi-level nature of psychotic illness, the myriad of factors influencing its development, and methodological hurdles to accurate and reliable prediction. Prospects and challenges for future generations of FHR studies are discussed in the context of early detection and intervention strategies.

A review of neuroimaging studies of young relatives of individuals with schizophrenia: a developmental perspective from schizotaxia to schizophrenia

In an effort to identify the developing abnormalities preceding psychosis, Dr. Ming T. Tsuang and colleagues at Harvard expanded Meehl's concept of "schizotaxia," and examined brain structure and function in families affected by schizophrenia (SZ). Here, we systematically review genetic (familial) high-risk (HR) studies of SZ using magnetic resonance imaging (MRI), examine how findings inform models of SZ etiology, and suggest directions for future research. Neuroimaging studies of youth at HR for SZ through the age of 30 were identified through a MEDLINE (PubMed) search. There is substantial evidence of gray matter volume abnormalities in youth at HR compared to controls, with an accelerated volume reduction over time in association with symptoms and cognitive deficits. In structural neuroimaging studies, prefrontal cortex (PFC) alterations were the most consistently reported finding in HR. There was also consistent evidence of smaller hippocampal volume. In functional studies, hyperactivity of the right PFC during performance of diverse tasks with common executive demands was consistently reported. The only longitudinal fMRI study to date revealed increasing left middle temporal activity in association with the emergence of psychotic symptoms. There was preliminary evidence of cerebellar and default mode network alterations in association with symptoms. Brain abnormalities in structure, function and neurochemistry are observed in the premorbid period in youth at HR for SZ. Future research should focus on the genetic and environmental contributions to these alterations, determine how early they emerge, and determine whether they can be partially or fully remediated by innovative treatments.

Gray Matter Alterations in Schizophrenia High-Risk Youth and Early-Onset Schizophrenia: A Review of Structural MRI Findings

This article reviews the literature on structural magnetic resonance imaging findings in pediatric and young adult populations at clinical or genetic high-risk for schizophrenia and early-onset schizophrenia. The implications of this research are discussed for understanding the pathophysiology of schizophrenia and for early intervention strategies. The evidence linking brain structural changes in prepsychosis development and early-onset schizophrenia with disruptions of normal neurodevelopmental processes during childhood or adolescence is described. Future directions are outlined for research to address knowledge gaps regarding the neurobiological basis of brain structural abnormalities in schizophrenia and to improve the usefulness of these abnormalities for preventative interventions.

The Early Recognition Inventory ERIraos detects at risk mental states of psychosis with high sensitivity

The identification of patients carrying an increased risk of psychosis is one of the most important demands in schizophrenia research. Currently used diagnostic instruments mainly focus on either attenuated psychotic symptoms and brief limited intermittent psychotic symptoms or solely cognitive basic symptoms. The "Early Recognition Inventory based on IRAOS" (ERIraos) has been developed as a comprehensive assessment of both symptom groups within one scale. We compared the results obtained by ERIraos with an international standard instrument, the "Comprehensive Assessment of At Risk Mental States" (CAARMS) and applied both scales in a sample of 121 outpatients positively tested on a screening checklist for at risk mental states (ARMS). Subsamples were classified as first episode of psychosis, late ARMS with prevalent attenuated psychotic symptoms and/or brief limited intermittent psychotic symptoms, earlier stages of ARMS presenting cognitive basic symptoms as well as a vulnerability group, also differing regarding mean age and psychosocial functioning. Our results point to a higher sensitivity of ERIraos compared to scales that mainly focus on attenuated psychotic symptoms and brief limited intermittent psychotic symptoms. A detailed assessment of cognitive basic symptoms seems to be important in early detection, might be an important focus for therapeutic interventions in ARMS patients and might sustain attempts to alleviate cognitive dysfunction in schizophrenia.

Broadly defined risk mental states during adolescence: disorganization mediates positive schizotypal expression

While schizotypal features are common during adolescence, they can also signal increased risk for the onset of schizophreniform disorders. Most studies with adolescents find that hallucination and delusion-like symptoms (positive schizotypal features) best predict future psychopathology. Still, the developmental process of positive schizotypy remains elusive, specifically with regards to 1) its relationships to negative and disorganization schizotypal dimensions; 2) its associations to maladaptive functioning during adolescence. This longitudinal study aimed to further characterize these relationships, thereby delineating "early and broadly defined psychosis risk mental states" (Keshavan et al., 2011). The current study presents the 3-year course of schizotypal trait expression in 34 clinical adolescents aged 12 to 18 years consulting for non-psychotic difficulties. Schizotypal expression was assessed twice using the Schizotypal Personality Questionnaire, accompanied by an examination of internalizing/externalizing problems using the Achenbach scales. Cross-sectional and longitudinal analyses were conducted to assess the expression and course of schizotypal dimensions; mediation analyses were further employed to highlight the developmental interactions promoting the maintenance of positive schizotypal expression. The results reveal that positive schizotypy, and more specifically unusual perceptual experiences, significantly declined during the study interval. Disorganization features were found to mediate the relationships between the negative and positive dimensions of schizotypy within and across evaluations. Somatic complaints and attentional difficulties further strengthened the expression of positive schizotypy during the study interval. These results suggest that the relationship between disorganization features and positive schizotypy may play a central role in establishing risk for psychosis during adolescence.

Young people at risk for psychosis: case finding and sample characteristics of the Oulu Brain and Mind Study

AIM

Set within the general population-based Northern Finland Birth Cohort 1986, the Oulu Brain and Mind Study aims to explore the causes and pathogenesis of psychotic illness by following young people at risk for psychosis due to having a first-degree relative with psychotic illness or due to having experienced psychotic-like symptoms themselves. We report the study methods and explore the relationship between these definitions of high risk for psychosis and operational criteria for a prodromal psychosis syndrome based on interview.

METHODS

Prospectively collected data from earlier follow-ups of this cohort were combined with health register data to categorize subjects as those with familial risk (n = 272), symptomatic risk (n = 117), psychosis (n = 78), attention deficit hyperactivity disorder (ADHD) (n = 103) and a sample of controls (n = 193) drawn randomly from the remaining cohort. The Structured Interview for Prodromal Syndromes (SIPS) was applied to all, 295 participants together with questionnaires measuring psychosis vulnerability and schizotypal traits.

RESULTS

There were 29 (10%) current prodromal cases. Criteria for the current prodromal syndrome were fulfilled by 12% of the familial risk group and 19% of the symptomatic risk group, compared with 5% of the ADHD group and 4% of controls.

CONCLUSION

We successfully detected young people with a prodromal psychosis syndrome although relatively few subjects deemed to be at high risk met the full operational criteria according to the SIPS interview. Combining methods from familial, clinical and psychometric high-risk approaches provides a tractable method for studying risk of psychosis in the general population.

Conceptual issues in the classification of psychosis

PURPOSE OF REVIEW

To provide an update on the conceptual status of attenuated psychosis syndrome (APS) as a psychiatric disorder.

RECENT FINDINGS

In May 2012, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Task Force announced that the planned introduction of APS as a new diagnosis in DSM-5 was cancelled and that APS was being moved to 'Section III' of the manual as a diagnostic construct requiring more work. Recent studies of APS have reflected this uncertainty and debate over its validity.

SUMMARY

Before and after the decision in May 2012 to remove APS as a new diagnosis in DSM-5, scientific work has proceeded in a robust manner to shore up the validity of APS as a diagnostic construct. Recent work on APS has revolved around a series of unresolved questions: the actual incidence of conversion of APS to full-blown psychosis, the identification of the subgroup that will convert, the appropriate treatment for APS, the ability of treatment to prevent conversion to psychosis, the wide range of long-term outcomes of APS and finally the decision whether to include APS as a formal psychiatric diagnosis. Although the debate continues, a substantial number of the major researchers have argued that APS does not yet enjoy a degree of validity that warrants inclusion as a formal diagnosis.

Secondary psychoses: an update

Psychotic disorders due to a known medical illness or substance use are collectively termed secondary psychoses. In this paper, we first review the historic evolution of the concept of secondary versus primary psychosis and how this distinction supplanted the earlier misleading classification of psychoses into organic and functional. We then outline the clinical features and approach to the diagnosis of secondary psychotic disorders. Features such as atypical presentation, temporal relation to detectable medical cause, evidence of direct physiological causal relationship to the etiological agent, and the absence of evidence of a primary psychotic illness that may better explain the presentation suggest consideration of a secondary psychosis. Finally, we discuss how careful studies of secondary psychotic disorders can help elucidate the pathophysiology of primary, or idiopathic, psychotic disorders such as schizophrenia. We illustrate this issue through a discussion of three secondary psychotic disorders - psychoses associated with temporal lobe epilepsy, velocardiofacial syndrome, and N-methyl D-aspartate (NMDA) receptor encephalitis - that can, respectively, provide neuroanatomical, genetic, and neurochemical models of schizophrenia pathogenesis.

Development of a brief self-report questionnaire for screening putative pre-psychotic states

BACKGROUND

Several self-report instruments were developed to capture psychotic prodrome, and were claimed to have good predictive validity. The feasibility of screening is questionable considering the heterogeneity of the targeted populations and the negative ramifications of false positive identification. This study developed a questionnaire using data covering a wide range of clinical characteristics.

METHODS

One hundred and eleven putative pre-psychotic participants, 129 normal comparison subjects, and 95 non-psychotic psychiatric outpatients completed a 231-item questionnaire comprising a 110-item Wisconsin psychotic prone scale, 74-item schizotypal personality questionnaire, 33-item basic symptoms, and 14-item cognitive symptoms. Items showing the best discriminating power, estimated using chi-square statistics with Bonferroni correction, were extracted to create a brief version. A two-stage cut-off approach emphasizing specific items was applied to maximize sensitivity and specificity. The concurrent validity of the proposed approach was estimated using a ten-fold cross-validation procedure.

RESULTS

A 15-item self-report questionnaire was developed. Respondents checking at least eight items, or those checking three to seven items including any of the three referring to feeling stress in crowds, aloofness, and perceptual disturbance, would be considered putatively pre-psychotic with the largest sensitivity+specificity (0.784+0.705=1.489). This cut-off selection was the best estimate by calculating 1000 permutations in the cross-validation procedure.

CONCLUSIONS

This investigation proposes a different orientation for applying questionnaires to screen putative pre-psychotic states, with less emphasis on attenuated psychotic symptoms and predictive values. Besides providing a handy tool for increasing awareness and referral, the instructions of such a screening questionnaire should be carefully worded.

The psychosis high-risk state: a comprehensive state-of-the-art review

CONTEXT

During the past 2 decades, a major transition in the clinical characterization of psychotic disorders has occurred. The construct of a clinical high-risk (HR) state for psychosis has evolved to capture the prepsychotic phase, describing people presenting with potentially prodromal symptoms. The importance of this HR state has been increasingly recognized to such an extent that a new syndrome is being considered as a diagnostic category in the DSM-5.

OBJECTIVE

To reframe the HR state in a comprehensive state-of-the-art review on the progress that has been made while also recognizing the challenges that remain.

DATA SOURCES

Available HR research of the past 20 years from PubMed, books, meetings, abstracts, and international conferences.

STUDY SELECTION AND DATA EXTRACTION

Critical review of HR studies addressing historical development, inclusion criteria, epidemiologic research, transition criteria, outcomes, clinical and functional characteristics, neurocognition, neuroimaging, predictors of psychosis development, treatment trials, socioeconomic aspects, nosography, and future challenges in the field.

DATA SYNTHESIS

Relevant articles retrieved in the literature search were discussed by a large group of leading worldwide experts in the field. The core results are presented after consensus and are summarized in illustrative tables and figures.

CONCLUSIONS

The relatively new field of HR research in psychosis is exciting. It has the potential to shed light on the development of major psychotic disorders and to alter their course. It also provides a rationale for service provision to those in need of help who could not previously access it and the possibility of changing trajectories for those with vulnerability to psychotic illnesses.

The ultra-high risk concept-a review

Attempts to identify people at imminent risk of psychotic disorder have been made during the past 20 years. High-risk criteria have been developed, and despite findings of a recent decline in the rate of onset of psychosis associated with these criteria, people identified still have a significantly greater risk, compared with the general population. Intervention studies in this group indicate that psychological treatments and fish oil appear to be just as effective as antipsychotics. Future research should refine risk factors for psychosis and examine outcomes other than psychosis. Research is also needed into what harms and benefits are associated with making the high-risk criteria into a formal diagnosis.

Psychotic-like or unusual subjective experiences? The role of certainty in the appraisal of the subclinical psychotic phenotype

The multi-dimensional features of Unusual Subjective Experiences (USEs) may be more accurate indicators of psychosis-proneness than simple frequency count. We tested whether subjective certainty or uncertainty of the occurrence of USEs can influence perceived wellbeing. Five hundred and four undergraduate students completed measures of delusion- and hallucination-proneness, general health and emotional processing. Participants' responses on the delusion- and hallucination-proneness scales were dichotomized on the basis of their certainty level. Results showed that, USEs rated with certainty were associated with poor self-perceived health and difficult emotional processing, while those rated with uncertainty were not. Certainty of USEs was associated with increased distress and may be important in characterizing psychopathological significance. Specific characteristics associated with USEs may be more important than their frequency in predicting psychosis risk.

Multivariate prediction of emerging psychosis in adolescents at high risk for schizophrenia

BACKGROUND

Accurate prediction of psychosis development in high-risk populations is an important but thus far elusive goal. Of the many diverse etiologic and risk factors identified thus far, few have been combined into prospective multivariate risk ascertainment models. We tested the predictive power of familial, neurobiological, socioenvironmental, cognitive and clinical risk factors through an integrative biopsychosocial model for emerging psychosis in young relatives at familial risk for schizophrenia.

METHODS

96 young first- and second- degree relatives of schizophrenia probands were followed for an average of 2.38 (SD=0.98) years to examine their trajectory towards psychosis. Iterative structural equation modelling utilizing multiple etiologic and risk factors was employed to estimate their joint contribution to prediction of psychosis development.

RESULTS

The rate of conversion to psychosis over the study period was 12.5%. In the final model, clinical measures of schizotypy were directly predictive of conversion, with early (familial, biological, socioenvironmental) and cognitive risk factors indirectly predictive of psychosis through increased baseline clinical symptomatology. Our model provided an excellent fit to the observed data, with sensitivity of 0.17, specificity of 0.99, positive predictive value of 0.67 and negative predictive value of 0.89.

CONCLUSIONS

Integrative modeling of multivariate data from familial, neurobiological, socioenvironmental, cognitive and clinical domains represents a powerful approach to prediction of psychosis development. The high specificity and low sensitivity found using a combination of such variables suggests that their utility may be in confirmatory testing among already selected high-risk individuals, rather than for initial screening. These findings also highlight the importance of data from a broad array of etiologic and risk factors, even within a familial high-risk population. With further refinement and validation, such methods could form key components of early detection, intervention and prevention programs.

Preoccupation and distress are relevant dimensions in delusional beliefs

BACKGROUND AND PURPOSE

A large number of subjective experiences and beliefs with some degree of affinity with psychotic symptoms can be found in the general population. However, the appraisal of these psychotic-like experiences in terms of associated distress, raised preoccupation, and the conviction with which the experience is held can be more discriminative in distinguishing people in need for care from those who simply hold unusual or uncommon beliefs because of cultural reasons.

METHOD

In this study, 81 patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of schizophrenia or an affective disorder with psychotic features were compared on the Peters et al Delusions Inventory (PDI) to 210 people from the same local area, who had never received a formal diagnosis of a mental disorder.

RESULTS

Patients scored higher than controls on the PDI total score and on its distress, preoccupation, and conviction subscales. A stepwise logistic regression model showed PDI-preoccupation (odds ratio, 2.46; 95% confidence interval, 1.52-3.98) and, marginally, PDI-distress (odds ratio = 1.58; 95% confidence interval, 0.93-2.58) adding discriminative power to PDI total score in distinguishing patients from controls.

CONCLUSIONS

The evaluation of the severity of delusion-like experiences and beliefs is important in discriminating patients diagnosed with psychosis from people who are not in need of care.

Auditory event-related potential of subjects with suspected pre-psychotic state and first-episode psychosis

BACKGROUND

Recent schizophrenia research exploring the complicated pathogenesis of schizophrenia has focused on the subjects with at-risk mental states in order to exclude the influence of confounding factors. This study explores 3 sets of auditory-related event potentials in subjects with different risk levels of psychosis.

METHODS

Subjects were recruited from the SOPRES study in Taiwan. P50 and N100 using an auditory paired-click paradigm and duration MMN were assessed on 32 first-episode psychosis (FEP), 30 ultra-high risk (UHR), 37 E-BARS (early/broad at-risk mental states) participants and 56 controls.

RESULTS

MMN was correlated with neither P50 nor N100, whereas many parameters of the latter two were intercorrelated with each other. Compared to healthy controls, MMNs were significantly lower in all 3 clinical groups (E-BARS, UHR and FEP). A gradient of sensory-gating deficits, manifested by increased P50 ratios (S2/S1) and decreased N100 differences, across different levels of clinical severity was suggested by a linear trend. For the UHR subjects, P50 gating ratio, N100 gating ratio, N100 difference, and N100S2 amplitude might be potential indicators to discriminate converters from non-converters.

CONCLUSIONS

By including subjects with E-BARS, our results provide new insight regarding pre-attentive auditory event-related potential in subjects across different risk levels of psychotic disorders. Impaired deviance detection shown by MMNs already exists in people at a pre-psychotic state regardless of clinical severity, while sensory-gating deficits shown by P50/N100 varies depending on the risk levels in prodromal period. Further longitudinal research exploring the relationship between ERPs and subjects with a suspected pre-psychotic state is needed.

Predictive value of thought disorder in new-onset psychosis

OBJECTIVE

This research addresses the relationship of formal thought disorder in the early stages of psychotic illness to the long-term outcome of mental health many years later. The specific topic of concern was to evaluate the prognostic significance of thought disorder on the severity of psychosis over time.

METHODS

Subjects with new-onset psychosis were evaluated on a variety of measures including education, physical health, Brief Psychiatric Rating Scale scores. They were also given the Thought, Language, and Communication Scale to evaluate thought disorder. Subjects were interviewed again at 10 and 20 years to evaluate variations in outcome. Appropriate statistical methods were used to evaluate changes in the level of functioning over time.

RESULTS

Thought disorder was not unique to schizophrenia. Bipolar patients presented with significant positive thought disorder at the onset of psychosis. Overtime positive thought disorder gradually improved in most patients. Negative thought disorder was more persistent, especially in subjects with schizophrenia. Initial psychosis with thought disorder characterized by poverty of content seemed to be associated with poor long-term outcome.

CONCLUSION

Formal thought disorder can predict outcome in some cases of psychosis. Not all types of thought disorder have the same prognostic implication. Positive forms of thought disorder (pressured speech, tangentiality) had no significant predictive value. Negative thought disorder (particularly poverty of speech and poverty of content) tend to predict a chronic, more unrelenting course of illness.

Psychotic-like experiences in a community sample of 8000 children aged 9 to 11 years: an item response theory analysis

BACKGROUND

Psychotic-like experiences (PLEs) in the general population are common, particularly in childhood, and may constitute part of a spectrum of normative development. Nevertheless, these experiences confer increased risk for later psychotic disorder, and are associated with poorer health and quality of life.

METHOD

This study used factor analytic methods to determine the latent structure underlying PLEs, problem behaviours and personal competencies in the general child population, and used item response theory (IRT) to assess the psychometric properties of nine PLE items to determine which items best represented a latent psychotic-like construct (PSY). A total of 7966 children aged 9-11 years, constituting 95% of eligible children, completed self-report questionnaires.

RESULTS

Almost two-thirds of the children endorsed at least one PLE item. Structural analyses identified a unidimensional construct representing psychotic-like severity in the population, the full range of which was well sampled by the nine items. This construct was discriminable from (though correlated with) latent dimensions representing internalizing and externalizing problems. Items assessing visual and auditory hallucination-like experiences provided the most information about PSY; delusion-like experiences identified children at more severe levels of the construct.

CONCLUSIONS

Assessing PLEs during middle childhood is feasible and supplements information concerning internalizing and externalizing problems presented by children. The hallucination-like experiences constitute appropriate items to screen the population to identify children who may require further clinical assessment or monitoring. Longitudinal follow-up of the children is required to determine sensitivity and specificity of the PLE items for later psychotic illness.

Examination of anomalous self-experience: initial study of the structure of self-disorders in schizophrenia spectrum

A growing body of evidence points to the clinical and heuristic value of anomalous subjective experiences (ASEs) for the characterization of schizophrenia spectrum vulnerability and early detection purposes. In particular, a subgroup of ASEs, entailing basic disorders of self-awareness (self-disorders [SDs]), has been shown to constitute a core feature of both clinically overt and latent (schizotaxic) spectrum phenotypes. However, a major limitation for the translational implementation of this research evidence has been a lack of assessment tools capable of encompassing the clinical richness of SDs. Here, we present the initial normative data and psychometric properties of a newly developed instrument (Examination of Anomalous Self-experience [EASE]), specifically designed to support the psychopathological exploration of SDs in both research and "real world" clinical settings. Our results support the clinical validity of the EASE as a tool for assessing anomalies of self-awareness (SDs) and lend credit to the translational potential of a phenomenological exploration of the subjective experience of vulnerability to schizophrenia.

The Temporal Experience of Pleasure Scale (TEPS): exploration and confirmation of factor structure in a healthy Chinese sample

BACKGROUND

The Temporal Experience of Pleasure Scale (TEPS) is a measure specifically designed to capture the anticipatory and consummatory facets of pleasure. However, few studies have examined the structure of the measure in non-Western samples. The current study aimed to evaluate the factor structure and psychometric properties of the TEPS in a Chinese sample.

METHODS

We administered the Chinese version of the TEPS to 2275 healthy Chinese college students. They were randomly split into two sub-samples. The first sub-sample was used for exploratory factor analysis (EFA) to examine the structure of the TEPS in a Chinese sample. The second sub-sample was used as a validation sample for the identified structure from the EFA and confirmatory factor analysis (CFA) was adopted.

RESULTS

Results of the EFA suggested a four-factor model (consummatory contextual, consummatory abstract, anticipatory contextual, and anticipatory abstract factors) instead of the original two-factor model (consummatory and anticipatory factors) ascertained from Western samples in the United States. The CFA results confirmed these results in the second sub-sample. Internal consistency and test-retest stability of the TEPS factors were good.

CONCLUSIONS

The TEPS has four factors among Chinese participants. Possible reasons for cultural difference and potential applications of the TEPS for cross-cultural comparison are discussed.

Early prodromal symptoms can predict future psychosis in familial high-risk youth

BACKGROUND

Efforts to predict psychosis in individuals at high risk for schizophrenia have focused on the identification of sub-threshold clinical criteria and neurobiological markers, including neuropsychological assessment, structural and functional brain imaging, and psychophysiological testing. We sought to evaluate the relative utility of "psychosis-proneness" measures for prospective prediction of psychotic disorders in a group of young relatives at familial risk for schizophrenia.

METHODS

We examined the receiver operating characteristics of sub-threshold symptoms in predicting conversion to psychosis in a group of 97 young first- and second- degree relatives of persons with schizophrenia over a 2-year period. Towards this end, we utilized the Structured Interview of prodromal symptoms to derive measures of two of the four Scale of Prodromal Symptoms subscales (positive and disorganized) and the Chapman Magical Ideation and Perceptual Aberration scales. These four measures were, together, taken to reflect a putative index of psychosis-proneness.

RESULTS

Eleven of the 97 subjects developed a psychotic disorder over 2 years of follow-up. Seventeen of the 97 subjects tested positive on this index of psychosis-proneness at baseline and of these 10 converted to psychosis. The sensitivity and specificity of the test were 91 percent and 92 percent respectively. The positive predictive value of the test was 59 percent and its negative predictive value was 99 percent. Addition of measures of cognitive or social function to the index decreased its predictive ability, reducing its specificity and/or sensitivity.

CONCLUSIONS

A relatively simple set of clinical measures can be utilized to prospectively identify familial high risk individuals who convert to psychosis with high specificity and sensitivity. Implications for the proposed addition of an "attenuated psychosis syndrome" in DSM-5 are discussed.

Attenuated psychosis and the schizophrenia prodrome: current status of risk identification and psychosis prevention

Recent efforts in the prevention of schizophrenia have focused on defining psychosis-risk syndromes and evaluating treatments that can prevent transition to psychosis in these ultra-high risk groups. In this review, different kinds of prevention approaches are enumerated and necessary conditions for a disease-prevention strategy are summarized. The broad overlap as well as the significant difference between a schizophrenia prodrome and a 'psychosis-risk syndrome' is discussed and the present status of approaches to identify individuals at increased risk for developing psychosis and schizophrenia are critically examined along with evaluations on therapeutic interventions to reduce these risks. Finally, to conclude, recommendations for current best clinical practice and key questions for the future are suggested.

Neurodevelopmental liability to schizophrenia: the complex mediating role of age at onset and premorbid adjustment

Large individual variation in the clinical presentation of schizophrenia-spectrum disorders raises key questions regarding their aetiological underpinnings. In this respect, age at onset of the disorder is a particularly interesting marker of liability, as it has been reported to be associated with other signs of developmental compromise, such as male gender, increased presence of familial history of psychosis and poor premorbid adjustment, as well as a more severe clinical outcome in terms of cognition and symptomatology. The association between these variables has encouraged a neurodevelopmental perspective of the aetiological mechanisms involved in the pathophysiology of schizophrenia. However, the complex relationships within neurobiological liability markers, and between these markers and clinical outcome, remain to be understood. In the present study, we used a path-analytic approach to explore: i) the fit of the model to observed data; and both ii) direct and iii) indirect associations between the variables. In a sample of 106 patients with schizophrenia-spectrum disorders, we found a good fit of the model to the observed data, providing further evidence that supports a neurodevelopmental pathway to the disease in a subgroup of patients. However, the most parsimonious model showed complex relationships, where age at onset and premorbid functioning acted as mediators between gender, familial history of psychosis and clinical outcome. These findings refine earlier explanations of the neurobiological basis of schizophrenia, with potential applications in genetic studies based on more homogeneous forms of the disease. We further discuss the putative implications of our results in clinical practice and prevention policies.

A systematic meta-review grading the evidence for non-genetic risk factors and putative antecedents of schizophrenia

INTRODUCTION

Identifying the relative strength of evidence associated with non-genetic risk factors and putative antecedents of schizophrenia will guide research and may inform the design of early detection and intervention strategies.

AIMS

To present and quality assess current evidence for non-genetic risk factors and putative antecedents derived from well-conducted systematic reviews that report pooled data.

METHOD

Medline, Embase, CINAHL, Current Contents, and PsycINFO databases were searched systematically, and supplemented by hand searching. Review reporting quality was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, review methodology was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist, and evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Twenty-four reviews met inclusion criteria. The risk factors with the highest quality evidence, reporting medium effect sizes, were advanced paternal age, obstetric complications, and cannabis use. The strongest evidence among the putative antecedents was identified for motor dysfunction and low IQ.

CONCLUSIONS

More research is required that applies sound methodological practices, taking into consideration specificity for schizophrenia and possible confounding factors, to robustly identify the non-genetic risk factors and putative antecedents of schizophrenia.

Gray matters!--mapping the transition to psychosis

Despite many neuroimaging studies on schizophrenia showing brain abnormalities the exact time course of their occurrence is unknown. Studies of gray matter are a powerful tool in biological psychiatry and provide an unprecedented opportunity for brain structure investigations. Here we compared cross-sectional and longitudinal structural neuroimaging studies distinguishing high-risk subjects developing psychosis from those who did not. These investigations on gray matter volumes in the prodromal phase potentially identify core structural markers of impending psychoses and clarify dynamic changes underlying the transition. Subjects at high risk of psychosis show qualitatively similar albeit less severe gray matter abnormalities as patients with psychosis.