EPA guidance on the early detection of clinical high risk states of psychoses

Genome-wide association exploratory studies in individuals with ultra-high risk for schizophrenia in Chinese Han nationality in two years follow-up: A subpopulation study

BACKGROUND

Although ultra-high risk for schizophrenia (UHR) is related to both genetic and environment factors, the precise pathogenesis is still unknow. To date, few studies have explored the Genome-Wide Association Studies (GWAS) in UHR or HR individuals especially in Han population in China.

METHODS

In this study, a GWAS analysis for 36 participants with UHR and 43 with HR were performed, and all deletion variations in 22q11 region were also compared.

RESULTS

Sixteen individuals with UHR (44.4%) and none with HR converted into schizophrenia in follow-up after two years. Six loci including neurexin-1(NRXN1) (rs1045881), dopamine D1 receptor (DRD1) (rs686, rs4532), chitinase-3-like protein 1 (CHI3L1) (rs4950928), velocardiofacial syndrome (ARVCF) (rs165815), dopamine D2 receptor (DRD2) (rs1076560) were identified higher expression with significant difference in individuals converted into schizophrenia after two years. The Family with Sequence Similarity 230 Member H (FAM230H) gene in the 22q11 region were also found high expression in UHR group.

CONCLUSIONS

Further expansion of sample size and validation studies are needed to explore the pathogenesis of these risk loci in UHR conversion into schizophrenia in the future.

[Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders]

Ethical Considerations of Including Minors in Clinical Trials Using the Example of the Indicated Prevention of Psychotic Disorders Abstract: As a vulnerable group, minors require special protection in studies. For this reason, researchers are often reluctant to initiate studies, and ethics committees are reluctant to authorize such studies. This often excludes minors from participating in clinical studies. This exclusion can lead to researchers and clinicians receiving only incomplete data or having to rely on adult-based findings in the treatment of minors. Using the example of the study "Computer-Assisted Risk Evaluation in the Early Detection of Psychotic Disorders" (CARE), which was conducted as an 'other clinical investigation' according to the Medical Device Regulation, we present a line of argumentation for the inclusion of minors which weighs the ethical principles of nonmaleficence (especially regarding possible stigmatization), beneficence, autonomy, and fairness. We show the necessity of including minors based on the development-specific differences in diagnostics and early intervention. Further, we present specific protective measures. This argumentation can also be transferred to other disorders with the onset in childhood and adolescence and thus help to avoid excluding minors from appropriate evidence-based care because of insufficient studies.

Cognitive disturbances basic symptoms in help-seeking patients with borderline personality disorder: Characteristics and association with schizotypy

AIM

Although the presence of psychotic symptoms has been widely recognized in Borderline Personality Disorder (BPD), no study previously investigated cognitive Basic Symptoms (BS) and their clinical implications in patients with BPD.

METHODS

This cross-sectional study specifically examined the prevalence of COGDIS (cognitive disturbances) BS criteria in 93 help-seeking outpatients with BPD by using the Schizophrenia Proneness Instrument-Adult Version (SPI-A). We then explored associations of COGDIS with personality traits, functioning and core psychopathological features of BPD.

RESULTS

The prevalence rates of COGDIS criterion were 62.4%. BPD patients meeting COGDIS criteria reported higher levels of schizotypal personality traits, dissociative experiences and work/social functional impairment compared to individuals without COGDIS criteria. Furthermore, the number of cognitive BSs showed a positive correlation with severity levels of schizotypy.

CONCLUSIONS

Cognitive BS are common in BPD. Cognitive disturbances are associated with schizotypal personality traits and specific clinical features. The presence of cognitive BSs may identify a more severe subgroup of patients with BPD, potentially vulnerable to psychotic symptoms and reliably identifiable through assessment of schizotypal traits.

Developmental changes in the endorsement of psychotic-like experiences from middle childhood through young adulthood

BACKGROUND

Children tend to endorse psychotic-like experiences (PLEs) at higher rates than adults, although little is known about how specific symptom endorsement changes across the span of development. Here we take an observational approach to examine trends in PLE endorsement by age in two non-clinical samples: one of school-aged children and another of late adolescents and early adults.

METHODS

Prodromal Questionnaire-Brief (child and adult versions) responses were investigated in individuals ages 9-13 (n = 11865) and 16-24 (n = 3209) from the Adolescent Brain and Cognitive Development Study (ABCD) and the Multisite Assessment of Psychosis-risk Study (MAP), respectively. Item-level endorsement and distressing item frequencies were examined by age throughout both cohorts.

RESULTS

Unusual perceptual experiences were generally endorsed more heavily in childhood, while other PLEs were endorsed in adolescents and adults up to 4.8 times more frequently than in children. Additionally, certain experiences were endorsed by as many as 73 percent of the older sample.

CONCLUSIONS

Considerations for the measurement of PLEs in childhood and adolescence are underscored. Findings from these two samples provide a window into the course of these PLEs and may serve as a scaffold for future research investigating normative versus risk-related experiences during development.

Clinical and neurodevelopmental predictors of psychotic disorders in children and adolescents at clinical high risk for psychosis: the CAPRIS study

BACKGROUND

The neurodevelopmental hypothesis of schizophrenia represents the disorder as an expression of an alteration during the brain development process early in life. Neurodevelopmental variables could become a trait marker, and the study of these variables in children and adolescents at clinical high risk for psychosis (CHR) could identify a specific cluster of patients who later developed psychosis. The aim of this study is to describe clinical and neurodevelopment predictors of transition to psychosis in child and adolescent participants at CHR. Naturalistic longitudinal two-center study of 101 CHR and 110 healthy controls (HC) aged 10-17. CHR participants were children and adolescents aged 10-17, meeting one or more of the CHR criteria assessed at baseline and at 18 months' follow-up. Neurodevelopmental variables assessed were obstetric complications, delay in principal development milestones, and presence of a neurodevelopment diagnosis. Pairwise comparisons, linear regressions, and binary logistic regression were performed.A transition rate of 23.3% at 1.5 years was observed. Participants who developed psychosis (CHR-P) showed higher rates of grandiosity and higher proportions of antipsychotic medication intake at baseline compared to participants who did not develop a psychotic disorder (CHR-NP). In terms of neurodevelopment alterations, CHR-P group showed a higher proportion of participants reporting delay in language development than the CHR-NP and HC groups. The odds of psychosis increased by 6.238 CI 95% [1.276-30.492] for a one-unit increase in having a positive score in grandiosity; they increased by 4.257 95% CI [1.293-14.023] for a one-unit increase in taking antipsychotic medication, and by 4.522 95% [1.185-64.180] for showing language development delay. However, the p-values did not reach significance after adjusting for multiple comparisons.A combination of clinical and neurodevelopmental alterations could help predict the transition to psychotic disorder in a CHR child and adolescent sample. Our results suggest the potential utility of collecting information about neurodevelopment and using these variable multifactorial models to predict psychosis disorders.

Clinical high risk state of major depressive episodes: Assessment of prodromal phase, its occurrence, duration and symptom patterns by the instrument the DEpression Early Prediction-INventory (DEEP-IN)

BACKGROUND

To decrease the incidence of major depressive episodes, indicated prevention that targets clinical high-risk individuals with first detectable signs that forecast mental disorder is a highly relevant topic of preventive psychiatry. Still little is known about the prodrome of MDE. The aim of the current study was to identify the occurrence of a clinical high-risk state of depression, its duration and symptom constellation.

METHODS

Seventy-three patients with a diagnosed affective disorder in partial remission were assessed with our newly developed semi-structured extensive clinical instrument, the DEpression Early Prediction-INventory (DEEP-IN). Within DEEP-IN the course of prodromal symptoms was explored by using a life-chart method.

RESULTS

The significant majority of patients (93.2 %) reported a prodromal phase. The mean duration was 7.9 months (SD = 12.5). Within the group with an identified prodromal phase, psychopathological (95.6 %) as well as somatic symptoms (88.2 %) were reported. Somatic symptoms showed a moderate-to-strong effect of sex with higher prevalence in females than in males (97.6 % vs 73.1 %; V = 0.370).

LIMITATIONS

This feasibility study had only a small sample size.

CONCLUSIONS

The majority of patients with affective disorders reported a clinical prodromal phase with both psychopathological and somatic symptoms that developed months before the onset of the depressive episode. The development of structured instruments for the assessment of depressive risk states is a promising approach for indicated prevention of depression in the future.

Cross-cultural adaptation and inter-rater reliability of the Schizophrenia proneness instrument adult version (SPI-A) in the Indonesian context

This study aims to adapt the Schizophrenia Proneness Instrument, Adult Version (SPI-A) for the assessment of basic symptoms to the Indonesian context (culturally and linguistically) and analyze the inter-rater reliability of the translated version. Following a specific methodology for cultural adaptation, direct and back-translations were conducted together with cognitive interviews to analyze the comprehensibility of the translated version. A linguistic expert analyzes the resulting version to determine its grammatical and linguistic adequacy. Finally, the interclass correlation (ICC) of the three expert ratings of the samples (N = 9) was analyzed. The direct and back-translation phases showed good conceptual equivalence to the original version. The cognitive interviews revealed items that were challenging to understand and required revision. The final version also considered the judgments of a linguistic expert for grammatical and conceptual improvements. Inter-rater reliability analysis showed an excellent degree of agreement (ICC value: 0.984; 95% CI: 0.950-0.996). The translated SPI-A fits the Indonesian context and can be used in clinical settings to assess basic symptoms in help-seeking individuals in Indonesia.

Pathways to professional mental care in the Swiss young adult community: a case-control study

Treatment success for mental health (MH) problems depends, among others, on the timeliness of help-seeking. Therefore, we studied the effect of symptoms and reasons for help-seeking on the point-of-contact and the most intensive professional treatment in a community sample. Participants were recruited as part of the 'Bern Epidemiological At-Risk' (BEAR) study on 16-40-year-old community persons of the Swiss canton Bern. Of the 2,683 participants, 615 (22.9%) reported at least one instance of help-seeking for MH problems and were selected for the presented analyses. Help-seeking behavior was assessed by a modified version of the 'WHO pathway-to-care questionnaire', from which the outcome 'most intensive MH professional contact' was generated. The effect of symptoms and reasons for help-seeking were analyzed in separate models using path analyses. Most help-seeking persons sought MH professional help (n = 405; 65.9%) with a high number of medical pre-contacts (n = 233; 37.9%). The 'most intensive MH professional contact' was provided after an average of 1.47 contacts. Both models showed negative associations between non-MH professional pre-contacts and the most intensive, likely most adequate MH treatment. In the symptom model, 'substance misuse' and 'central-vegetative problems' increased the general likelihood of MH professional contact. Our findings highlight the importance of the first point-of-contact in pathways to adequate MH care and, when seeking help from non-MH professional, of quick referrals to MH professionals. Awareness campaigns or training of health professionals, such as general practitioners, may support timely contact with MH professionals to improve diagnosis, prognosis, and outcome.

Adapting the early recognition inventory ERIraos to Estonian: A validation study

AIM

Validated assessment tools are needed to identify clinically high risk for psychosis. This study aimed to validate the early recognition inventory ERIraos, which consists of the ERIraos Checklist for risk screening and the ERIraos Symptom List for a more thorough risk assessment in the Estonian language to detect psychotic prodromal symptoms.

METHODS

A prospective cohort study provided an opportunity to evaluate the characteristics of the ERIraos instrument in predicting the increased risk of a psychotic disorder in the future. The 177 study participants, aged 13-42 years old, were divided into groups without an increased risk and three risk groups with different risk severity levels based on the ERIraos Symptom List assessment.

RESULTS

The results indicated excellent inter-rater reliability for the ERIraos Symptom List total score. The ability of the ERIraos checklist to screen persons with an elevated psychosis risk was very good (ROC-AUC = 0.86). The capability of the ERIraos Symptom List scores to predict the probability of transitioning to psychosis within 2 years was very good (ROC-AUC = 0.83). Brief limited intermittent psychotic symptoms and observable behavioural and affective symptoms were statistically significant predictors of transition to psychosis. There were strong and statistically significant correlations between the ERIraos Symptom List scores and other clinical measures assessing functioning and psychopathology.

CONCLUSIONS

The results of this study demonstrate the reliability and validity of the Estonian version of the ERIraos instrument and support the usability of ERIraos as a two-step tool for the early recognition of psychosis risk.

EEG microstate D as psychosis-specific correlate in adolescents and young adults with clinical high risk for psychosis and first-episode psychosis

Resting-state electroencephalography (EEG) microstates are brief periods (60-120 ms) of quasi-stable scalp field potentials, indicating simultaneous activity of large-scale networks. Microstates are assumed to reflect basic neuronal information processing. A common finding in psychosis spectrum disorders is that microstates classes C and D are altered. Whereas evidence in adults with schizophrenia is substantial, little is known about effects in underage patients, particularly in those at clinical high risk for psychosis (CHR) and first-episode psychosis (FEP). The present study used 74-channel EEG to investigate microstate effects in a large sample of patients with CHR (n = 100) and FEP (n = 33), clinical controls (CC, n = 18), as well as age-matched healthy controls (HC, n = 68). Subjects span an age range from 9 to 35 years, thus, covering underage patients as well as the most vulnerable period for the emergence of psychosis and its prodrome. Four EEG microstates classes were analyzed (A-D). In class D, CHR and FEP patients showed a decrease compared to HC, and CHR patients also to CC. An increase in class C was found in CHR and FEP compared to HC but not to CC. Results were independent of age and no differences were found between the psychosis spectrum groups. The findings suggest an age-independent decrease of microstate class D to be specific to the psychosis spectrum, whereas the increase in class C seems to reflect unspecific psychopathology. Overall, present data strengthens the role of microstate D as potential biomarker for psychosis, as early as in adolescence and already in CHR status.

Reduced anterior callosal white matter in risk for psychosis associated with processing speed as a fundamental cognitive impairment

BACKGROUND

Previous research in psychotic disorders discovered associations between reduced integrity of white matter (WM) in the corpus callosum (CC) and impaired cognitive functions, suggesting processing speed as a central construct. However, it is still largely unexplored to what extent disruption in callosal WM is related to cognitive deficits during the risk stage prior to psychosis.

METHODS

To address this gap, we measured the WM integrity in CC by fractional anisotropy (FA) and assessed cognition in 60 clinical-high risk for psychosis (CHR) patients during adolescence/young adulthood and 38 healthy control (HC) subjects. We employed tract based spatial statistics to examine group differences and associations between CC-FA and processing speed, executive function, and spatial working memory.

RESULTS

We revealed deficits in processing speed, executive function, and spatial working memory of CHR patients, and reductions in FA of the genu and the body of the CC (p < 0.05, corrected for multiple comparisons) compared to HC. A mediation analysis using the combined sample (CHR + HC) showed that processing speed mediates the associations between the impaired CC structure and executive function and spatial working memory, respectively. Exploratory analyses between CC-FA and the cognitive domains located associations of processing speed in the genu and the body of CC with distinct spatial distributions of executive function and spatial working memory.

CONCLUSION

We suggest processing speed as a subordinate cognitive factor contributing to the associations between callosal WM, executive function and working memory. These results extend findings in psychotic disorders to the prior risk stage.

Debate: The prevention of psychosis in child and adolescent mental health services

Psychopathological conditions in adolescence and young adulthood often result from an altered neurodevelopment already phenotypically expressed in childhood. Child and adolescent mental health services are ideally placed to intercept in the developmental trajectories of younger adolescents and contribute to the early detection of a risk for psychosis, as proposed by Salazar de Pablo and Arango (2023, Child and Adolescent Mental Health), opening a debate to which we contribute. The early detection of a specific risk for psychosis and of a broader risk for severe mental illness requires an understanding of the clinical staging of psychosis, neurodevelopmental antecedents of severe mental illness and of heterotypic trajectories between childhood phenotypes and adult disorders.

Cognitive predictors of transition and remission of psychosis risk syndrome in a child and adolescent sample: longitudinal findings from the CAPRIS study

Cognitive impairments are proposed as predictors in the differentiation between subjects with psychosis risk syndrome (PRS) who will develop a psychotic disorder (PRS-P) and those who will not (PRS-NP). More in-depth study of the PRS-NP group could contribute to defining the role of cognitive alterations in psychosis. This study aims to analyze cognition of children and adolescents with PRS in terms of their clinical outcome at 18-month follow-up (psychosis, remission, and non-remission) and of determinate predictors of transition to psychosis and remission of PRS. The method is two-site, naturalistic, longitudinal study design, with 98 help-seeking adolescents with PRS and 64 healthy controls (HC). PRS-P (n = 24) and PRS-NP (n = 74) participants were clinically and cognitively assessed at baseline, and when full-blown psychotic disorder had developed or at 18-month follow-up. PRS-P subjects showed lower scores at baseline in processing speed, visuospatial memory, attention, and executive function (cognitive flexibility/processing speed) compared to HC. PRS-NP subjects showed lower baseline scores in verbal working memory and verbal fluency compared to HC. This deficit is also observed in the PRS group of participants still presenting attenuated psychotic symptoms at 18-month follow-up, while PRS subjects in remission showed a similar cognitive profile to HC subjects. Baseline score on processing speed, measured with a coding task, appeared to be a predictive variable for the development of a psychotic disorder. Performance in verbal working memory was predictive of remission in the PRS-NP. Post hoc comparisons indicate the need for careful interpretation of cognitive markers as predictors of psychosis. Cognitive impairments are present in both PRS-P and PRS-NP. Those individuals who recover from PRS show baseline cognitive performance comparable to the HC group. Together with sociodemographic variables, this observation could help in the differentiation of a variety of PRS trajectories in children and adolescents.

Aberrant brain dynamics in individuals with clinical high risk of psychosis

Background

Resting-state network (RSN) functional connectivity analyses have profoundly influenced our understanding of the pathophysiology of psychoses and their clinical high risk (CHR) states. However, conventional RSN analyses address the static nature of large-scale brain networks. In contrast, novel methodological approaches aim to assess the momentum state and temporal dynamics of brain network interactions.

Methods

Fifty CHR individuals and 33 healthy controls (HC) completed a resting-state functional MRI scan. We performed an Energy Landscape analysis, a data-driven method using the pairwise maximum entropy model, to describe large-scale brain network dynamics such as duration and frequency of, and transition between, different brain states. We compared those measures between CHR and HC, and examined the association between neuropsychological measures and neural dynamics in CHR.

Results

Our main finding is a significantly increased duration, frequency, and higher transition rates to an infrequent brain state with coactivation of the salience, limbic, default mode and somatomotor RSNs in CHR as compared to HC. Transition of brain dynamics from this brain state was significantly correlated with processing speed in CHR.

Conclusion

In CHR, temporal brain dynamics are attracted to an infrequent brain state, reflecting more frequent and longer occurrence of aberrant interactions of default mode, salience, and limbic networks. Concurrently, more frequent and longer occurrence of the brain state is associated with core cognitive dysfunctions, predictors of future onset of full-blown psychosis.

The 68 symptoms of the clinical high risk for psychosis: Low similarity among fourteen screening questionnaires

The Clinical High Risk for psychosis (CHR) is a heterogeneous condition with multiple symptoms. CHR screening is challenging in routine care, as a wide variety of questionnaires exists. We propose to explore the extent to which these questionnaires differ or overlap in item content. We performed a systematic and quantitative analysis of item content in a set of widely-used CHR screening questionnaires. Items were extracted from questionnaires and reworded according to the Structured Interview for Psychosis-Risk Syndromes (SIPS). Then, symptoms were generated from individual items. The Jaccard Index was calculated to assess content overlap. The 14 analysed questionnaires were composed of 347 items, from which 198 symptoms were generated and, in turn, collapsed into 68 distinct symptoms. Positive symptoms were the most commonly represented. The overall overlap across questionnaires showed weak similarity (Jaccard = 0.19±0.50). CHR screening questionnaires might evaluate the same broad clinical construct, but have different scopes within that construct, and may be more or less comprehensive than one another. Clinicians and researchers should be mindful of the specific features of each instrument for optimal CHR screening.

Correlations between Negative Symptoms and Cognitive Deficits in Individuals at First Psychotic Episode or at High Risk of Psychosis: A Systematic Review

The present review aims to identify correlations between negative symptoms (NS) and deficits in neurocognition and social cognition in subjects with first-episode psychosis (FEP) and at-high-risk populations (HR). A systematic search of the literature published between 1 January 2005 and 31 December 2022 was conducted on PubMed, Scopus, and PsycInfo. Out of the 4599 records identified, a total of 32 studies met our inclusion/exclusion criteria. Data on a total of 3086 FEP and 1732 HR were collected. The available evidence shows that NS correlate with executive functioning and theory of mind deficits in FEP subjects, and with deficits in the processing speed, attention and vigilance, and working memory in HR subjects. Visual learning and memory do not correlate with NS in either FEP or HR subjects. More inconsistent findings were retrieved in relation to other cognitive domains in both samples. The available evidence is limited by sample and methodological heterogeneity across studies and was rated as poor or average quality for the majority of included studies in both FEP and CHR populations. Further research based on shared definitions of first-episode psychosis and at-risk states, as well as on more recent conceptualizations of negative symptoms and cognitive impairment, is highly needed.

Risk stratification for treating people at ultra-high risk for psychosis: A cost-effectiveness analysis

People who are at ultra-high risk (UHR) for psychosis receive clinical care with the aim to prevent first-episode psychosis (FEP), regardless of the risk of conversion to psychosis. An economic model from the Canadian health system perspective was developed to evaluate the cost-effectiveness of treating all with UHR compared to risk stratification over a 15-year time horizon, based on conversion probability, expected quality-of-life and costs. The analysis used a decision tree followed by a Markov model. Health states included: Not UHR, UHR with <20 % risk of conversion to FEP (based on the North American Prodrome Longitudinal Study risk calculator), UHR with ≥20 % risk, FEP, Remission, Post-FEP, and Death. The analysis found that: risk stratification (i.e., only treating those with ≥20 % risk) had lower costs ($1398) and quality-adjusted life-years (0.055 QALYs) per person compared to treating all. The incremental cost-effectiveness ratio for 'treat all' was $25,448/QALY, and suggests treating all may be cost-effective. The model was sensitive to changes to the probability of conversion.

The identification and management of people with an at-risk mental state (ARMS) for psychosis in primary and secondary care services: A qualitative interview study

AIMS

Early intervention in people with an at-risk mental state (ARMS) for psychosis can prevent the onset of psychosis. Clinical guidelines recommend that ARMS are referred to triage services, and then to Early Intervention (EI) teams in secondary care for assessment and treatment. However, little is known about how ARMS patients are identified and managed in UK primary and secondary care. This study explored patients' and clinicians' views of ARMS patients' care pathways.

METHODS

Eleven patients, 20 GPs, 11 clinicians from the triaging Primary Care Liaison Services (PCLS) and 10 EI clinicians were interviewed. Data were analysed thematically.

RESULTS

Most patients said their symptoms started in adolescence with depression and anxiety. Before being referred to EI teams, most patients were referred by their GP to well-being services for talking therapies, which they had not found helpful. Some GPs said secondary care's high acceptance thresholds and scarce treatment availability made them reluctant to refer to EI teams. Triage in PCLS was influenced by patients' risk of self-harm, and formulation of psychotic symptoms; only those without clear evidence of other pathology and not at high risk of self-harm were referred to EI teams, the others being referred to Recovery/Crisis services. Although patients referred to EI teams were offered an assessment, only some EI teams were commissioned to treat ARMS.

CONCLUSIONS

Individuals meeting ARMS criteria might not receive early intervention due to high treatment thresholds and limited treatment availability in secondary care, suggesting clinical guidelines are not being met for this patient group.

Psychotic Vulnerability and its Associations with Clinical Characteristics in Adolescents with Obsessive-Compulsive Disorder

Compared to peers, children and adolescents with obsessive-compulsive disorder (OCD) are at increased risk of developing psychotic disorders. Yet very few studies have examined early indicators of psychosis in pediatric OCD. In the present study, 52 youth with a primary diagnosis of OCD (Mage = 15.66 [SD = 2.33], 59.6% girls) were interviewed using the Schizophrenia Proneness Instrument Child and Adolescent version (SPI-CY), which is a comprehensive clinical interview assessing both Cognitive-Perceptual basic symptoms (COPER) and high-risk criterion Cognitive Disturbances (COGDIS). Associations between COPER/COGDIS symptoms and demographic and clinical characteristics were examined. Findings showed that COPER or COGDIS symptoms were present in 44% of participants, with no significant difference between girls and boys. Psychotic vulnerability was associated with an earlier age of OCD onset, greater OCD severity, poorer insight, and more contamination/cleaning symptoms. Psychotic vulnerability was also strongly associated with worse psychosocial functioning. Findings suggest that early indicators of psychosis are frequent in pediatric OCD and associated with more severe OCD and poorer functioning. Research examining how psychotic vulnerability is associated with short- and long-term outcomes for youth with OCD is needed.

An ecological momentary assessment study of age effects on perceptive and non-perceptive clinical high-risk symptoms of psychosis

Among individuals with clinical high risk for psychosis (CHR), perceptive symptoms are more frequent but have less clinical significance in children/adolescents compared to adults. However, findings are based on clinical interviews relying on patient's recall capacity. Ecological momentary assessment (EMA) can be used to explore experiences in real-time in the subject's daily life. The aim of this study was to assess frequency and stability of (perceptive and non-perceptive) CHR symptoms and to explore potential age effects. EMA was used in a sample of an early detection for psychosis service in Bern, Switzerland (N = 66; 11-36 years). CHR symptoms were recorded in random time intervals for seven days: eight assessments per day per subject, minimum time between prompts set at 25 min. CHR symptoms were additionally assessed with semi-structured interviews including the 'Structured Interview for Psychosis-Risk Syndromes' and the 'Schizophrenia Proneness Instruments'. Mixed-effects linear regression analysis on the frequency of CHR symptoms revealed a significant effect of age group, and the interaction CHR symptoms x age group for both perceptive and non-perceptive symptoms. Further, regarding stability of CHR symptoms, there was a significant effect of the interaction CHR symptoms x age group for perceptive symptoms only. Based on EMA, perceptive CHR symptoms were more frequently reported but less stable in children/adolescents compared with adults. Together with previous findings, our finding of higher instability/variability of perceptive symptoms in younger persons might suggest that with advancing age and more stability of CHR symptoms, clinical relevance (reduced psychosocial functioning) may increase.

The role of mentalizing in the relationship between schizotypal personality traits and state signs of psychosis risk captured by cognitive and perceptive basic symptoms

Objective

Schizotypal traits and disturbances in mentalizing (the capacity to understand the mental states driving one's own and others' behaviors) have been implicated in increased vulnerability for psychosis. Therefore, we explored the associations linking schizotypal traits, mentalizing difficulties and their interactions to clinical high-risk for psychosis (CHR-P), as captured by the Basic Symptoms (BS) approach, during adolescence and young adulthood.

Methods

Eighty-seven adolescents and young adults from the general population (46% male, 44% female; age: 14-23 years) were assessed with the Schizophrenia Proneness Interview (SPI-CY/A) for 11 perceptive and cognitive BS, with the Schizotypal Personality Questionnaire (SPQ) for schizotypal traits, and with the Reflective Functioning Questionnaire (RFQ) for self-reported mentalizing abilities. The RFQ evaluates the level of certainty (RFQc scale) and uncertainty (RFQu scale) with which individuals use mental state information to explain their own and others' behaviors.

Results

Logistic regression models showed significant positive effects of the SPQ disorganization scale on perceptive BS and of the SPQ interpersonal scale on cognitive BS. Post-hoc analyses revealed that schizotypal features pertaining to odd speech and social anxiety, respectively, were associated with perceptive and cognitive BS. Furthermore, higher scores on the RFQu scale and lower scores on the RFQc scale independently explained the presence of cognitive BS. Finally, significant interaction effects between RFQc and SPQ odd speech on perceptive BS, and between RFQc and SPQ social anxiety on cognitive BS were found.

Conclusion

Our findings suggest that schizotypal traits and mentalizing significantly relate both independently and through their interactions to the presence of cognitive and perceptive BS included in CHR-P criteria. Furthermore, mentalizing dysfunction may contribute in the relation between schizotypal traits and early state signs of CHR-P. Mentalizing may support both detection and early treatment of CHR-P among adolescents and young adults who present with trait risk for psychosis.

Suicide risk among individuals at Ultra-High Risk (UHR) of psychosis in a developing North African country: A 12-month naturalistic prospective cohort study from the TRIP project

BACKGROUND

The limited studies that focused on suicidality in individuals at Ultra-High Risk (UHR) of psychosis were predominantly cross-sectional, emerging from Western countries. We aimed to examine suicide risk among Tunisian UHR and First Episode Psychosis (FEP) patients at baseline, and to evaluate the evolution and correlates of suicidal ideation over a 12-month period in the UHR group exclusively.

METHODS

35 UHR (aged 22.8 ± 4.0 years, 45.7% male) and 33 FEP (aged 27.3 ± 4.8 years, 63.6% male) participants were included. The Comprehensive Assessment of at Risk Mental States, the Positive and Negative Syndrome Scale (PANSS), The Rosenberg Self-Esteem Scale, and The Multidimensional Scale of Perceived Social Support were used.

RESULTS

No significant differences were found between the UHR and the FEP groups with regard to levels of suicidal ideation at baseline. Suicidal ideation scores showed a significant decrease over time in UHR participants (p=.014; η2=0.242). An increase in total PANSS scores at 1 year (Beta=0.03; p=.048; 95%CI 0.001, 0.060; η2=0.182) significantly increased suicidal ideation scores at 1 year in the UHR group.

CONCLUSION

Our findings contribute to the limited body of evidence on this topic by providing new prospective data from a population, country and region that has never been researched previously.

A new scale for the screening of childhood early psychotic symptoms

This study aimed to develop a new scale, the Early Psychotic Symptoms screening scale (EPSy), to assess the prodromes of psychotic symptoms in children aged 4 to 13 years. Two versions were proposed: one to assess the child's current behavior and one to assess the child's behavior when he/she was 2 years old. The second aim of this study was to investigate the presence of these symptoms at the age of 2 years and their evolution up to the child's current age. The analysis of EPSy identified three main factors, namely mistrust/paranoia, perceptual aberrations/hallucinations and disorganized symptoms. It has good psychometric properties. Data also shows that, independently of the participant's age, the total score on the 2-years-old version predicts the total score on the current-age version, and this is also the case for each individual factor. Finally, it is of clinical interest since it makes it possible to describe symptomatology both at age 2 and at the child's present age depending on the group to which the children are assigned (control children, psychotic children, non-psychotic children).

Age-related change in cortical thickness in adolescents at clinical high risk for psychosis: a longitudinal study

Progression to psychosis has been associated with increased cortical thinning in the frontal, temporal and parietal lobes in individuals at clinical high risk for the disorder (CHR-P). The timing and spatial extent of these changes are thought to be influenced by age. However, most evidence so far stems from adult samples. Longitudinal studies are essential to understanding the neuroanatomical changes associated to transition to psychosis during adolescence, and their relationship with age. We conducted a longitudinal, multisite study including adolescents at CHR-P and healthy controls (HC), aged 10-17 years. Structural images were acquired at baseline and at 18-month follow-up. Images were processed with the longitudinal pipeline in FreeSurfer. We used a longitudinal two-stage model to compute the regional cortical thickness (CT) change, and analyze between-group differences controlling for age, sex and scan, and corrected for multiple comparisons. Linear regression was used to study the effect of age at baseline. A total of 103 individuals (49 CHR-P and 54 HC) were included in the analysis. During follow-up, the 13 CHR-P participants who transitioned to psychosis exhibited greater CT decrease over time in the right parietal cortex compared to those who did not transition to psychosis and to HC. Age at baseline correlated with longitudinal changes in CT, with younger individuals showing greater cortical thinning in this region. The emergence of psychosis during early adolescence may have an impact on typical neuromaturational processes. This study provides new insights on the cortical changes taking place prior to illness onset.

Predictors of transition in patients with clinical high risk for psychosis: an umbrella review

Diagnosis of a clinical high-risk (CHR) state enables timely treatment of individuals at risk for a psychotic disorder, thereby contributing to improving illness outcomes. However, only a minority of patients diagnosed with CHR will make the transition to overt psychosis. To identify patients most likely to benefit from early intervention, several studies have investigated characteristics that distinguish CHR patients who will later develop a psychotic disorder from those who will not. We aimed to summarize evidence from systematic reviews and meta-analyses on predictors of transition to psychosis in CHR patients, among characteristics and biomarkers assessed at baseline. A systematic search was conducted in Pubmed, Scopus, PsychInfo and Cochrane databases to identify reviews and meta-analyses of studies that investigated specific baseline predictors or biomarkers for transition to psychosis in CHR patients using a cross-sectional or longitudinal design. Non-peer-reviewed publications, gray literature, narrative reviews and publications not written in English were excluded from analyses. We provide a narrative synthesis of results from all included reviews and meta-analyses. For each included publication, we indicate the number of studies cited in each domain and its quality rating. A total of 40 publications (21 systematic reviews and 19 meta-analyses) that reviewed a total of 272 original studies qualified for inclusion. Baseline predictors most consistently associated with later transition included clinical characteristics such as attenuated psychotic and negative symptoms and functioning, verbal memory deficits and the electrophysiological marker of mismatch negativity. Few predictors reached a level of evidence sufficient to inform clinical practice, reflecting generalizability issues in a field characterized by studies with small, heterogeneous samples and relatively few transition events. Sample pooling and harmonization of methods across sites and projects are necessary to overcome these limitations.

Personality functioning and self-disorders in individuals at ultra-high risk for psychosis, with first-episode psychosis and with borderline personality disorder

BACKGROUND

Assessment of personality functioning in different stages of psychotic disorders could provide valuable information on psychopathology, course of illness and treatment planning, but empirical data are sparse.

AIMS

To investigate personality functioning and sense of self in individuals at ultra-high risk (UHR) for psychosis and with first-episode psychosis (FEP) in comparison with a clinical control group of individuals with borderline personality disorder (BPD) and healthy controls.

METHOD

In a cross-sectional design, we investigated personality functioning (Structured Interview of Personality Organization, STIPO; Level of Personality Functioning Scale, LPFS) and disturbances of the basic self (Examination of Anomalous Self-Experience, EASE) in 107 participants, comprising 24 individuals at UHR, 29 individuals with FEP, 27 individuals with BPD and 27 healthy controls.

RESULTS

The UHR, FEP and BPD groups had moderate to severe deficits in personality organisation (STIPO) compared with the healthy control group. Self-functioning with its subdomain (facet) 'self-direction' (LPFS) was significantly worse in participants with manifest psychosis (FEP) compared with those at-risk for psychosis (UHR). The FEP group showed significantly worse overall personality functioning than the UHR group and significantly higher levels of self-disturbance (EASE) than the BPD group, with the UHR group lying between these diagnostic groups. Hierarchical cluster analysis based on the seven STIPO domains yielded three clusters differing in level of personality functioning and self-disturbances.

CONCLUSIONS

Our data demonstrate that psychotic disorders are associated with impaired personality functioning and self-disturbances. Assessment of personality functioning can inform treatment planning for patients at different stages of psychotic disorder.

Mismatch negativity generation in subjects at risk for psychosis: source analysis is more sensitive than surface electrodes in risk prediction

Background

Deficits of mismatch negativity (MMN) in patients with schizophrenia have been demonstrated many times and there is growing evidence that alterations of MMN already exist in individuals at risk for psychosis. The present study examines differences in MMN between subjects fulfilling ultra-high risk (UHR) or only basic symptoms criteria and it addresses the question, if MMN source analysis can improve prediction of transition to psychosis.

Methods

The MMN to duration, frequency, and intensity deviants was recorded in 50 healthy controls and 161 individuals at risk for psychosis classified into three subgroups: only basic symptoms (n = 74), only ultra-high risk (n = 13) and persons who fulfill both risk criteria (n = 74). Based on a three-source model of MMN generation, we conducted an MMN source analysis and compared the amplitudes of surface electrodes and sources among the three groups.

Results

Significant differences in MMN generation among the four groups were revealed at surface electrodes Cz and C4 (p < 0.05) and at the frontal source (p < 0.001) for duration deviant stimuli. The 15 subjects from the risk groups who subsequently developed a manifest psychosis had a significantly lower MMN amplitude at frontal source (p = 0.019) without showing significant differences at surface electrodes. Low activity at frontal MMN source increased the risk of transition to manifest disease by the factor 3.12 in UHR subjects.

Conclusion

MMN activity differed significantly between subjects presenting only basic symptoms and subjects which additionally meet UHR criteria. The largest differences between groups as well as between individuals with and without transition were observed at the frontal source. The present results suggest that source analysis is more sensitive than surface electrodes in psychosis risk prediction by MMN.

The heterogeneity of attenuated and brief limited psychotic symptoms: association of contents with age, sex, country, religion, comorbidities, and functioning

Introduction

The Attenuated Psychosis Symptoms (APS) syndrome mostly represents the ultra-high-risk state of psychosis but, as does the Brief Intermittent Psychotic Symptoms (BIPS) syndrome, shows a large variance in conversion rates. This may be due to the heterogeneity of APS/BIPS that may be related to the effects of culture, sex, age, and other psychiatric morbidities. Thus, we investigated the different thematic contents of APS and their association with sex, age, country, religion, comorbidity, and functioning to gain a better understanding of the psychosis-risk syndrome.

Method

A sample of 232 clinical high-risk subjects according to the ultra-high risk and basic symptom criteria was recruited as part of a European study conducted in Germany, Italy, Switzerland, and Finland. Case vignettes, originally used for supervision of inclusion criteria, were investigated for APS/BIPS contents, which were compared for sex, age, country, religion, functioning, and comorbidities using chi-squared tests and regression analyses.

Result

We extracted 109 different contents, mainly of APS (96.8%): 63 delusional, 29 hallucinatory, and 17 speech-disorganized contents. Only 20 contents (18.3%) were present in at least 5% of the sample, with paranoid and referential ideas being the most frequent. Thirty-one (28.5%) contents, in particular, bizarre ideas and perceptual abnormalities, demonstrated an association with age, country, comorbidity, or functioning, with regression models of country and obsessive-compulsive disorders explaining most of the variance: 55.8 and 38.3%, respectively. Contents did not differ between religious groups.

Conclusion

Psychosis-risk patients report a wide range of different contents of APS/BIPS, underlining the psychopathological heterogeneity of this group but also revealing a potential core set of contents. Compared to earlier reports on North-American samples, our maximum prevalence rates of contents were considerably lower; this likely being related to a stricter rating of APS/BIPS and cultural influences, in particular, higher schizotypy reported in North-America. The various associations of some APS/BIPS contents with country, age, comorbidities, and functioning might moderate their clinical severity and, consequently, the related risk for psychosis and/or persistent functional disability.

Prevention of First-Episode Psychosis in People at Clinical High Risk: A Randomized Controlled, Multicentre Trial Comparing Cognitive-Behavioral Therapy and Clinical Management Plus Low-Dose Aripiprazole or Placebo (PREVENT)

BACKGROUND

There is limited knowledge of whether cognitive-behavioral therapy (CBT) or second-generation antipsychotics (SGAs) should be recommended as the first-line treatment in individuals at clinical high risk for psychosis (CHRp).

HYPOTHESIS

To examine whether individual treatment arms are superior to placebo and whether CBT is non-inferior to SGAs in preventing psychosis over 12 months of treatment.

STUDY DESIGN

PREVENT was a blinded, 3-armed, randomized controlled trial comparing CBT to clinical management plus aripiprazole (CM + ARI) or plus placebo (CM + PLC) at 11 CHRp services. The primary outcome was transition to psychosis at 12 months. Analyses were by intention-to-treat.

STUDY RESULTS

Two hundred eighty CHRp individuals were randomized: 129 in CBT, 96 in CM + ARI, and 55 in CM + PLC. In week 52, 21 patients in CBT, 19 in CM + ARI, and 7 in CM + PLC had transitioned to psychosis, with no significant differences between treatment arms (P = .342). Psychopathology and psychosocial functioning levels improved in all treatment arms, with no significant differences.

CONCLUSIONS

The analysis of the primary outcome transition to psychosis at 12 months and secondary outcomes symptoms and functioning did not demonstrate significant advantages of the active treatments over placebo. The conclusion is that within this trial, neither low-dose aripiprazole nor CBT offered additional benefits over clinical management and placebo.

Meta-analysis of gender differences in transition prevalence among individuals at clinical high risk of psychosis

Gender differences have been found in several areas of individuals at clinical-high risk for psychosis(CHR). Therefore the risk of transition to psychosis may differ between male and female CHR, but previous work has not systematically reviewed and analyzed gender differences in conversion rates.We performed a meta-analysis according to PRISMA guidelines including all studies that assessed CHR with reliable instruments and provided data on the transition from male CHR and female CHR to psychosis to understand the conversion rate conversion in male and female CHR. Seventy-nine article were identified.A total of 1250 out of 5770 in the male CHR individuals, and 832 out of 4468 in the female CHR individuals translated to psychotic disorders. Transition prevalence were 19.4%(95%CI:14.2-25.8%)at 1 year, 20.6% at 2 year (95%CI:17.1-24.8%),24.3% at 3 years (95%CI:21.5-27.4%),26.3% at 4 years or older (95%CI:20.9-32.5%) and 22.3% at all (95%CI:20.0-24.8%) in male CHR and 17.7% (95%CI:12.6-24.4%) at 1 years, 17.5% (95%CI:14.2-21.4%) at 2 year, 19.9%(95%CI:17.3-0.228%) at 3 years,and 0.267 (95%CI:22.1-31.9%) at 4 years or older follow-up,20.4% at all (95%CI:18.1-22.9%) in female CHR. There were differences between the two groups in the overall conversion, the 2-year, and the 3-year follow up transition prevalence, which were higher in men CHR than in female CHR. Future research characterizing male versus female CHR is needed with the expectation that interventions will be developed that are tailored to the respective gender, further reducing the rate of conversion to CHR.

Sex- and Age-Specific Deviations in Cerebellar Structure and Their Link With Symptom Dimensions and Clinical Outcome in Individuals at Clinical High Risk for Psychosis

BACKGROUND

The clinical high-risk (CHR) period offers a temporal window into neurobiological deviations preceding psychosis onset, but little attention has been given to regions outside the cerebrum in large-scale studies of CHR. Recently, the North American Prodrome Longitudinal Study (NAPLS)-2 revealed altered functional connectivity of the cerebello-thalamo-cortical circuitry among individuals at CHR; however, cerebellar morphology remains underinvestigated in this at-risk population, despite growing evidence of its involvement in psychosis.

STUDY DESIGN

In this multisite study, we analyzed T1-weighted magnetic resonance imaging scans obtained from N = 469 CHR individuals (61% male, ages = 12-36 years) and N = 212 healthy controls (52% male, ages = 12-34 years) from NAPLS-2, with a focus on cerebellar cortex and white matter volumes separately. Symptoms were rated by the Structured Interview for Psychosis-Risk Syndromes (SIPS). The outcome by two-year follow-up was categorized as in-remission, symptomatic, prodromal-progression, or psychotic. General linear models were used for case-control comparisons and tests for volumetric associations with baseline SIPS ratings and clinical outcomes.

STUDY RESULTS

Cerebellar cortex and white matter volumes differed between the CHR and healthy control groups at baseline, with sex moderating the difference in cortical volumes, and both sex and age moderating the difference in white matter volumes. Baseline ratings for major psychosis-risk dimensions as well as a clinical outcome at follow-up had tissue-specific associations with cerebellar volumes.

CONCLUSIONS

These findings point to clinically relevant deviations in cerebellar cortex and white matter structures among CHR individuals and highlight the importance of considering the complex interplay between sex and age when studying the neuromaturational substrates of psychosis risk.

Detection of clinical high risk for psychosis in child and adolescent mental health services: Validation of the first step with the French versions of the Prodromal Questionnaire (fPQ-16) and scale of Perceptual and Cognitive Aberrations (fPCA)

AIM

To validate the French versions of the 16-items Prodromal Questionnaire (PQ-16) and the 9-items scale of Perceptual and Cognitive Aberrations (PCA) to facilitate screening of psychosis risk in native French-speaking young individuals referred to Child and Adolescent Mental Health Services.

METHOD

Participants (N = 87, age range 10-18 years) were diagnosed with a non-psychotic disorder according to the Diagnostic and Statistical Manual of Mental Disorders. The French versions of the PQ-16 and PCA were developed using a forward-backward translation procedure. Psychometric properties were tested including (i) internal validity with Pearson correlations and Cronbach's coefficients, and (ii) external validity by correlations with each other's.

RESULTS

(i) Correlations between fPQ-16 and fPCA total scores and individual items were mostly >.4. Cronbach's coefficients were .80 for the fPQ-16 and .61 for the fPCA. (ii) The fPQ-16 and fPCA total scores were significantly correlated with a large effect size (r_s  = 0.66).

CONCLUSION

The fPQ-16 and the fPCA are psychometrically acceptable instruments for the screening of potential psychotic symptoms in French-speaking children and young adolescents under 18 years old referred to Child and Adolescent Mental Health Services.

Longitudinal Changes in Cortical Surface Area Associated With Transition to Psychosis in Adolescents at Clinical High Risk for the Disease

OBJECTIVE

Identifying biomarkers of transition to psychosis in individuals at clinical high risk for psychosis (CHR-P) is essential to understanding the mechanisms underlying the disease. Although cross-sectional abnormalities in cortical surface area (CSA) have been demonstrated in individuals at CHR-P who transition to psychosis (CHR-P-T) compared with those who do not (CHR-P-NT), how CSA longitudinally develops remains unclear, especially in younger individuals. We set out to compare CSA in adolescents at CHR-P and healthy controls (HC) over 2 points in time.

METHOD

A longitudinal multicenter study was performed in adolescents at CHR-P in comparison to HC and according to transition to psychosis. Magnetic resonance imaging scans were acquired at baseline, at 18-month follow-up, or at the time of transition. Images were pre-processed and hemisphere and regional CSA were computed using FreeSurfer. Between-group analyses were performed with linear mixed-effects models.

RESULTS

A total of 313 scans (107 CHR-P and 102 HC) were included in the analysis. At 18 months, the rate of transition to psychosis in CHR-P was 23.4%. Adolescents at CHR-P-T presented greater age-related decrease in CSA in the left parietal and occipital lobes compared with HC, and in the bilateral parietal lobe and right frontal lobe relative to CHR-P-NT. These results were not influenced by antipsychotic treatment, cannabis use, or intelligence quotient (IQ).

CONCLUSION

Adolescents at CHR-P that developed a psychotic disorder presented different developmental trajectories of CSA relative to those who did not. A relatively greater decrease in CSA in the parietal and frontal lobes may index clinical transition to psychosis in adolescents at CHR-P.

Predictive validity of psychosis risk models when applied to adolescent psychiatric patients

BACKGROUND

Several multivariate algorithms have been developed for predicting psychosis, as attempts to obtain better prognosis prediction than with current clinical high-risk (CHR) criteria. The models have typically been based on samples from specialized clinics. We evaluated the generalizability of 19 prediction models to clinical practice in an unselected adolescent psychiatric sample.

METHODS

In total, 153 adolescent psychiatric patients in the Helsinki Prodromal Study underwent an extensive baseline assessment including the SIPS interview and a neurocognitive battery, with 50 participants (33%) fulfilling CHR criteria. The adolescents were followed up for 7 years using comprehensive national registers. Assessed outcomes were (1) any psychotic disorder diagnosis (n = 18, 12%) and (2) first psychiatric hospitalization (n = 25, 16%) as an index of overall deterioration of functioning.

RESULTS

Most models improved the overall prediction accuracy over standard CHR criteria (area under the curve estimates ranging between 0.51 and 0.82), although the accuracy was worse than that in the samples used to develop the models, also when applied only to the CHR subsample. The best models for transition to psychosis included the severity of positive symptoms, especially delusions, and negative symptoms. Exploratory models revealed baseline negative symptoms, low functioning, delusions, and sleep problems in combination to be the best predictor of psychiatric hospitalization in the upcoming years.

CONCLUSIONS

Including the severity levels of both positive and negative symptomatology proved beneficial in predicting psychosis. Despite these advances, the applicability of extended psychosis-risk models to general psychiatric practice appears limited.

Elucidating gut microbiota-hippocampus interactions in emerging psychosis: A new perspective for the development of early interventions for memory impairments

Hippocampal dysregulation might be a key pathophysiological factor for memory impairments in psychosis. Contemporary models particularly postulate that an imbalance of hippocampal glutamate and GABA leads to impaired memory and may thus serve as a therapeutic target to improve memory deficits. However, currently available interventions in early stages of psychosis do not explicitly target hippocampal pathology. A novel approach for manipulating hippocampus-dependent memory processes is provided via the gut microbiota. In this perspective article, we first recapitulate compelling evidence for emerging hippocampus pathology during the development of psychosis. The following sections emphasize the critical role of the gut microbiota in hippocampus plasticity and memory, and summarize existing evidence of gut microbiota alterations in different stages of psychosis. Finally, we propose a novel conceptual roadmap for future studies deciphering gut microbiota-hippocampus synergisms in emerging psychosis and argue that specific microbial supplementation might be promising for improving hippocampus-dependent memory deficits in early stages of psychosis.

Relationships between global functioning and neuropsychological predictors in subjects at high risk of psychosis or with a recent onset of depression

OBJECTIVE

Psychotic disorders are frequently associated with decline in functioning and cognitive difficulties are observed in subjects at clinical high risk (CHR) for psychosis. In this work, we applied automatic approaches to neurocognitive and functioning measures, with the aim of investigating the link between global, social and occupational functioning, and cognition.

METHODS

102 CHR subjects and 110 patients with recent onset depression (ROD) were recruited. Global assessment of functioning (GAF) related to symptoms (GAF-S) and disability (GAF-D). and global functioning social (GF-S) and role (GF-R), at baseline and of the previous month and year, and a set of neurocognitive measures, were used for classification and regression.

RESULTS

Neurocognitive measures related to GF-R at baseline (r = 0.20, p = 0.004), GF-S at present (r = 0.14, p = 0.042) and of the past year (r = 0.19, p = 0.005), for GAF-F of the past month (r = 0.24, p < 0.001) and GAF-D of the past year (r = 0.28, p = 0.002). Classification reached values of balanced accuracy of 61% for GF-R and GAF-D.

CONCLUSION

We found that neurocognition was related to psychosocial functioning. More specifically, a deficit in executive functions was associated to poor social and occupational functioning.

Major depressive disorder and attenuated negative symptoms in a child and adolescent sample with psychosis risk syndrome: the CAPRIS study

Some 70-80% of subjects with psychotic risk syndrome (PRS) have lifetime comorbidity, with depressive disorders being the most common. A high proportion of patients with PRS present nonspecific symptoms which can be confounding factors for diagnosis. Depressive and negative symptoms may be difficult to distinguish and it is important to differentiate them. The aim of this study is to assess the presence of depressive disorder in a child and adolescent sample of PRS and to examine the presence of negative symptoms and detect possible confounding characteristics between them and depressive symptoms. This is a naturalistic multi-site study with subjects who met PRS criteria. A sample of 89 PRS adolescent patients was included. Major depressive disorder (MDD) is the most prevalent comorbid disorder (34.83%). The sample was divided into patients who met criteria for MDD (PRS-MDD, n = 31) and those who did not have this disorder (PRS-ND, n = 44). We obtained significant differences in the attenuated negative symptoms (ANS) between PRS-MDD and PRS-ND (68.18 vs. 90.32%, respectively, p = 0.021). Subjects with MDD presented a higher score in ANS and Hamilton Depression Rating Scale (HDRS). Moreover, we obtained a correlation between negative symptomatology and HDRS score with a higher score on HDRS in subjects with higher negative symptom scores (r = 0.533, p < 0.001). More research is needed to fine tune differentiation between depressive and negative symptoms and learn more about the possible impact of MDD on PRS children and adolescents.

Bridging the phenomenological gap between predictive basic-symptoms and attenuated positive symptoms: a cross-sectional network analysis

Attenuated positive symptoms (APS), transient psychotic-like symptoms (brief, limited intermittent psychotic symptoms, BLIPS), and predictive cognitive-perceptive basic-symptoms (BS) criteria can help identify a help-seeking population of young people at clinical high-risk of a first episode psychosis (CHRp). Phenomenological, there are substantial differences between BS and APS or BLIPS. BS do not feature psychotic content as delusion or hallucinations, and reality testing is preserved. One fundamental problem in the psychopathology of CHRp is to understand how the non-psychotic BS are related to APS. To explore the interrelationship of APS and predictive BS, we fitted a network analysis to a dataset of 231 patients at CHRp, aged 24.4 years (SD = 5.3) with 65% male. Particular emphasis was placed on points of interaction (bridge symptoms) between the two criteria sets. The BS ‘unstable ideas of reference’ and “inability to discriminate between imagination and reality” interacted with attenuated delusional ideation. Perceptual BS were linked to perceptual APS. Albeit central for the network, predictive cognitive basic BS were relatively isolated from APS. Our analysis provides empirical support for existing theoretical accounts that interaction between the distinct phenomenological domains of BS and APS is characterized by impairments in source monitoring and perspective-taking. Identifying bridge symptoms between the symptom domains holds the potential to empirically advance the etiological understanding of psychosis and pave the way for tailored clinical interventions.

Transdiagnostic Psychopathology in a Help-Seeking Population of an Early Recognition Center for Mental Disorders: Protocol for an Experience Sampling Study

BACKGROUND

Prevention in psychiatry provides a promising way to address the burden of mental illness. However, established approaches focus on specific diagnoses and do not address the heterogeneity and manifold potential outcomes of help-seeking populations that present at early recognition services. Conceptualizing the psychopathology manifested in help-seeking populations from a network perspective of interacting symptoms allows transdiagnostic investigations beyond binary disease categories. Furthermore, modern technologies such as smartphones facilitate the application of the Experience Sampling Method (ESM).

OBJECTIVE

This study is a combination of ESM with network analyses to provide valid insights beyond the established assessment instruments in a help-seeking population.

METHODS

We will examine 75 individuals (aged 18-40 years) of the help-seeking population of the Cologne early recognition center. For a maximally naturalistic sample, only minimal exclusion criteria will be applied. We will collect data for 14 days using a mobile app to assess 10 transdiagnostic symptoms (ie, depressive, anxious, and psychotic symptoms) as well as distress level 5 times a day. With these data, we will generate average group-level symptom networks and personalized symptom networks using a 2-step multilevel vector autoregressive model. Additionally, we will explore associations between symptom networks and sociodemographic, risk, and resilience factors, as well as psychosocial functioning.

RESULTS

The protocol was designed in February 2020 and approved by the Ethics Committee of the University Hospital Cologne in October 2020. The protocol was reviewed and funded by the Köln Fortune program in September 2020. Data collection began in November 2020 and was completed in November 2021. Of the 258 participants who were screened, 93 (36%) fulfilled the inclusion criteria and were willing to participate in the study. Of these 93 participants, 86 (92%) completed the study. The first results are expected to be published in 2022.

CONCLUSIONS

This study will provide insights about the feasibility and utility of the ESM in a help-seeking population of an early recognition center. Providing the first explorative phenotyping of transdiagnostic psychopathology in this population, our study will contribute to the innovation of early recognition in psychiatry. The results will help pave the way for prevention and targeted early intervention in a broader patient group, and thus, enable greater intended effects in alleviating the burden of psychiatric disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35206.

Neural Correlates of Facial Emotion Recognition in Non-help-seeking University Students With Ultra-High Risk for Psychosis

Background

Since the introduction of the neurodevelopmental perspective of schizophrenia research on individuals at ultra-high risk for psychosis (UHR) has gained increasing interest, aiming at early detection and intervention. Results from fMRI studies investigating behavioral and brain functional changes in UHR during facial emotion recognition, an essential component of social cognition, showed heterogenous results, probably due clinical diversity across these investigations. This fMRI study investigated emotion recognition in a sub-group of the UHR spectrum, namely non-help-seeking, drug-naïve UHR with high cognitive functioning to reveal the neurofunctional underpinnings of their social functioning in comparison to healthy controls.

Methods

Two large cohorts of students from an elite University (n 1 = 4,040, n 2 = 4,364) were screened firstly with the Prodromal Questionnaires and by surpassing predefined cut-offs then interviewed with the semi-structured Interview for Psychosis-Risk Syndromes to verify their UHR status. Twenty-one identified non-help-seeking UHR and 23 non-UHR control subjects were scanned with functional magnetic resonance imaging while classifying emotions (i.e., neutral, happy, disgust and fear) in a facial emotion recognition task.

Results

Behaviorally, no group differences were found concerning accuracy, reaction times, sensitivity or specificity, except that non-help-seeking UHR showed higher specificity when recognizing neutral facial expressions. In comparison to healthy non-UHR controls, non-help-seeking UHR showed generally higher activation in the superior temporal and left Heschl's gyrus as well as in the somatosensory, insular and midcingulate cortex than the control subjects during the entire recognition task regardless of the emotion categories. In an exploratory analysis, in the non-help-seeking UHR group, functional activity in the left superior temporal gyrus was significantly correlated with deficits in the ability to experience emotions at uncorrected statistical thresholds.

Conclusions

Compared to healthy controls, non-help-seeking UHR show no behavioral deficits during facial emotion recognition, but functional hyperactivities in brain regions associated with this cognitive process. Our study may inspire future early intervention and provide loci for treatment using neural stimulation.

White matter microstructure and the clinical risk for psychosis: A diffusion tensor imaging study of individuals with basic symptoms and at ultra-high risk

•

This DTI cross-sectional study compared UHR, basic symptom & control groups (n = 112).

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The splenium of UHR individuals exhibited differences in fractional anisotropy (FA).

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Basic symptoms alone were not associated with white matter microstructure changes.

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Large differences in FA & radial diffusivity were found in converters to psychosis.

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Regional FA was inversely correlated with the general psychopathology domain.

Background

Widespread white matter abnormalities are a frequent finding in chronic schizophrenia patients. More inconsistent results have been provided by the sparser literature on at-risk states for psychosis, i.e., emerging subclinical symptoms. However, considering risk as a homogenous construct, an approach of earlier studies, may impede our understanding of neuro-progression into psychosis.

Methods

An analysis was conducted of 3-Tesla MRI diffusion and symptom data from 112 individuals (mean age, 21.97 ± 4.19) within two at-risk paradigm subtypes, only basic symptoms (n = 43) and ultra-high risk (n = 37), and controls (n = 32). Between-group comparisons (involving three study groups and further split based on the subsequent transition to schizophrenia) of four diffusion-tensor-imaging-derived scalars were performed using voxelwise tract-based spatial statistics, followed by correlational analyses with Structured Interview for Prodromal Syndromes responses.

Results

Relative to controls, fractional anisotropy was lower in the splenium of the corpus callosum of ultra-high-risk individuals, but only before stringent multiple-testing correction, and negatively correlated with General Symptom severity among at-risk individuals. At-risk participants who transitioned to schizophrenia within 3 years, compared to those that did not transition, had more severe WM differences in fractional anisotropy and radial diffusivity (particularly in the corpus callosum, anterior corona radiata, and motor/sensory tracts), which were even more extensive compared to healthy controls.

Conclusions

These findings align with the subclinical symptom presentation and more extensive disruptions in converters, suggestive of severity-related demyelination or axonal pathology. Fine-grained but detectable differences among ultra-high-risk subjects (i.e., with brief limited intermittent and/or attenuated psychotic symptoms) point to the splenium as a discrete site of emerging psychopathology, while basic symptoms alone were not associated with altered fractional anisotropy.

Clinical high risk for psychosis in children and adolescents: A meta-analysis of transition prevalences

The strategic value of early, preventive intervention in psychosis has been a catalytic stepping stone to promoting early intervention in Mental Health. Central to such momentum is the construct of clinical high risk states for psychosis (CHR). While CHR emerge in developmental years, the meta-analytical risk of psychosis among children and adolescents (age 9-18 years) at CHR is still unknown. We conducted a meta-analysis according to PRISMA guidelines including all studies that assessed CHR in children and adolescents (age ≤ 18 years) with validated instruments and provided follow-data on transition to psychosis up to December 31, 2018. We identified 11 eligible studies. Mean age was 15.8 ± 0.8 years, range: 13.8 to 16.8. Transition to psychosis occurred in 93 CHR subjects out of 533 that were enrolled at inception, over a follow-up period ranging from 6 to 72 months. Conversion prevalence was 17.5% (95% CI: 9.9% to 26.5%) in the random-effects model (Q = 30.9; p < .001; I² = 68%), and slightly lower (16.0; 12.9% to 19.5%) in the fixed-effect model. Gender ratio, the criteria used to diagnose the CHR status, and quality of studies had an impact on the estimates of conversion prevalence in the intention-to-treat model without the outlier. Studies of fair quality produced lower estimates of conversion prevalence (11%; 95% CI: 2% to 24%) than those produced by studies of good quality (19%; 95% CI: 11% to 28%). These findings suggest that CHR in adolescence presents commensurable transition prevalences to those found in adult samples, confirming the relevance of CHR criteria for timely risk inception in developmental years. Outcomes other than transition to psychosis (e.g. remission, persistent CHR, socio-functional status or treatment responses) were not systematically reported thereby preventing further, more sophisticated, prognostic stratifications.

(Attenuated) hallucinations join basic symptoms in a transdiagnostic network cluster analysis

Hallucinations are considered characteristic symptoms of psychosis and part of the 'psychosis superspectrum' of the Hierarchical Taxonomy Of Psychopathology (HiTOP) initiative. To gain insight into their psychopathological relevance, we studied their dimensional placement within a single dense transdiagnostic network constituting of basic symptoms as well as of attenuated and frank psychotic, and related symptoms. Newman's modularity analysis was used to detect symptom clusters in an earlier generated network (Jimeno, N., et al., 2020. Main symptomatic treatment targets in suspected and early psychosis: New insights from network analysis. Schizophr. Bull. 46, 884-895. https://doi.org/10.1093/schbul/sbz140). The constituting 86 symptoms were assessed with the Schizophrenia Proneness Instrument, Adult version (SPI-A), the Structured Interview for Psychosis-Risk Syndromes (SIPS), and the Positive And Negative Syndrome Scale (PANSS) in three adult samples of an early detection service: clinical high-risk (n = 203), first-episode psychosis (n = 153), and major depression (n = 104). Three clusters were detected: "subjective disturbances", "positive symptoms and behaviors", and "negative and anxious-depressive symptoms". The predominately attenuated hallucinations of both SIPS and PANSS joined the basic symptoms in "subjective disturbances", whereas other positive symptoms entered "positive symptoms and behaviors". Our results underline the importance of insight in separating true psychotic hallucinations from other hallucinatory experiences that, albeit phenomenologically similar are still experienced with some insight, i.e., are present in an attenuated form. We conclude that, strictly, hallucinations held with any degree of insight should not be used to diagnose transition to or presence of frank psychoses and, relatedly, to justify antipsychotic medication.

What is obsession? Differentiating obsessive-compulsive disorder and the schizophrenia spectrum

Obsessive-compulsive symptoms are frequent in schizophrenia-spectrum disorders and often cause differential diagnostic challenges, especially in first-contact patients. Drawing upon phenomenology of cognition, we critically review classic and contemporary psychopathological notions of obsessive-compulsive phenomena and discuss their relevance for differential diagnosis between obsessive-compulsive disorder (OCD) and schizophrenia-spectrum disorders. The classic psychopathological literature defines true obsession as intrusions with intact resistance and insight and regards these features as essential to the diagnosis of OCD. In schizophrenia, the classic literature describes pseudo-obsessive-compulsive phenomena characterized by lack of resistance and an affinity with other symptoms such as thought disorder and catatonia. By contrast, the notions of obsession and compulsion are broader and conceptually vague in current diagnostic systems and research instruments. Here, these phenomena overlap with delusions as well as various subjective and behavioral anomalies, which we discuss in detail. Furthermore, we examine a link between obsessive-compulsive phenomena and disturbances of basic structures of experience in schizophrenia-spectrum disorders addressed in contemporary psychopathological research. We suggest that these experiential alterations have relevance for differential diagnosis and early detection in this complex symptom domain.

Systematic Review and Meta-analysis: Psychosis Risk in Children and Adolescents With an At-Risk Mental State

OBJECTIVE

The "At Risk Mental State" (ARMS) approach to psychosis, also called "Clinical/Ultra High Risk," has had a major impact on psychosis services internationally. Despite well-established developmental differences in the prevalence and expression of psychotic symptoms from childhood into adulthood, there has been no systematic review of psychosis transitions specifically in children and adolescents up to age of 18 years. Evidence for this age group is crucial for developmentally appropriate clinical decisions by child and adolescent psychiatrists.

METHOD

Systematic review and meta-analysis of psychosis risk among children diagnosed with ARMS up to age 18 years, with pooled transition rates after 1-year, 2-year and ≥5-year follow-up.

RESULTS

We retrieved 1,107 records and identified 16 articles from 9 studies reporting transition rates on 436 individuals with ARMS aged 9 to 18 years. The pooled transition rate to psychosis at 1 year was 9.5% (95% CI = 5.5%-14.2%, 7 studies included), at 2-years 12.1% (95% CI = 6.7%-18.6%, 4 studies included), and at ≥5 years 16.1% (95% CI = 5.6%-30.0%, 4 studies included). We did not find evidence that the diagnosis of ARMS was associated with increased risk of psychosis once risk-enriching recruitment strategies were taken into account.

CONCLUSION

At 5-year follow-up, 1 in 6 youths diagnosed with an ARMS had transitioned to psychosis, but we did not find evidence that this risk was related to ARMS diagnosis as opposed to sampling/recruitment strategies. Our findings indicate a need for caution in applying ARMS methodology to children and adolescents. and highlight the need for developmentally sensitive approaches when considering psychosis risk.

Cognitive Patterns and Conversion in a Representative Sample of Individuals at Risk for Psychosis

ABSTRACT

Clinical high-risk (CHR) individuals belong to a heterogeneous group, of which only a few will cross the threshold for a clinical diagnosis. Cognitive disturbances are present in CHR subjects and may be indicative of transition. Our study aims to identify such deficits in a representative CHR for psychosis sample. Our sample comprised 92 CHR individuals and 54 controls from a representative cohort of the general population. They were followed up for a mean of 2.5 years, with 15 individuals converting to schizophrenia or other Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnoses. Neurocognitive assessment was performed with the University of Pennsylvania Computerized Neuropsychological Testing, and CHR status was assessed with the Structured Interview for Prodromal Syndromes (SIPS). Baseline scores were entered in a latent profile analysis model. Our study brought forward a four-class model on cognitive performance. One class displayed better performance, whereas the other three performed worse, all compared with controls. The class with lower executive function also had the highest score on disorganized communication (SIPS P5 = 1.36, p < 0.05), although unrelated to conversion. Among the low performers, the class significantly related to conversion (p = 0.023) had the highest score in decreased expression of emotion (SIPS N3 = 0.85, p < 0.05). Our study brings new and relevant data on non-help-seeking CHR individuals and the relationship between cognitive patterns and conversion. We have highlighted a specific cognitive signature, associated with negative symptoms, which represents a stable trait with presumed lower conversion to a psychiatric illness.