Puberty and the onset of psychosis

Do help-seeking adolescents report more psychotic-like experiences than young adults on the 16-item version of the prodromal questionnaire (PQ-16)?

AIM

To compare psychotic-like experiences (PLEs) in adolescents and young adults referred to the Mental Health Services (MHSs).

METHODS

Participants scored the 16-item Prodromal Questionnaire (PQ-16) as part of the intake procedure. Data on the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification and demographic data were collected.

RESULTS

The PQ-16 was completed by 13 783 respondents (mean age 24.63 years, SD = 6.09; 62.6% female). Overall, the scores on the PQ-16 were not higher for adolescents (11-17 years; m = 4.84, SD = 3.62) than for young adults (18-35 years; m = 5.47, SD = 3.85). On PQ-16 item level, adolescents reported seeing and hearing things more than adults did. Across all age groups, males scored lower on the PQ-16 than females. Specifically, adolescent males scored lower than other participants. For adolescents and young adults alike, PQ-16 scores were higher for participants with borderline personality disorder, PTSD, and mood disorder than for those with other DSM classifications.

CONCLUSIONS

Although help-seeking adolescents did not score higher on the PQ-16 than help-seeking young adults, more of them reported perceptual anomalies. Irrespective of age, participants with borderline personality disorder, PTSD and mood disorder scored higher on the PQ-16 than those with other DSM classifications.

Impact of cannabinoids on synapse markers in an SH-SY5Y cell culture model

Patients suffering from schizophrenic psychosis show reduced synaptic connectivity compared to healthy individuals, and often, the use of cannabis precedes the onset of schizophrenic psychosis. Therefore, we investigated if different types of cannabinoids impact methylation patterns and expression of schizophrenia candidate genes concerned with the development and preservation of synapses and synaptic function in a SH-SY5Y cell culture model. For this purpose, SH-SY5Y cells were differentiated into a neuron-like cell type as previously described. Effects of the cannabinoids delta-9-THC, HU-210, and Anandamide were investigated by analysis of cell morphology and measurement of neurite/dendrite lengths as well as determination of methylation pattern, expression (real time-qPCR, western blot) and localization (immunocytochemistry) of different target molecules concerned with the formation of synapses. Regarding the global impression of morphology, cells, and neurites appeared to be a bit more blunted/roundish and to have more structures that could be described a bit boldly as resembling transport vesicles under the application of the three cannabinoids in comparison to a sole application of retinoic acid (RA). However, there were no obvious differences between the three cannabinoids. Concerning dendrites or branch lengths, there was a significant difference with longer dendrites and branches in RA-treated cells than in undifferentiated control cells (as shown previously), but there were no differences between cannabinoid treatment and exclusive RA application. Methylation rates in the promoter regions of synapse candidate genes in cannabinoid-treated cells were in between those of differentiated cells and untreated controls, even though findings were significant only in some of the investigated genes. In other targets, the methylation rates of cannabinoid-treated cells did not only approach those of undifferentiated cells but were also valued even beyond. mRNA levels also showed the same tendency of values approaching those of undifferentiated controls under the application of the three cannabinoids for most investigated targets except for the structural molecules (NEFH, MAPT). Likewise, the quantification of expression via western blot analysis revealed a higher expression of targets in RA-treated cells compared to undifferentiated controls and, again, lower expression under the additional application of THC in trend. In line with our earlier findings, the application of RA led to higher fluorescence intensity and/or a differential signal distribution in the cell in most of the investigated targets in ICC. Under treatment with THC, fluorescence intensity decreased, or the signal distribution became similar to the dispersion in the undifferentiated control condition. Our findings point to a decline of neuronal differentiation markers in our in vitro cell-culture system under the application of cannabinoids.

Associations Between Genetic Risk, Physical Activities, and Distressing Psychotic-like Experiences

BACKGROUND AND HYPOTHESIS

Persistent distressing psychotic-like experiences (PLE) are associated with impaired functioning and future psychopathology. Prior research suggests that physical activities may be protective against psychopathology. However, it is unclear whether physical activities may interact with genetics in the development of psychosis.

STUDY DESIGN

This study included 4679 participants of European ancestry from the Adolescent Brain Cognitive Development Study. Persistent distressing PLE was derived from the Prodromal-Questionnaire-Brief Child Version using four years of data. Generalized linear mixed models tested the association between polygenic risk score for schizophrenia (PRS-SCZ), physical activities, and PLE. The models adjusted for age, sex, parental education, income-to-needs ratio, family history of psychosis, body mass index, puberty status, principal components for PRS-SCZ, study site, and family.

STUDY RESULTS

PRS-SCZ was associated with a greater risk for persistent distressing PLE (adjusted relative risk ratio (RRR) = 1.14, 95% CI [1.04, 1.24], P = .003). Physical activity was associated with less risk for persistent distressing PLE (adjusted RRR = 0.87, 95% CI [0.79, 0.96], P = .008). Moreover, physical activities moderated the association between PRS-SCZ and persistent distressing PLE (adjusted RRR = 0.89, 95% CI [0.81, 0.98], P = .015), such that the association was weaker as participants had greater participation in physical activities.

CONCLUSIONS

These findings demonstrate that the interaction between genetic liability and physical activities is associated with trajectories of distressing PLE. Further research is needed to understand the mechanisms of physical activities and genetic liability for schizophrenia in the development of psychosis.

Immune and oxidative stress biomarkers in pediatric psychosis and psychosis-risk: Meta-analyses and systematic review

OBJECTIVE

While genetic and cohort studies suggest immune and reduction/oxidation (redox) alterations occur in psychosis, less is known about potential alterations in children and adolescents.

METHODS

We conducted a systematic review to identify immune and redox biomarker studies in children and adolescents (mean age ≤ 18 years old) across the psychosis spectrum: from psychotic like experiences, which are common in children, to threshold psychotic disorders like schizophrenia. We conducted meta-analyses when at least three studies measured the same biomarker.

RESULTS

The systematic review includes 38 pediatric psychosis studies. The meta-analyses found that youth with threshold psychotic disorders had higher neutrophil/lymphocyte ratio (Hedge's g = 0.40, 95 % CI 0.17 - 0.64), tumor necrosis factor (Hedge's g = 0.38, 95 % CI 0.06 - 0.69), C-reactive protein (Hedge's g = 0.38, 95 % CI 0.05 - 0.70), interleukin-6 (Hedge's g = 0.35; 95 % CI 0.11 - 0.64), and total white blood cell count (Hedge's g = 0.29, 95 % CI 0.12 - 0.46) compared to youth without psychosis. Other immune and oxidative stress meta-analytic findings were very heterogeneous.

CONCLUSION

Results from several studies are consistent with the hypothesis that signals often classified as "proinflammatory" are elevated in threshold pediatric psychotic disorders. Data are less clear for immune markers in subthreshold psychosis and redox markers across the subthreshold and threshold psychosis spectrum. Immune and redox biomarker intervention studies are lacking, and research investigating interventions targeting the immune system in threshold pediatric psychosis is especially warranted.

Systematically mapping gray matter abnormal patterns in drug-naïve first-episode schizophrenia from childhood to adolescence

BACKGROUND

Schizophrenia originates early in neurodevelopment, underscoring the need to elaborate on anomalies in the still maturing brain of early-onset schizophrenia (EOS).

METHODS

Gray matter (GM) volumes were evaluated in 94 antipsychotic-naïve first-episode EOS patients and 100 typically developing (TD) controls. The anatomical profiles of changing GM deficits in EOS were detected using 2-way analyses of variance with diagnosis and age as factors, and its timing was further charted using stage-specific group comparisons. Interregional relationships of GM alterations were established using structural covariance network analyses.

RESULTS

Antagonistic interaction results suggested dynamic GM abnormalities of the left fusiform gyrus, inferior occipital gyrus, and lingual gyrus in EOS. These regions comprise a dominating part of the ventral stream, a ventral occipitotemporal (vOT) network engaged in early social information processing. GM abnormalities were mainly located in the vOT regions in childhood-onset patients, whereas in the rostral prefrontal cortex (rPFC) in adolescent-onset patients. Moreover, compared with TD controls, patients' GM synchronization with the ventral stream was disrupted in widespread high-order social perception regions including the rPFC and salience network.

CONCLUSIONS

The current findings reveal age-related anatomical abnormalities of the social perception system in pediatric patients with schizophrenia.

Sex and pubertal influences on the neurodevelopmental underpinnings of schizophrenia: A case for longitudinal research on adolescents

Sex is a significant source of heterogeneity in schizophrenia, with more negative symptoms in males and more affective symptoms and internalizing comorbidity in females. In this narrative review, we argue that there are likely sex differences in the pathophysiological mechanisms of schizophrenia-spectrum disorders (SZ) that originate during puberty and relate to the sex-specific impacts of pubertal maturation on brain development. Pubertal maturation might also trigger underlying (genetic or other) vulnerabilities in at-risk individuals, influencing brain development trajectories that contribute to the emergence of SZ. This review is the first to integrate links between pubertal development and neural development with cognitive neuroscience research in SZ to form and evaluate these hypotheses, with a focus on the frontal-striatal and frontal-limbic networks and their hypothesized contribution to negative and mood symptoms respectively. To test these hypotheses, longitudinal research with human adolescents is needed that examines the role of sex and pubertal development using large cohorts or high risk samples. We provide recommendations for such studies, which will integrate the fields of psychiatry, developmental cognitive neuroscience, and developmental endocrinology towards a more nuanced understanding of the role of pubertal factors in the hypothesized sex-specific pathophysiological mechanisms of schizophrenia.

Sex and gender differences in symptoms of early psychosis: a systematic review and meta-analysis

First-episode psychosis (FEP) can be quite variable in clinical presentation, and both sex and gender may account for some of this variability. Prior literature on sex or gender differences in symptoms of psychosis have been inconclusive, and a comprehensive summary of evidence on the early course of illness is lacking. The objective of this study was to conduct a systematic review and meta-analysis of the literature to summarize prior evidence on the sex and gender differences in the symptoms of early psychosis. We conducted an electronic database search (MEDLINE, Scopus, PsycINFO, and CINAHL) from 1990 to present to identify quantitative studies focused on sex or gender differences in the symptoms of early psychosis. We used random effects models to compute pooled standardized mean differences (SMD) and risk ratios (RR), with 95% confidence intervals (CI), for a range of symptoms. Thirty-five studies met the inclusion criteria for the systematic review, and 30 studies were included in the meta-analysis. All studies examined sex differences. Men experienced more severe negative symptoms (SMD =  - 0.15, 95%CI =  - 0.21, - 0.09), whereas women experienced more severe depressive symptoms (SMD = 0.21, 95%CI = 0.14, 0.27) and had higher functioning (SMD = 0.16, 95%CI = 0.10, 0.23). Women also had a lower prevalence of substance use issues (RR = 0.65, 95%CI = 0.61, 0.69). Symptoms of early psychosis varied between men and women; however, we were limited in our ability to differentiate between biological sex and gender factors. These findings may help to inform early detection and intervention efforts to better account for sex and gender differences in early psychosis presentation.

Estrogens in schizophrenia: progress, current challenges and opportunities

PURPOSE OF REVIEW

Schizophrenia is a heterogeneous psychiatric disorder with a different, but not necessarily milder clinical presentation in women as compared to men. These sex differences have largely been attributed to the protective role of estrogens. This article reviews the current state of estrogen research in schizophrenia.

RECENT FINDINGS

Estrogens regulate important pathophysiological pathways in schizophrenia, including dopamine activity, mitochondrial function, and the stress system. Estrogen deficiency is common in both sexes and is associated with increases in psychotic symptoms. Hyperprolactinemia causes secondary estrogen deficiency and can be a reaction to stress, or secondary to prolactin-raising antipsychotics. Therefore, prolactin-sparing antipsychotics should be preferred especially in premenopausal women, who are more prone to hyperprolactinemia. Premenopausal women furthermore require lower doses of antipsychotics than men, since estrogens raise the availability and efficacy of antipsychotics.

SUMMARY

The past years have established the importance of estrogens in the pathophysiology of schizophrenia and have shown its relevance to clinical practice through its influence on antipsychotic drug efficacy. Future research should focus on the neurobiological and clinical effect of contraceptives in premenopausal women with schizophrenia. Furthermore, the potential of estrogen-like augmentation with raloxifene and phytoestrogens in schizophrenia should be established in the coming years.

Adolescent Neurodevelopment and Vulnerability to Psychosis

Adolescence is characterized by significant changes in several domains, including brain structure and function, puberty, and social and environmental factors. Some of these changes serve to increase the likelihood of psychosis onset during this period, while others may buffer this risk. This review characterizes our current knowledge regarding the unique aspects of adolescence that may serve as risk factors for schizophrenia spectrum disorders. In addition, we provide potential future directions for research into adolescent-specific developmental mechanisms that impart vulnerability to psychosis and the possibility of interventions that capitalize on adolescents' unique characteristics. Specifically, we explore the ways in which gray and white matter develop throughout adolescence in typically developing youth as well as in those with psychosis spectrum disorders. We also discuss current views on the function that social support and demands, as well as role expectations, play in risk for psychosis. We further highlight the importance of considering biological factors such as puberty and hormonal changes as areas of unique vulnerability for adolescents. Finally, we discuss cannabis use as a factor that may have a unique impact during adolescent neurodevelopment, and subsequently potentially impact psychosis onset. Throughout, we include discussion of resilience factors that may provide unique opportunities for intervention during this dynamic life stage.

Mental health profile and its relation with parental alcohol use problems and/or the experience of abuse in a sample of Moroccan high school students: an explorative study

BACKGROUND

Studies on mental health are scarce from Arab countries, especially studies focusing on adolescents. In addition to the neurobiological and physiological changes that occur during adolescent development, psychological, societal and cultural influences have strong effects on adolescents' behavior and on their somatic and mental health. The present study aimed (1) to describe the mental health profile, operationalized as psychological distress, of a sample of Moroccan adolescents, and (2) to investigate how specific psychosocial factors (parental alcohol use problems and the experience of physical and/or psychological abuse) may affect adolescents' mental health.

METHODS

The sample included 375 adolescents from conveniently selected classes of four high schools in the city of Tetouan in Morocco. The participants responded to an anonymous survey containing, beside other inventories, the Brief Symptom Inventory (BSI) and identified those reporting parental alcohol use problems and/or the previous experience of abuse. The sample characteristics were defined using descriptive statistics. The effects of the defined psychosocial factors were identified using the Kruskal-Wallis test, followed by the post hoc Fisher's least significant difference test.

RESULTS

The most common problems found in high school students from an urban region of Morocco were memory problems, concentration difficulties, restlessness, fear, nervosity and feelings of inadequacy during interpersonal interactions. The female students reported significantly higher psychological distress levels when compared to the male students (p < 0.001). The adolescents reporting parental alcohol use problems and the experience of physical/psychological abuse showed significantly higher levels of psychological distress (p = 0.02), especially symptoms of somatization (p < 0.001), hostility (p = 0.005) and anxiety (p = 0.01), than those not reporting any of these psychosocial factors.

CONCLUSION

The mental health profile of female adolescents from an urban area of Morocco is worse than that of their male fellow students. Adolescents reporting parental alcohol use problems and/or the experience of physical/psychological abuse need synchronized support from social- and healthcare services.

Relationship between menarche and psychosis onset in women with first episode of psychosis

AIM

The aim of this study was to explore the relationship between age at menarche and age at first episode of psychosis, as well as clinical severity and outcome, in a population of women with first-episode psychosis.

METHODS

Clinical and socio-demographical data, age at menarche and at first-episode psychosis, parental history of psychosis and cannabis-use habits were obtained from 42 subjects with a first episode of psychosis. Positive and Negative Syndrome Scale, Clinical Global Impression, Global Assessment Function, Disability Assessment Schedule, Wechsler Adult Intelligence Scale and Wechsler Intelligence Scale for Children, European Quality of Life, and Lewis and Murray Obstetric Complication Scales were administered. Statistical analysis was performed by means of zero-order correlations and Mann-Whitney U and Kruskal-Wallis tests using SPSS version 17.0.

RESULTS

We found no significant correlation between age at menarche and age at first-episode psychosis, or with the clinical scores performed. We observed that subjects with earlier age at menarche had more parental history of psychosis.

CONCLUSIONS

Our negative results do not support the theory of a possible protective role of oestrogen, which seems to be more complex than previously thought. We would suggest that further research is needed to investigate developmental influences of sex steroids on the onset of psychosis and potentially therapeutic benefits based upon oestrogen.

Psychotic experiences co-occur with sleep problems, negative affect and mental disorders in preadolescence

BACKGROUND

Knowledge on the significance of childhood psychotic symptoms and experiences (PE) is still limited. This study aimed to investigate the prevalence and clinical significance of PE in preadolescent children from the general population by use of in-depth psychopathological interviews and comprehensive diagnostic assessments.

METHODS

We investigated 1,632 children from the general population-based Copenhagen Child Cohort 2000. PE were measured by semistructured interviews using the K-SADS-PL-items on psychotic and affective symptoms, each symptom scored as not present versus likely or definitely present. The Development and Well-Being Assessment (DAWBA) was used independently to diagnose DSM-IV-mental disorders. Puberty development and sleep disturbance were self-reported. The associations between PE (any lifetime hallucination and/or delusion) and various mental problems and disorders were examined by multivariable binomial regression analyses, adjusting for gender and onset of puberty.

RESULTS

The weighted life time prevalence of PE at age 11-12 years was 10.9% (CI 9.1-12.7). The majority of children with PE (n = 172) either had a diagnosable DSM-IV-mental disorder (31.4%) or self-reported mental health difficulties in absence of a diagnosis (31.4%). The risk of delusions increased with onset of puberty. The risk of PE increased with emotional and neurodevelopmental disorders, subthreshold depressive symptoms, sleep problems and lack of sleep, regardless of whether PE were expressed as hallucinations and/or delusions. The highest correlations were seen for emotional and multiple disorders.

CONCLUSIONS

Psychotic experiences are particularly prevalent in the context of affective dysregulation and sleep disturbance, increase with onset of puberty and represent a trans-diagnostic marker of psychopathology.

Direct comparison of first-contact versus longitudinal register-based case finding in the same population: early evidence that the incidence of schizophrenia may be three times higher than commonly reported

BACKGROUND

The incidence of schizophrenia is commonly estimated by screening for psychosis among subjects presenting to psychiatric services. This approach (using a first-contact sampling frame) cannot account for cases that did not meet criteria for schizophrenia at first contact. We compared the usual approach directly with a register-based approach (using a longitudinal sampling frame) that also includes subjects initially diagnosed with other non-schizophrenic disorders.

METHOD

We compared data from the Longitudinal Psychiatric Register (LPR) of The Hague over 1980-2009 with data previously collected in a first-contact study, and applied both methods to calculate the incidence of schizophrenia for subjects aged 20-54 years in the same catchment area and over the same period (October 2000 to September 2005). We reconstructed treatment pathways and diagnostic histories up to the end of 2009 and performed sensitivity analyses.

RESULTS

The LPR identified 843 first onsets of schizophrenia, corresponding to a treated incidence rate (IR) of 69 per 100,000 person-years [95% confidence interval (CI) 64-74]. The first-contact study identified 254 first onsets, corresponding to a treated IR of 21 per 100,000 person-years (95% CI 18-23). Two-thirds of the difference was accounted for by subjects treated for other disorders before the onset of psychosis, and by patients in older age groups.

CONCLUSIONS

The incidence of schizophrenia was three times higher in a longitudinal register study than in a high-quality first-contact study conducted in the same population. Risk estimates based only on first-contact studies may have been affected by selection bias.

The experience of engaging with mental health services among young people who hear voices and their families: a mixed methods exploratory study

Background

Research shows us that auditory hallucinations or ‘hearing voices’ may be more common than previously thought, particularly in childhood and adolescents. Importantly, not all individuals are affected negatively by their voice hearing experiences, yet child and adolescent mental health services (CAMHS) have traditionally understood voice hearing as a symptom of psychosis and severe mental illness, with implications for the way interventions are offered. The purpose of the present study was to gain an understanding of how young people who hear voices and their families find engaging with mental health service, and to better understand their experience of mental health professionals.

Methods

A two-stage, mixed methods study was used. In the first stage, semi-structured interviews were carried out with two young people and their parents who had engaged with mental health services, and the collected data were analysed using Interpretative Phenomenological Analysis (IPA). In the second stage, a questionnaire was designed to test the generalizability of the themes arising from the first stage, and was completed online by 32 young voice hearers and 27 parents.

Results

IPA analysis produced 4 themes: (1) The struggle to understand the hearing voices phenomenon; (2) Battle with the Mental Health Services; (3) ‘Stuck in a limbo’; and (4) The wish for a more holistic approach from mental health services and professionals. The survey partially confirmed the findings of study one, with young people and parents finding useful information difficult to come by, and many reported feeling lost in CAMHS. Additionally, young voice hearers and parents often felt not listened to, and many parents expressed the need for a holistic care, whilst young people wanted a more normalizing and less stigmatizing experience.

Conclusions

Young people and their families had varying experiences of mental health services. Whilst the survey showed that some young people and their families had more positive experiences, many expressed dissatisfaction. To fulfil the needs of young people and their families, mental health services would benefit from developing alternative approaches to voice hearing and running support groups that could form part of a ‘normalising’ and ‘holistic care’ package.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0527-z) contains supplementary material, which is available to authorized users.

MATRICS cognitive consensus battery (MCCB) performance in children, adolescents, and young adults

BACKGROUND

Neurodevelopmental models of schizophrenia suggest that cognitive deficits may be observed during childhood and adolescence, long before the onset of psychotic symptoms. Elucidating the trajectory of normal cognitive development during childhood and adolescence may therefore provide a basis for identifying specific abnormalities related to the development of schizophrenia. The MATRICS Consensus Cognitive Battery (MCCB), which was designed for use in clinical trials targeting cognitive deficits most common in schizophrenia, may provide a mechanism to understand this trajectory. To date, however, there is no performance data for the MCCB in healthy children and adolescents. The present study sought to establish performance data for the MCCB in healthy children, adolescents, and young adults.

METHODS

The MCCB was administered to a community sample of 190 healthy subjects between the ages of 8 and 23years. All MCCB domain scores were converted to T-scores using sample means and standard deviations and were compared for significant performance differences between sex and age strata.

RESULTS

Analyses revealed age effects following quadratic trends in all MCCB domains, which is consistent with research showing a leveling off of childhood cognitive improvement upon approaching late adolescence. Sex effects after controlling for age only presented for one MCCB domain, with males exhibiting well-known spatial reasoning advantages.

CONCLUSIONS

Utilizing this performance data may aid future research seeking to elucidate specific deficits that may be predictive of later development of SZ.

Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses

BACKGROUND

We conducted a systematic review of incidence rates in England over a sixty-year period to determine the extent to which rates varied along accepted (age, sex) and less-accepted epidemiological gradients (ethnicity, migration and place of birth and upbringing, time).

OBJECTIVES

To determine variation in incidence of several psychotic disorders as above.

DATA SOURCES

Published and grey literature searches (MEDLINE, PSycINFO, EMBASE, CINAHL, ASSIA, HMIC), and identification of unpublished data through bibliographic searches and author communication.

STUDY ELIGIBILITY CRITERIA

Published 1950-2009; conducted wholly or partially in England; original data on incidence of non-organic adult-onset psychosis or one or more factor(s) pertaining to incidence.

PARTICIPANTS

People, 16-64 years, with first -onset psychosis, including non-affective psychoses, schizophrenia, bipolar disorder, psychotic depression and substance-induced psychosis.

STUDY APPRAISAL AND SYNTHESIS METHODS

Title, abstract and full-text review by two independent raters to identify suitable citations. Data were extracted to a standardized extraction form. Descriptive appraisals of variation in rates, including tables and forest plots, and where suitable, random-effects meta-analyses and meta-regressions to test specific hypotheses; rate heterogeneity was assessed by the I²-statistic.

RESULTS

83 citations met inclusion. Pooled incidence of all psychoses (N = 9) was 31.7 per 100,000 person-years (95%CI: 24.6-40.9), 23.2 (95%CI: 18.3-29.5) for non-affective psychoses (N = 8), 15.2 (95%CI: 11.9-19.5) for schizophrenia (N = 15) and 12.4 (95%CI: 9.0-17.1) for affective psychoses (N = 7). This masked rate heterogeneity (I²: 0.54-0.97), possibly explained by socio-environmental factors; our review confirmed (via meta-regression) the typical age-sex interaction in psychosis risk, including secondary peak onset in women after 45 years. Rates of most disorders were elevated in several ethnic minority groups compared with the white (British) population. For example, for schizophrenia: black Caribbean (pooled RR: 5.6; 95%CI: 3.4-9.2; N = 5), black African (pooled RR: 4.7; 95%CI: 3.3-6.8; N = 5) and South Asian groups in England (pooled RR: 2.4; 95%CI: 1.3-4.5; N = 3). We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported.

LIMITATIONS

Incidence studies were predominantly cross-sectional, limiting causal inference. Heterogeneity, while evidencing important variation, suggested pooled estimates require interpretation alongside our descriptive systematic results.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Incidence of psychotic disorders varied markedly by age, sex, place and migration status/ethnicity. Stable incidence over time, together with a robust socio-environmental epidemiology, provides a platform for developing prediction models for health service planning.

Integrated treatment to achieve functional recovery for first-episode psychosis

This study describes an integrated treatment approach that was implemented to enhance functional recovery in first-episode psychotic patients. Patients were randomized to two treatment conditions: either to an integrated treatment approach: pharmacotherapy, psychosocial treatment, and psychoeducation (experimental group: N = 39) or to medication alone (control group: N = 34). Patients were evaluated at baseline and after one year of treatment. Functional recovery was assessed according to symptomatic and functional remission. At the end of treatment, experimental patients showed a 94.9% of symptomatic remission compared to 58.8% of the control group. Functional remission was 56.4% for the experimental group and 3.6% for the control group, while 56.4% of the experimental group met both symptomatic and functional remission criteria and were considered recovered compared to 2.9% of the control group.

Affectively salient meaning in random noise: a task sensitive to psychosis liability

Stable differences in the tendency to attribute meaning and emotional value to experience may represent an indicator of liability to psychosis. A brief task was developed assessing variation in detecting affectively meaningful speech (speech illusion) in neutral random signals (white noise) and the degree to which this was associated with psychometric and familial vulnerability for psychosis. Thirty patients, 28 of their siblings, and 307 controls participated. The rate of speech illusion was compared between cases and controls. In controls, the association between speech illusion and interview-based positive schizotypy was assessed. The hypothesis of a dose-response increase in rate of speech illusion across increasing levels of familial vulnerability for psychosis (controls, siblings of patients, and patients) was examined. Patients were more likely to display speech illusions than controls (odds ratio [OR] = 4.0, 95% confidence interval [CI] = 1.4-11.7), also after controlling for neurocognitive variables (OR = 3.8, 95% CI = 1.04-14.1). The case-control difference was more accentuated for speech illusion perceived as affectively salient (positively or negatively appraised) than for neutrally appraised speech illusions. Speech illusion in the controls was strongly associated with positive schizotypy but not with negative schizotypy. In addition, the rate of speech illusion increased with increasing level of familial risk for psychotic disorder. The data suggest that the white noise task may be sensitive to psychometric and familial vulnerability for psychosis associated with alterations in top-down processing and/or salience attribution.

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

Summary

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

Declaration of Interests

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

Identifying at-risk states beyond positive symptoms: a brief task assessing how neurocognitive impairments impact on misrepresentation of the social world through blunted emotional appraisal

OBJECTIVE: Neurocognitive impairments observed in psychotic disorder may impact on emotion recognition and theory of mind, resulting in altered understanding of the social world. Early intervention efforts would be served by further elucidation of this mechanism. METHOD: Patients with a psychotic disorder (n=30) and a reference control group (n=310) were asked to offer emotional appraisals of images of social situations (EASS task). The degree to which case-control differences in appraisals were mediated by neurocognitive alterations was analyzed. RESULTS: The EASS task displayed convergent and discriminant validity. Compared to controls, patients displayed blunted emotional appraisal of social situations (B=0.52, 95% CI: 0.30, 0.74, P<0.001; adjusted for age, sex and number of years of education: B=0.44, 95% CI: 0.20, 0.68, P<0.001), a difference of 0.88 (adjusted: 0.75) standard deviation. After adjustment for neurocognitive variables, the case-control difference was reduced by nearly 75% and was non-significant (B=0.12, 95% CI: -0.14, 0.39, P=0.37). CONCLUSIONS: Neurocognitive impairments observed in patients with psychotic disorder may underlie misrepresentation of the social world, mediated by altered emotion recognition. A task assessing the social impact of cognitive alterations in clinical practice may be useful in detecting key alterations very early in the course of psychotic illness.

The structure of the extended psychosis phenotype in early adolescence--a cross-sample replication

The extended psychosis phenotype, or the expression of nonclinical positive psychotic experiences, is already prevalent in adolescence and has a dose-response risk relationship with later psychotic disorder. In 2 large adolescent general population samples (n = 5422 and n = 2230), prevalence and structure of the extended psychosis phenotype was investigated. Positive psychotic experiences, broadly defined, were reported by the majority of adolescents. Exploratory analysis with Structural Equation Modelling (Exploratory Factor Analysis followed by Confirmatory Factor Analysis [CFA]) in sample 1 suggested that psychotic experiences were best represented by 5 underlying dimensions; CFA in sample 2 provided a replication of this model. Dimensions were labeled Hallucinations, Delusions, Paranoia, Grandiosity, and Paranormal beliefs. Prevalences differed strongly, Hallucinations having the lowest and Paranoia having the highest rates. Girls reported more experiences on all dimensions, except Grandiosity, and from age 12 to 16 years rates increased. Hallucinations, Delusions, and Paranoia, but not Grandiosity and Paranormal beliefs, were associated with distress and general measures of psychopathology. Thus, only some of the dimensions of the extended psychosis phenotype in young people may represent a continuum with more severe psychopathology and predict later psychiatric disorder.

Neurobiology and phenotypic expression in early onset schizophrenia

AIM

Early-onset schizophrenia (onset before adulthood) is a rare and severe form of the disorder that shows phenotypic and neurobiological continuity with adult-onset schizophrenia. Here, we provide a synthesis of keynote findings in this enriched population to understand better the neurobiology and pathophysiology of early-onset schizophrenia.

METHODS

A synthetic and integrative approach is applied to review studies stemming from epidemiology, phenomenology, cognition, genetics and neuroimaging data. We provide conclusions and future directions of research on early-onset schizophrenia.

RESULTS

Childhood and adolescent-onset schizophrenia is associated with severe clinical course, greater rates of premorbid abnormalities, poor psychosocial functioning and increased severity of brain abnormalities. Early-onset cases show similar neurobiological correlates and phenotypic deficits to adult-onset schizophrenia, but show worse long-term psychopathological outcome. Emerging technological advances have provided important insights into the genomic architecture of early-onset schizophrenia, suggesting that some genetic variations may occur more frequently and at a higher rate in young-onset than adult-onset cases.

CONCLUSIONS

Clinical, cognitive, genetic and imaging data suggest increased severity in early-onset schizophrenia. Studying younger-onset cases can provide useful insights into the neurobiological mechanisms of schizophrenia and the complexity of gene-environment interactions leading to the emergence of this debilitating disorder.

Growth in young adults who screen positive for non-affective psychosis: birth cohort study

OBJECTIVE

While birth cohort studies have shown that individuals who develop non-affective psychosis show subtle deviations in cognitive and behavioural developmental trajectories, there is less evidence about deviations in physical growth in these individuals. The purpose of the present study was to examine the association between behaviour and growth and maturation from infancy, through childhood and adolescence to early adulthood and the development of non-affective psychosis in young adults.

METHOD

Based on a birth cohort of 3801 young adults, weight and length/height were examined at birth and at years 5, 14 and 21, together with pubertal maturation at year 14. Behavioural measures taken at years 5 and 14 were also examined. Screen-positive non-affective psychosis (SP-NAP) was assessed at year 21 using Composite International Diagnostic Interview, or a self-report checklist. The association between the behavioural and growth measures at birth and at years 5, 14 and 21, and SP-NAP at year 21 was examined using logistic regression.

RESULTS

There were 60 subjects in the cohort who were classified as having SP-NAP. In female subjects SP-NAP was significantly associated with being longer with a larger head circumference at birth, and less likely to be associated with being shorter at 21 years, with consistent trend associations for height between. There were no differences for weight. There was no significant association between the variables of interest in male subjects or for the total group. There was also no significant association between pubertal development at age 14 and risk of SP-NAP in either sex.

CONCLUSIONS

Unlike developmental behavioural problems, which showed continuity from childhood through adolescence, SP-NAP was not associated with marked deviations in growth trajectory for male subjects, but the present data suggests that female subjects with SP-NAP had an altered skeletal growth trajectory.

Public health implications of altered puberty timing

Changes in puberty timing have implications for the treatment of individual children, for the risk of later adult disease, and for chemical testing and risk assessment for the population. Children with early puberty are at a risk for accelerated skeletal maturation and short adult height, early sexual debut, potential sexual abuse, and psychosocial difficulties. Altered puberty timing is also of concern for the development of reproductive tract cancers later in life. For example, an early age of menarche is a risk factor for breast cancer. A low age at male puberty is associated with an increased risk for testicular cancer according to several, but not all, epidemiologic studies. Girls and, possibly, boys who exhibit premature adrenarche are at a higher risk for developing features of metabolic syndrome, including obesity, type 2 diabetes, and cardiovascular disease later in adulthood. Altered timing of puberty also has implications for behavioral disorders. For example, an early maturation is associated with a greater incidence of conduct and behavior disorders during adolescence. Finally, altered puberty timing is considered an adverse effect in reproductive toxicity risk assessment for chemicals. Recent US legislation has mandated improved chemical testing approaches for protecting children's health and screening for endocrine-disrupting agents, which has led to changes in the US Environmental Protection Agency's risk assessment and toxicity testing guidelines to include puberty-related assessments and to the validation of pubertal male and female rat assays for endocrine screening.

Pathophysiology of early onset schizophrenia

Early onset schizophrenia (with onset before adulthood) represents a rarer and possibly more severe form of the disorder which has received particular attention in the last two decades. Current evidence strongly suggest continuity with adult onset schizophrenia, with phenomenological, cognitive, genetic and neuroimaging data pointing towards similar neurobiological correlates and clinical deficits but worse long term outcome. Future research in early onset cases is likely to increase further our insight into the neurodevelopmental origins of schizophrenia and the complex gene-environment interactions affecting its emergence.

Relationship between estrogen and schizophrenia

There is a wealth of historical and circumstantial evidence to suggest that female patients with schizophrenia may suffer from a deficit in estrogenic function. The prolactin-inducing properties of most antipsychotic drugs, and subsequent negative feedback on estrogen levels, is in keeping with this. The functions of estrogen, its complex receptor organization and its numerous actions are the focus of ongoing research activity. Of particular interest are its neuroprotective properties, particularly with regard to cognitive impairment, and its involvement with neurotransmitter systems, which are the substrate for psychotropic drugs. Estrogen has now been used as an adjunct to standard antipsychotic medication in quite a few studies of female schizophrenia patients. However, most of these are not double-blind, randomized, controlled trials. Only two relatively small double-blind, randomized clinical trials returned positive results: one long-term study that selected for hypoestrogenism reported negative findings. Furthermore, recent evidence of the risks of long-term hormone replacement therapy is of concern. The advent of specific estrogen receptor modulators, which may avoid excess risks of cancer and cardiovascular events, will have little to add to schizophrenia treatment if estrogen is, essentially, devoid of any specific antipsychotic or adjuvant mechanism of action relevant to the pathophysiology of this disorder.

Sex differences in the relationship between white matter microstructure and impulsivity in adolescents

Rapid maturational brain changes occur during adolescence--a time associated with risk-taking behaviors and improvements in cognition. The present study examined the relationship between white matter (WM) microstructure, impulsive behavior and response inhibition in female and male adolescents. Twenty-one healthy adolescents underwent diffusion tensor imaging using a 3.0-T magnetic resonance imaging system. Impulse control was assessed using the Bar-On Emotional Quotient Inventory, Youth Version. Response inhibition was assessed using the Stroop Color-Word Interference Test. Fractional anisotropy (FA), a measure of WM coherence, and trace, a measure of overall diffusivity, were determined from voxels manually placed in the midline and in the left and right forward-projecting arms of the genu and the splenium of the corpus callosum. Sex-specific differences were observed for the relationship between FA and impulsive behavior in the right anterior callosum for males and in the splenium for females. Males, compared to females, displayed significantly higher FA in the left WM region. Although trace was not associated with impulse control, trace in the genu (for females) and splenium (males and females) was associated with Stroop performance. Regional differences in trace also were evident, with lower values in the splenium observed than in all other regions. Although the latter significantly improved with age, no sex differences in impulse control or in Stroop performance were detected. The present findings provide supporting evidence for sex-related differences in the development of WM microstructure during adolescence. These data further suggest a neurobiological mechanism underlying some of the emotional and cognitive changes commonly observed in males versus females during the adolescent period.

Childhood victimisation and developmental expression of non-clinical delusional ideation and hallucinatory experiences: victimisation and non-clinical psychotic experiences

BACKGROUND

Victimisation in childhood may be associated with adult psychosis. The current study examined this association in the crucial developmental period of early adolescence and investigated whether (1) unwanted sexual experiences, and (2) being bullied, were associated with non-clinical delusional ideation and hallucinatory experiences in a general population sample of 14 year olds.

METHODS

Data were derived from standard health screenings of the Youth Health Care Divisions of the Municipal Health Services in Maastricht, the Netherlands. A self-report questionnaire was filled out by a total of 1290 adolescents to assess non-clinical psychotic experiences, as well as experiences of being bullied and sexual trauma.

RESULTS

Non-clinical psychotic experiences were strongly and independently associated with both bullying (OR=2.9, 95% CI 1.8-4.8) and sexual trauma (OR=4.8, 95% CI 2.3-10.1).

CONCLUSIONS

The results suggest that reported associations between childhood victimisation and adult psychosis can be understood in a developmental framework of onset of at-risk mental states in early adolescence. In addition, the data suggest that the traumatic experience of being bullied may also feed the cognitive and biological mechanisms underlying formation of psychotic ideation.

Associations between delusion proneness and personality structure in non-clinical participants: comparison between young and elderly samples

BACKGROUND

Few studies have explored the prevalence of delusions in the non-clinical, elderly population. In addition, the association between personality structure and delusions remains poorly investigated. The aims of the present study were, first, to explore the relation between age and the prevalence of delusion proneness and, second, to examine the association between personality and delusion proneness in young and elderly participants.

SAMPLING AND METHODS

A sample of young (n = 343; aged 18-30 years) and elderly (n = 183; aged 60-75 years) non-clinical participants completed the 21-item version of the Peters et al. Delusions Inventory (PDI-21), an elaborated and validated version of the Launay-Slade Hallucinations Scale, and the revised version of the NEO Personality Inventory (NEO-PI-R).

RESULTS

Mean scores on the PDI-21 for the young and elderly participants were compared. An independent t test revealed that the total mean scores were significantly higher for young participants compared to elderly participants. PDI-21 items were then re-grouped into previously validated factors. Independent t tests revealed that young participants had significantly higher scores for items related to suspiciousness and persecutory ideas, thought disturbances and jealousy, grandiose ideas, paranormal beliefs and apocalyptic ideas. In contrast, elderly participants scored significantly higher than young participants on the religious ideation factor. Associations between scores on the NEO-PI-R and the PDI-21 were then examined for the two groups. For the young sample, correlational analyses revealed a significant relationship between the total score on the PDI-21 and scores on the openness, neuroticism and agreeability facets of the NEO-PI-R. For the elderly sample, correlational analyses revealed a significant relationship between the total score on the PDI-21 and the openness facet of the NEO-PI-R.

DISCUSSION

Results from the study reveal that delusional ideation is a relatively common experience for both young and elderly non-clinical participants. In addition, findings are in line with studies suggesting that neuroticism and aspects related to neuroticism increase the risk for the development of psychotic symptoms such as delusions. However, it is important to mention that, because the present study includes non-clinical subjects and is a cross-sectional study, more research is needed.

Cumulative exposure to estrogen and psychosis: a peak bone mass, case-control study in first-episode psychosis

The organizational structural effects of estrogen may be cumulative and permanent by impacting on neurodevelopment, giving rise to "neuroprotective" effects and eventually reduction of psychosis risk. Reduction in bone mineral density (BMD, in g/cm2), as a biological marker of reduced cumulative exposure to estrogen, may be a marker of increased psychosis risk. A sample of 19 first-episode female psychosis patients with minimal previous antipsychotic exposure (mean 10 weeks) and 20 female controls underwent advanced fan-beam dual X-ray absorptiometry (DXA) to assess lumbal spine BMD of the region of L1-L4. Mean BMD was around one standard deviation lower in patients (1.13, S.D.=0.10) than in controls (1.25, S.D.=0.12; p=0.0021), and 84% of patients scored below the median value of the controls (OR=5.3, 95% CI: 1.2, 24.2). The results are compatible with the hypothesis that psychosis in women may be associated causally with a reduced protective effect of estrogen over the course of development.

Influence of diagnostic classification on gender ratio in schizophrenia - a meta-analysis of youths hospitalized for psychosis

BACKGROUND

The research literature on hospital admissions for psychoses in youths was reviewed in order to test whether there was a gender ratio discrepancy in diagnostic subgroups; the effect of the diagnostic criteria classification on this measure was also investigated.

METHOD

A meta-analysis was conducted on 12 primary studies by assessing the male/female odds ratio (OR) in the schizophrenia and mood disorders with psychosis subgroups as well as the amount of variability between studies. Study inclusion criteria were: patients between the ages of 8 and 19, at least 15 patients with psychosis and a standardized diagnostic criteria classification system such as DSM, ICD or RDC.

RESULTS

The male/female OR measured in this meta-analysis implies that a male subject with psychosis is 1.7 times as likely to obtain a diagnosis of schizophrenia; conversely, a female subject with psychosis is 2.1 times as likely to be assigned in the mood disorders with psychosis subgroup. Disparity in diagnostic criteria nomenclature (ICD-9 vs. DSM) could account for a statistically significant difference in male/female OR for the schizophrenia subgroup in a subset of 11 studies.

CONCLUSIONS

Under the narrower definition of schizophrenia in studies using DSM diagnostic criteria classification, the shift towards a greater proportion of patients diagnosed with mood disorders with psychosis could be explained by the time criteria; the simultaneous emergence of the gender ratio difference is discussed. This study shows that subtle changes in diagnostic criteria in psychiatric illnesses can greatly influence observational data pertaining to youths.

The role of age in the development of Schneiderian symptoms in patients with a first psychotic episode

OBJECTIVE

The likelihood of developing psychotic symptoms greatly increases after puberty. In acute psychotic disorders, first rank symptoms (FRS) are prevalent and considered useful for the diagnostic process. The aim of this study was to test for a linear association between age and the probability of occurrence of FRS in patients with a first psychotic episode (FPE).

METHOD

A total of 112 patients, consecutively admitted with an FPE, were included at baseline and evaluated yearly over a 3-year period using SCID-I and a checklist of 11 items of FRS.

RESULTS

FRS were documented for 65.2% patients at baseline. There was a dose-response relationship in the association between age and FRS. There was no interaction with sex or with final diagnostic category.

CONCLUSION

Variation in the expression of the core positive symptoms of psychosis is subject to the influence of underlying age-dependent maturational processes both in terms of occurrence and level of severity.

Estrogen receptor gene expression in relation to neuropsychiatric disorders

Compelling evidence now exists for estrogen's involvement in the regulation of mood and cognitive functions. Serum estrogen levels have been shown to play an important role in the expression of psychiatric disorders such as depression and schizophrenia. We have characterized the distribution of the estrogen receptors, ERalpha and ERbeta, in the human brain and showed a preferential limbic-related expression pattern for these transcripts. The ERalpha mRNA dominates in the amygdala and hypothalamus, suggesting estrogen modulation of autonomic and neuroendocrine as well as emotional functions. In contrast, the hippocampal formation, entorhinal cortex, and thalamus appear to be ERbeta-dominant areas, suggesting a role for ERbeta in cognition, non-emotional memory, and motor functions. The role of estradiol can also be examined in regard to its relationship to other neurotransmitter systems known to be linked to specific psychiatric disorders. Estradiol has been shown to regulate the serotonin (5-HT) system, which has been strongly implicated in affective disorders. We have studied a genetic animal model of depression, and found altered 5-HT receptor mRNA levels in discrete brain regions; many of the abnormalities are reversed by estradiol treatment, especially for the 5-HT(2A) receptor subtype. The norepinephrine (NE) system is, similar to serotonin, a target for antidepressant drugs, and projects to mesocorticolimbic structures implicated in mood disorders. We have recently observed that NE neurons in the human locus coeruleus (LC) express moderate levels of both ER transcripts. The possibility of estrogen's regulating LC function has been documented in animal studies. Results from our preliminary experiments have revealed that the ERbeta mRNA is decreased in persons committing suicide, a cause of death that is highly linked to affective disorder. Follow-up studies are currently under way with a much larger population to validate these results. Overall, the discrete anatomical organization of the ER mRNAs in the human brain provide evidence as to the specific neuronal populations in which the actions of ERs could modulate mood and thus underlie the neuropathology of psychiatric disorders such as depression.

Sex differences in psychosis: normal or pathological?

BACKGROUND

Schizophrenia first appears in adolescence, in boys at an earlier age than girls. The interpretation of this key epidemiological finding crucially depends on whether similar age-related sex differences exist in the expression of associated, subclinical psychosis-like experiences.

METHODS

Findings are based on a population sample of 2548 adolescents and young adults aged 17-28. Subjects were assessed with the core psychosis sections on delusions and hallucinations of the Munich-Composite International Diagnostic Interview.

RESULTS

The risk of subclinical psychotic experiences was significantly higher for males in the younger half of the cohort (17-21 years), but similar in the older half (22-28 years).

CONCLUSIONS

These findings suggest that normal maturational changes in adolescence with differential age of onset in boys and girls cause the expression of psychosis, the extreme of which is schizophrenia.

Independent course of childhood auditory hallucinations: a sequential 3-year follow-up study

BACKGROUND

Childhood hallucinations of voices occur in a variety of contexts and have variable long-term outcomes.

AIM

To study the course of experience of voices sequentially over a 3-year period in those with and those without a need for mental health care (patient status).

METHOD

In a group of 80 children of mean age 12.9 years (s.d. = 3.1), of which around 50% were not receiving mental health care, baseline measurement of voice characteristics, voice attributions, psychopathology, stressful life events, coping mechanisms and receipt of professional care were used to predict 3-year course and patient status.

RESULTS

The rate of voice discontinuation over the 3-year period was 60%. Patient status was associated with more perceived influence on behaviour and feelings and more negative affective appraisals in relation to the voices. Predictors of persistence of voices were severity and frequency of the voices, associated anxiety/depression and lack of clear triggers in time and place.

CONCLUSIONS

Need for care in the context of experience of voices is associated with appraisal of the voices in terms of intrusiveness and 'omnipotence'. Persistence of voices is related to voice appraisals, suggesting that experience of voices by children should be the target of specific interventions.

The role of estrogen in schizophrenia: implications for schizophrenia practice guidelines for women

OBJECTIVE

The objective of this paper is to integrate what is known about estrogen effects on symptoms and treatment response into a global understanding of schizophrenia. The aim is to expand Canadian schizophrenia guidelines to include the specific needs of women.

METHOD

We searched the Medline database; keywords included estrogen, estrogen replacement therapy, schizophrenia, psychosis, treatment, tardive dyskinesia (TD), and women. We examined reference lists from relevant articles to ensure that our review was complete. We review the evidence for the effects of estrogen in schizophrenia and we make recommendations for the next revision of official practice guidelines.

RESULTS

The epidemiologic evidence suggests that, relative to men, women show an initial delay in onset age of schizophrenia, with a second onset peak after age 44 years. This points to a protective effect of estrogen, confirming animal research that has documented both neurotrophic and neuromodulatory effects. Clinical research results indicate that symptoms in women frequently vary with the menstrual cycle, worsening during low estrogen phases. Pregnancy is often, though not always, a less symptomatic time for women, but relapses are frequent postpartum. Some work suggests that in the younger age groups women require lower antipsychotic dosages than men but that following menopause they require higher dosages. Estrogen has been used effectively as an adjunctive treatment in women with schizophrenia. Estrogen may also play a preventive role in TD.

CONCLUSIONS

Symptom evaluation and diagnosis in women needs to take hormonal status into account. Consideration should be given to cycle-modulated neuroleptic dosing and to careful titration during pregnancy, postpartum, and at menopause. We recommend that discretionary use of newer neuroleptic medication and adjuvant estrogen therapy be considered.

A neuroactive steroid, pregnenolone, alters the striatal dopaminergic tone before and after puberty

Neuroactive steroids are known to modulate excitability in neurons. Neuronal activity during early development is critical to normal development of the brain. A neuroactive steroid, pregnenolone, was administered (10 microg/g) to rats from postnatal day 3 (PD 3) through PD 7. Dopamine (DA), serotonin (5-HT) and their metabolites were measured in the striatum. The results showed that neonatal treatment with pregnenolone increases DA and 5-HT turnover in the striatum at 3 weeks of age. The increased 5-HT turnover in the pregnenolone-treated animals was normalized at 14 weeks of age whereas the DA turnover in the pregnenolone-treated group was lower than in the control group. The present study indicated that pregnenolone treatment during the neonatal period induced abnormal development of the striatal dopaminergic function in adulthood.

Childhood-onset schizophrenia: research update

This review is a research update of recent literature related to childhood-onset schizophrenia (onset of psychotic symptoms by age 12 years). This subgroup of patients has attracted considerable research interest because patients with a childhood onset may represent a more homogeneous patient population in which to search for risk or etiologic factors. We examine data indicating that childhood-onset schizophrenia (COS) shares the same clinical and neurobiologic features as later-onset forms of the disorder. Compared with adults with schizophrenia, however, this subgroup of patients appears to have more severe premorbid neuro-developmental abnormalities, more cytogenetic anomalies, and potentially greater family histories of schizophrenia and associated spectrum disorders. While preliminary, these data indicate that a greater genetic vulnerability may be one of the underpinnings of COS. Future studies of this subgroup may provide important clues as to the genetic basis for schizophrenia and how gene products influence certain features of the disease, such as age of onset and mode of inheritance.

The continuity of psychotic experiences in the general population

Schizophrenia is a severe mental illness that affects 1% of the population. The diagnosis is made according to current diagnostic systems of DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health Association, 1992) on the basis of characteristic 'positive' and 'negative' symptoms. The traditional medical model assumes a categorical view of the schizophrenia syndrome and its core symptoms, in which differences between psychotic symptoms and their normal counterparts are considered to be qualitative. An alternative, dimensional approach assumes that schizophrenia is not a discrete illness entity, but that psychotic symptoms differ in quantitative ways from normal experiences and behaviours. This paper reviews evidence for the continuity of psychotic symptoms with normal experiences, focusing on the symptoms of hallucinations and delusions. It concludes by discussing the theoretical and treatment implications of such a continuum.

Psychotic and mood disorders associated with the perimenopausal period: epidemiology, aetiology and management

Contrary to widely held beliefs, menopause is not associated with an increase in psychiatric illness. Although just prior to menopause there is a slight increase in minor psychological symptoms, prevalence rates of depression fall postmenopause. Hypotheses for the occurrence of depression in some perimenopausal women include: a pre-existing sensitivity to the change in the gonadal hormones leading to decreases in neural transmitters; reactions to the physiological changes associated with menopause such as night sweats, or the influence of a multitude of negative attitudes and expectations concerning menopause. The loss of the protective effects of estrogen may be related to the slight increase in the incidence of schizophrenia in women at menopause. The role of hormone replacement therapy (HRT) in treating psychiatric symptoms remains poorly understood. In nondepressed women, HRT may improve well-being either as a direct effect or as a consequence of reduced physical symptoms and fear of aging. In women with moderate to severe depressions, HRT alone does not appear to be beneficial. HRT may have some beneficial effects on short term memory. More research is needed to assess the possible role of HRT in augmenting the effects of antidepressant and antipsychotic medications.

Estrogen receptors in the human forebrain and the relation to neuropsychiatric disorders

The steroid hormone estrogen influences brain function and neuropsychiatric disorders, but neuroanatomical information about the estrogen receptors (ERs) are rather limited. The main focus of this article is to provide an overview of the current status of the ER distribution and possible function in the human brain. The ERs are ligand activated transcription factors that belong to the steroid hormone receptors, included in the nuclear receptor superfamily. To date, there are two known ER subtypes, alpha and beta. In the human forebrain, both estrogen receptor subtypes are predominantly expressed in limbic-related areas, although they show distinct distribution patterns. The ERalpha mRNA expression appears to dominate in the hypothalamus and amygdala, indicating that the alpha-subtype might modulate neuronal cell populations involved in autonomic and reproductive neuroendocrine functions as well as emotional interpretation and processing. In contrast, the hippocampal formation, entorhinal cortex, and thalamus appear to be ERbeta dominant areas, suggesting a putative role for ERbeta in cognition, non-emotional memory and motor functions. Clinical observations of estrogenic effects together with the information available today regarding ER expression in the primate brain provide important clues as to the functional aspects of the two ER subtypes. However, further characterization of the different phenotypes of the ER expressing cells in the human brain is needed as well as the delineation of the genes which are regulated by the ERs and how this transcriptional control correlates with human behavior and mental status.

Relationship between sex differences in onset of schizophrenia and puberty

Some neurodevelopmental hypotheses of schizophrenia have postulated that sex differences in onset of illness could be explained by sexual dimorphism in onset of puberty, suggesting that early maturation accounts for the later onset of illness in women. The objective of this study was to analyse the relationship between age of menarche and age of onset of schizophrenia in a sample of Chilean patients. The medical records of 105 schizophrenic women diagnosed according to DSM-III-R criteria were studied. In all cases age of onset (first psychotic symptoms) and age of menarche were obtained. Pearson's correlation and student's t-test were used to analyse the data. The mean age of menarche in the sample of female patients (12. 98 years, S.D.=1.49) was significantly different from that of the general population of Santiago, Chile (12.53 years, S.D.=1.32) (t=2. 38; P<0.05). The mean age of onset of schizophrenia in female patients (19.92 years, S.D.=5.13) was significantly earlier in the Chilean sample than that reported in European and North American samples (P<0.05). No differences were observed when comparing the mean age at menarche. The subtypes with the earliest onset presented the earliest age of menarche and the subtypes with the latest onsets showed the latest ages at menarche. However, no correlation was observed between the age at onset of illness and the age at menarche, both in the total sample and in the analysis by subtype. The results of this study do not support a correlation between puberty and age of onset of illness.

Developmental instability and schizotypy

INTRODUCTION

It has been suggested that evidence of developmental disturbance of cognition and lateralisation in schizophrenia can be best understood from the perspective of developmental stability (DS), an indicator of the extent to which an individual develops according to a specified ontogenic programme in the presence of environmental noise. Higher levels of fluctuating asymmetry (FA; the difference between right and left side of a quantitative morphological trait such as dermatoglyphics) are thought to reflect less DS. We examined this issue for dimensions of schizotypy.

METHODS

Associations between FA, measures of laterality and cognitive function on the one hand, and negative and positive dimensions of schizotypy on the other, were examined in a sample of 260 healthy adolescents aged 11.9-15.6years. FA was measured as a-b ridge count right-left differences. Neuropsychological measures yielded a general cognitive ability score and a frontal function score. Laterality was assessed with the Annett scale.

RESULTS

Measures of psychosis proneness were normally distributed. Negative schizotypy was associated with more FA and lower general cognitive ability in a dose-response fashion. The association with FA was more apparent in boys. No associations existed with laterality or frontal function.

CONCLUSION

The negative dimension of schizotypy may be associated with early developmental instability, resembling the pattern seen in the negative symptom dimension of schizophrenia. Measures of fluctuating asymmetry may be more sensitive with regard to the schizotypy phenotype than measures of laterality.

The age of onset of schizophrenia and the theory of anticipation

The clinical phenomenon called anticipation is usually defined as a decrease in age at onset and/or an increase in disease severity in successive generations of afflicted families. The purpose of this study was to examine variables that might influence anticipation in schizophrenia. A total of 380 Austrian patients, born between 1935 and 1964, met criteria for schizophrenia with ICD-8 or ICD-9, SADS-L and DSM-III-R criteria. The inclusion criteria also required medical records of patients to contain information about the year of birth, season of birth, age at onset, accidents or meningoencephalitic diseases during childhood, first- and second-degree relatives afflicted with schizophrenia, sibship size, sib order, education of patient, age of parents, occupation of parents, loss of parents, and place of residence. A Cox multiple-regression analysis showed three factors as having a significant influence on the age of disease onset, including year of birth (which had the largest influence), family history (sporadic cases showed an onset 2 years later than familial cases) and residence (urban dwellers showed psychotic symptoms approximately 1 year sooner than rural ones). A Kaplan-Meier Survival Analysis showed that younger cohorts had onset approximately 10 years earlier in sporadic and familial cases. This cohort effect might be a major source of bias in studies of anticipation.

The ESSEN study of childhood-onset schizophrenia: selected results

INTRODUCTION

We present the results of a 42 year long-term follow-up of 44 patients (19 males, 25 females) with childhood-onset schizophrenia (COS, age at onset: 7-14 years) who could be traced for a second follow-up examination 27 years after the first follow-up.

METHOD

Data from interviews, clinical records, premorbid and social disability assessments were evaluated for statistical analyses. The symptomatology observed during the whole course of illness was rediagnosed by DSM-IV criteria.

RESULTS

The paranoid, catatonic, and schizoaffectives subtypes appeared most frequently. There have been no gender differences in age of first psychiatric symptoms (AFS), AFPS, and age of first hospitalization. Kaplan-Meier's survival-analysis carried out for AFPS with sex as the grouping factor revealed that the cumulative prevalence appears to be earlier in females (between 7 and 15 years) than in males (between 10 and 18 years). Of the 44 patients 50 % had a continuing severe course. Patients with onset before 12 years of age were characterized by a chronic/insidious onset, marked premorbid abnormalities, and by a poorer remission. Premorbid features of social withdrawal and reluctance indicated a risk for social disability within the later course.

CONCLUSION

COS, as a rare but severe variant of schizophrenia, frequently develops from premorbid social maladaptation to an insidious onset but is subsequently followed by a transition to a course and outcome not distinguishable from that of adult-onset schizophrenia.

Is early adulthood a critical developmental stage for psychosis proneness? A survey of delusional ideation in normal subjects

It has been hypothesized that late adolescence and early adulthood might be a brain developmental stage favoring the clinical expression of psychotic symptoms in psychiatric or neurological diseases. The aim of the present survey was to examine the relationship between age and delusional ideation in a sample of subjects with no psychiatric disorder. The survey was carried out with the Aquitaine Sentinel Network of general practitioners. Consecutive practice attenders were invited to complete the PDI-21 (Peters Delusional Inventory 21 items), a self-report questionnaire designed to measure delusional ideation in the normal population. The study concerned 444 patients who had no lifetime history of psychiatric disorder and who completed the PDI-21. A principal component analysis of the PDI-21 items was performed in order to identify delusional dimensions. An age-related decrease in the likelihood to report delusional ideas was found, younger subjects scoring higher on most dimensions of delusional ideation, such as 'persecution', 'thought disturbance', 'grandiosity' and 'paranormal beliefs'. 'Religiosity' was the only dimension positively associated with age. The results suggest that there may be a physiological neurodevelopmental stage favouring the expression of psychosis proneness in normal subjects, and support the hypothesis that the association between age and positive psychotic symptoms in functional and organic psychoses may be linked to the interaction between normal brain maturational processes and cerebral abnormalities involved in the aetiology of functional and organic psychoses.

Pubertal development and onset of psychosis in childhood onset schizophrenia

In this study, pubertal development was examined for a sample of children and adolescents with childhood onset schizophrenia (COS) defined as psychosis by age 12. Developmental and psychiatric histories were obtained for 28 adolescents (mean age 14.5 +/- 2.3 years) with severe, treatment refractory COS (14 males, 14 females). Age of onset of psychosis was also examined in relation to menarche and development of secondary sex characteristics. Girls had a trend towards developing secondary sex characteristics earlier than boys (P = 0.06), consistent with North American norms. Males (N = 14) and females (N = 14) had similar age of onset of psychosis. The age of development of secondary sex characteristics was associated with onset of psychosis for girls, but this finding was driven by one outlier. There was no significant correlation between development of psychosis and menarche. Neither male nor female probands differed significantly from their well siblings or from North American norms in their age of onset of pubertal development. There was no evidence of early onset of secondary sex characteristics for this sample. Finally, there was an absence of a clear relationship between onset of psychosis and indices of sexual development for these very early onset cases.

Incorporating lag effects in register-based age-of-onset distributions in schizophrenia

Epidemiological studies often use age-of-first-admission from psychiatric case registers to estimate age-of-onset in schizophrenia. Retrospective, interview-based methods have shown that there is a delay between onset of symptoms and eventual contact with psychiatric services, and that this delay can vary both among individuals and at different ages. This delay or lag can confound the interpretation of first admission data such as age-of-onset. To evaluate the potential impact of this factor, we constructed a flexible mathematical model which integrates age-at-first-admission with estimates of this lag, which were derived from interview-based studies and clinical judgement. We applied this model to age-of-first-admission data for 4218 patients with ICD8/9 schizophrenia drawn from a state-wide psychiatric register. Both the raw age-of-first-admission distribution curve and the transformed data ('estimated age-of-onset') reinforce previous findings that (a) there is a wide range of age-of-onset and (b) the shapes of the curves differ between the sexes. Inspection of the mathematically derived distribution supports the proposition that (a) transformation for a lag effect produces a lower onset age and (b) including a variable length of lag produces a change in shape of the distribution. We propose that the mathematical transformation of age-of-first-admission data may have heuristic value, but requires further empirical data on which to base the assumptions of the model.