Symptom assessment in early psychosis: the use of well-established rating scales in clinical high-risk and recent-onset populations

Preliminary Outcomes of an Ecological Momentary Intervention for Social Functioning in Schizophrenia: Pre-Post Study of the Motivation and Skills Support App

BACKGROUND

People with schizophrenia and other serious mental illnesses often lack access to evidence-based interventions, particularly interventions that target meaningful recovery outcomes such as social functioning and quality of life. Mobile technologies, including smartphone apps, have the potential to provide scalable support that places elements of evidence-based interventions at the palm of patients' hands.

OBJECTIVE

We aim to develop a smartphone app-called Motivation and Skills Support-to provide targeted social goal support (eg, making new friends and improving existing relationships) for people with schizophrenia enrolled in a stand-alone open trial.

METHODS

In this paper, we presented preliminary outcomes of 31 participants who used the Motivation and Skills Support app for 8 weeks, including social functioning pre- to postintervention, and momentary reports of treatment targets (eg, social motivation and appraisals) during the intervention.

RESULTS

The findings suggest that the intervention improved self-reported social functioning from baseline to treatment termination, particularly in female participants. Gains were not maintained at the 3-month follow-up. Furthermore, increased social functioning was predicted by momentary reports of social appraisals, including perceived social competence and the extent to which social interactions were worth the effort.

CONCLUSIONS

The implications of these findings and future directions for addressing social functioning in schizophrenia using mobile technology have been discussed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03404219; https://clinicaltrials.gov/ct2/show/NCT03404219.

Differential sensitivity to the acute psychotomimetic effects of delta-9-tetrahydrocannabinol associated with its differential acute effects on glial function and cortisol

BACKGROUND

Cannabis use has been associated with psychosis through exposure to delta-9-tetrahydrocannabinol (Δ9-THC), its key psychoactive ingredient. Although preclinical and human evidence suggests that Δ9-THC acutely modulates glial function and hypothalamic-pituitary-adrenal (HPA) axis activity, whether differential sensitivity to the acute psychotomimetic effects of Δ9-THC is associated with differential effects of Δ9-THC on glial function and HPA-axis response has never been tested.

METHODS

A double-blind, randomized, placebo-controlled, crossover study investigated whether sensitivity to the psychotomimetic effects of Δ9-THC moderates the acute effects of a single Δ9-THC dose (1.19 mg/2 ml) on myo-inositol levels, a surrogate marker of glia, in the Anterior Cingulate Cortex (ACC), and circadian cortisol levels, the key neuroendocrine marker of the HPA-axis, in a set of 16 healthy participants (seven males) with modest previous cannabis exposure.

RESULTS

The Δ9-THC-induced change in ACC myo-inositol levels differed significantly between those sensitive to (Δ9-THC minus placebo; M = -0.251, s.d. = 1.242) and those not sensitive (M = 1.615, s.d. = 1.753) to the psychotomimetic effects of the drug (t(14) = 2.459, p = 0.028). Further, the Δ9-THC-induced change in cortisol levels over the study period (baseline minus 2.5 h post-drug injection) differed significantly between those sensitive to (Δ9-THC minus placebo; M = -275.4, s.d. = 207.519) and those not sensitive (M = 74.2, s.d. = 209.281) to the psychotomimetic effects of the drug (t(13) = 3.068, p = 0.009). Specifically, Δ9-THC exposure lowered ACC myo-inositol levels and disrupted the physiological diurnal cortisol decrease only in those subjects developing transient psychosis-like symptoms.

CONCLUSIONS

The interindividual differences in transient psychosis-like effects of Δ9-THC are the result of its differential impact on glial function and stress response.

Pharmacological management of comorbid obsessive–compulsive disorder and chronic non-affective psychosis

The comorbidity of obsessive–compulsive symptoms (OCS) in the context of schizophrenia is often not recognised by clinicians, and patients may not report these symptoms until they become severe. However, there is a reported prevalence of 10–24% for obsessive–compulsive disorder (OCD) in schizophrenia and related disorders. The onset of OCS/OCD has been noted to occur both before and after the diagnosis of schizophrenia or schizoaffective disorder. It has also been known to occur following commencement of treatment with antipsychotic medications, especially clozapine. Current literature provides limited guidance for treatment. Review of the current evidence supports: addition of selective serotonin reuptake inhibitors (SSRIs) to antipsychotics; addition of aripiprazole, amisulpride or lamotrigine; or reduction in the dosage of clozapine. There is also evidence supporting the addition of cognitive–behavioural therapy and electroconvulsive therapy (ECT). The SSRIs that are evidenced to be useful are fluvoxamine, escitalopram, sertraline and paroxetine. More studies are needed to expand the evidence base. Early targeted interventions are recommended.

Brain changes associated with negative symptoms in clinical high risk for psychosis: A systematic review

The negative symptoms of schizophrenia are linked to poorer functional outcomes and decreases in quality of life, and are often the first to develop in individuals who are at clinical high risk (CHR) for psychosis. However, the accompanying neurobiological changes are poorly understood. Therefore, we conducted a systematic review of the studies that have examined the brain metrics associated with negative symptoms in those at CHR. Electronic databases were searched from inception to August 2019. Studies were selected if they mentioned negative symptoms in youth at CHR for psychosis, and brain imaging. Of 261 citations, 43 studies with 2144 CHR participants met inclusion criteria. Too few studies were focused on the same brain regions using similar neuroimaging methods to perform a meta-analysis, however, the results of this systematic review suggest a relationship between negative symptom increases and decreases in grey matter. The paucity of studies linking changes in brain structure and function with negative symptoms in those at CHR suggests that future work should focus on examining these relationships.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a scientific effort to address shortcomings of traditional mental disorder diagnoses, which suffer from arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. This paper synthesizes evidence on the validity and utility of the thought disorder and detachment spectra of HiTOP. These spectra are composed of symptoms and maladaptive traits currently subsumed within schizophrenia, other psychotic disorders, and schizotypal, paranoid and schizoid personality disorders. Thought disorder ranges from normal reality testing, to maladaptive trait psychoticism, to hallucinations and delusions. Detachment ranges from introversion, to maladaptive detachment, to blunted affect and avolition. Extensive evidence supports the validity of thought disorder and detachment spectra, as each spectrum reflects common genetics, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, biomarkers, and treatment response. Some of these characteristics are specific to one spectrum and others are shared, suggesting the existence of an overarching psychosis superspectrum. Further research is needed to extend this model, such as clarifying whether mania and dissociation belong to thought disorder, and explicating processes that drive development of the spectra and their subdimensions. Compared to traditional diagnoses, the thought disorder and detachment spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and higher acceptability to clinicians. Validated measures are available to implement the system in practice. The more informative, reliable and valid characterization of psychosis-related psychopathology offered by HiTOP can make diagnosis more useful for research and clinical care.

Delta-9-tetrahydrocannabinol increases striatal glutamate levels in healthy individuals: implications for psychosis

The neurobiological mechanisms underlying the association between cannabis use and acute or long-lasting psychosis are not completely understood. While some evidence suggests altered striatal dopamine may underlie the association, direct evidence that cannabis use affects either acute or chronic striatal dopamine is inconclusive. In contrast, pre-clinical research suggests that cannabis may affect dopamine via modulation of glutamate signaling. A double-blind, randomized, placebo-controlled, crossover design was used to investigate whether altered striatal glutamate, as measured using proton magnetic resonance spectroscopy, underlies the acute psychotomimetic effects of intravenously administered delta-9-tetrahydrocannabinol (Δ9-THC; 1.19 mg/2 ml), the key psychoactive ingredient in cannabis, in a set of 16 healthy participants (7 males) with modest previous cannabis exposure. Compared to placebo, acute administration of Δ9-THC significantly increased Glutamate (Glu) + Glutamine (Gln) metabolites (Glx) in the left caudate head (P = 0.027). Furthermore, compared to individuals who were not sensitive to the psychotomimetic effects of Δ9-THC, individuals who developed transient psychotic-like symptoms (~70% of the sample) had significantly lower baseline Glx (placebo; P 7= 0.023) and a 2.27-times higher increase following Δ9-THC administration. Lower baseline Glx values (r = -0.55; P = 0.026) and higher previous cannabis exposure (r = 0.52; P = 0.040) were associated with a higher Δ9-THC-induced Glx increase. These results suggest that an increase in striatal glutamate levels may underlie acute cannabis-induced psychosis while lower baseline levels may be a marker of greater sensitivity to its acute psychotomimetic effects and may have important public health implications.

Individualized Prediction of Transition to Psychosis in 1,676 Individuals at Clinical High Risk: Development and Validation of a Multivariable Prediction Model Based on Individual Patient Data Meta-Analysis

Background: The Clinical High Risk state for Psychosis (CHR-P) has become the cornerstone of modern preventive psychiatry. The next stage of clinical advancements rests on the ability to formulate a more accurate prognostic estimate at the individual subject level. Individual Participant Data Meta-Analyses (IPD-MA) are robust evidence synthesis methods that can also offer powerful approaches to the development and validation of personalized prognostic models. The aim of the study was to develop and validate an individualized, clinically based prognostic model for forecasting transition to psychosis from a CHR-P stage. Methods: A literature search was performed between January 30, 2016, and February 6, 2016, consulting PubMed, Psychinfo, Picarta, Embase, and ISI Web of Science, using search terms ("ultra high risk" OR "clinical high risk" OR "at risk mental state") AND [(conver* OR transition* OR onset OR emerg* OR develop*) AND psychosis] for both longitudinal and intervention CHR-P studies. Clinical knowledge was used to a priori select predictors: age, gender, CHR-P subgroup, the severity of attenuated positive psychotic symptoms, the severity of attenuated negative psychotic symptoms, and level of functioning at baseline. The model, thus, developed was validated with an extended form of internal validation. Results: Fifteen of the 43 studies identified agreed to share IPD, for a total sample size of 1,676. There was a high level of heterogeneity between the CHR-P studies with regard to inclusion criteria, type of assessment instruments, transition criteria, preventive treatment offered. The internally validated prognostic performance of the model was higher than chance but only moderate [Harrell's C-statistic 0.655, 95% confidence interval (CIs), 0.627-0.682]. Conclusion: This is the first IPD-MA conducted in the largest samples of CHR-P ever collected to date. An individualized prognostic model based on clinical predictors available in clinical routine was developed and internally validated, reaching only moderate prognostic performance. Although personalized risk prediction is of great value in the clinical practice, future developments are essential, including the refinement of the prognostic model and its external validation. However, because of the current high diagnostic, prognostic, and therapeutic heterogeneity of CHR-P studies, IPD-MAs in this population may have an limited intrinsic power to deliver robust prognostic models.

A Comprehensive Review of Computational Methods for Automatic Prediction of Schizophrenia With Insight Into Indigenous Populations

Psychiatrists rely on language and speech behavior as one of the main clues in psychiatric diagnosis. Descriptive psychopathology and phenomenology form the basis of a common language used by psychiatrists to describe abnormal mental states. This conventional technique of clinical observation informed early studies on disturbances of thought form, speech, and language observed in psychosis and schizophrenia. These findings resulted in language models that were used as tools in psychosis research that concerned itself with the links between formal thought disorder and language disturbances observed in schizophrenia. The end result was the development of clinical rating scales measuring severity of disturbances in speech, language, and thought form. However, these linguistic measures do not fully capture the richness of human discourse and are time-consuming and subjective when measured against psychometric rating scales. These linguistic measures have not considered the influence of culture on psychopathology. With recent advances in computational sciences, we have seen a re-emergence of novel research using computing methods to analyze free speech for improving prediction and diagnosis of psychosis. Current studies on automated speech analysis examining for semantic incoherence are carried out based on natural language processing and acoustic analysis, which, in some studies, have been combined with machine learning approaches for classification and prediction purposes.

The component structure of the scales for the assessment of positive and negative symptoms in first-episode psychosis and its dependence on variations in analytic methods

A secondary analysis was undertaken on Scales for the Assessment of Positive and Negative Symptoms (SAPS/SANS) data from 345 first-episode psychosis (FEP) patients gathered in the West London FEP study. The purpose of this study was to determine: (i) the component structure of these measures in FEP (primary analyses), and (ii) the dependence of any findings in these primary analyses on variations in analytic methods. Symptom ratings were exposed to data reduction methods and the effects of the following manipulations ascertained: (i) level of analysis (individual symptom vs. global symptom severity ratings), (ii) extraction method (principal component vs. exploratory factor analysis) and (iii) retention method (scree test vs. Kaiser criterion). Whilst global ratings level analysis rendered the classic triad of psychotic syndromes (positive, negative and disorganisation), symptom level analyses revealed a hierarchical structure, with 11 first-order components subsumed by three second-order components, which also mapped on to this syndrome triad. These results were robust across data reduction but not component retention methods, suggesting that discrepancies in the literature regarding the component structure of the SAPS/SANS partly reflect the level of analysis and component retention method used. Further, they support a hierarchical symptom model, the implications of which are discussed.

Factor structure of the positive and negative syndrome scale (PANSS) in people at ultra high risk (UHR) for psychosis

INTRODUCTION

The Positive and Negative Syndrome Scale (PANSS), a comprehensive psychopathology assessment scale used in the evaluation of psychopathology in schizophrenia, is also often used in the Ultra-High-Risk (UHR) population. This paper examined the dimensional structure of the PANSS in a UHR sample.

METHODS

A total of 168 individuals assessed to be at UHR for psychosis on the Comprehensive Assessment of At-Risk Mental States (CAARMS) were evaluated on the PANSS, Calgary Depression Scale for Schizophrenia (CDSS), Beck Anxiety Inventory (BAI), Brief Assessment of Cognition in Schizophrenia (BACS), and Global Assessment of Functioning (GAF). Exploratory factor analysis (EFA) of the PANSS was performed to identify the factorial structure. Convergent validity was explored with the CAARMS, CDSS, BAI and BACS.

RESULTS

EFA of the PANSS yielded five symptom factors - Positive, Negative, Cognition/Disorganization, Anxiety/Depression, and Hostility. This 5-factor solution showed good convergent validity with the CAARMS composite score, CDSS, BAI, and BACS. Positive, Negative and Anxiety/Depression factors were associated with functioning.

CONCLUSION

The reported PANSS factor structure may serve to improve the understanding and measurement of clinical symptom dimensions manifested in people with UHR for future research and clinical setting.

Corpus callosum shape and morphology in youth across the psychosis Spectrum

The corpus callosum is the largest white matter tract in the human brain connecting and coordinating homologous regions of the right and left hemispheres and has been strongly implicated in the pathogenesis of psychosis. We investigated corpus callosum morphology in a large community cohort of 917 individuals (aged 8-21), including 267 endorsing subsyndromal or threshold psychotic symptoms (207 on the psychosis spectrum and 60 with limited psychosis based on previously published criteria) and 650 non-psychotic volunteers. We used a highly reliable and previously published algorithm to automatically identify the midsagittal plane and to align the corpus callosum along the anterior and posterior commissures for segmentation, thereby eliminating these sources of error variance in dependent measures, which included perimeter, length, mean thickness and shape (circularity). The parcellation scheme divided the corpus callosum into 7 subregions that consisted of the rostrum, genu, rostral body, anterior midbody, posterior midbody, isthmus, and splenium. Both individuals endorsing psychotic symptoms and those with limited psychosis had significantly (p<.05) smaller area and lower thickness measures compared to healthy volunteers, but did not differ significantly from each other. Findings were relatively widespread indicating a relatively global effect not circumscribed to any particular corpus callosum subregion. These data are consistent with the hypothesis that corpus callosum abnormalities may be evident early in the course of illness and predate the onset of frank psychosis. Given that these measures can be easily obtained and are highly reliable they may assist in the identification of individuals at future risk for psychosis.

North American Prodrome Longitudinal Study (NAPLS 2): The Prodromal Symptoms

In studies describing the long-term follow-up up of youth at clinical high risk (CHR) of psychosis, little attention has been given to details of specific prodromal symptoms. In this paper, we describe the prodromal symptoms of 764 CHR participants recruited in the multi-site North American Prodrome Longitudinal Study (NAPLS). Symptoms were rated on the Scale of Prodromal Symptoms (SOPS) at baseline and 6-, 12-, 18-, and 24-month follow-ups. Clinical outcome at the 2-year assessment was categorized as psychotic, prodromal progression, symptomatic or in remission. Most of the CHR sample (92%) met criteria for the attenuated positive symptoms syndrome (APSS). Significant improvements in SOPS symptoms were observed over time. Unusual thought content, disorganized communication, and overall ratings on disorganized symptoms differentiated those who transitioned to psychosis from the other clinical outcome groups. Suspiciousness and total positive symptoms differentiated those in remission from the other clinical outcome groups.