Basic symptoms in the general population and in psychotic and non-psychotic psychiatric adolescents

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.

On the proportion of patients who experience a prodrome prior to psychosis onset: A systematic review and meta-analysis

BACKGROUND

Preventing or delaying the onset of psychosis requires identification of those at risk for developing psychosis. For predictive purposes, the prodrome - a constellation of symptoms which may occur before the onset of psychosis - has been increasingly recognized as having utility. However, it is unclear what proportion of patients experience a prodrome or how this varies based on the multiple definitions used.

METHODS

We conducted a systematic review and meta-analysis of studies of patients with psychosis with the objective of determining the proportion of patients who experienced a prodrome prior to psychosis onset. Inclusion criteria included a consistent prodrome definition and reporting the proportion of patients who experienced a prodrome. We excluded studies of only patients with a prodrome or solely substance-induced psychosis, qualitative studies without prevalence data, conference abstracts, and case reports/case series. We searched Ovid MEDLINE, Embase (Ovid), APA PsycInfo (Ovid), Web of Science Core Collection (Clarivate), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, APA PsycBooks (Ovid), ProQuest Dissertation & Thesis, on March 3, 2021. Studies were assessed for quality using the Critical Appraisal Checklist for Prevalence Studies. Narrative synthesis and proportion meta-analysis were used to estimate prodrome prevalence. I2 and predictive interval were used to assess heterogeneity. Subgroup analyses were used to probe sources of heterogeneity. (PROSPERO ID: CRD42021239797).

RESULTS

Seventy-one articles were included, representing 13,774 patients. Studies varied significantly in terms of methodology and prodrome definition used. The random effects proportion meta-analysis estimate for prodrome prevalence was 78.3% (95% CI = 72.8-83.2); heterogeneity was high (I2 97.98% [95% CI = 97.71-98.22]); and the prediction interval was wide (95% PI = 0.411-0.936). There were no meaningful differences in prevalence between grouped prodrome definitions, and subgroup analyses failed to reveal a consistent source of heterogeneity.

CONCLUSIONS

This is the first meta-analysis on the prevalence of a prodrome prior to the onset of first episode psychosis. The majority of patients (78.3%) were found to have experienced a prodrome prior to psychosis onset. However, findings are highly heterogenous across study and no definitive source of heterogeneity was found despite extensive subgroup analyses. As most studies were retrospective in nature, recall bias likely affects these results. While the large majority of patients with psychosis experience a prodrome in some form, it is unclear if the remainder of patients experience no prodrome, or if ascertainment methods employed in the studies were not sensitive to their experiences. Given widespread investment in indicated prevention of psychosis through prospective identification and intervention during the prodrome, a resolution of this question as well as a consensus definition of the prodrome is much needed in order to effectively direct and organize services, and may be accomplished through novel, densely sampled and phenotyped prospective cohort studies that aim for representative sampling across multiple settings.

[Basic symptoms in young female patients with depression within the framework of schizophrenia and affective spectrum disorders]

OBJECTIVE

To investigate the structure and severity of basic symptoms in young female patients with endogenous depression.

MATERIAL AND METHODS

One hundred and nineteen female patients, aged from 16 to 26 years, were examined. Three groups were identified: patients meeting the criteria of high risk of psychosis (51 patients, mean age 18.55±3.84 years), patients not meeting the criteria of high risk of psychosis(48 patients, mean age 20.12±3.84 years), patients with postpsychotic depression (20 patients, mean age 21.8±4.5 years). The main method of the study was the application of COGDIS (Cognitive Distortions) and COPER (Cognitive-perceptual baseline symptoms) criteria.

RESULTS

The baseline symptoms criteria were met by 83.3% of depressed patients without psychosis risk symptoms (mean severity score 24.0±14.7), 96% of depressed patients with high psychosis risk symptoms (38.1±15.9 points), and 50% of patients with postpsychotic depression (15.3±12.9 points). COGDIS criteria were met by 62.5% of depressed patients without psychosis risk symptoms (16.2±10.1 points), 68.6% of depressed patients with high psychosis risk symptoms (22.3±9.6 points), and 25% of patients with postpsychotic depression (9.2±8.4 points). The COPER criteria were met by 77.5% of patients with depression without psychosis risk symptoms (16.2±10.3 points), 92.2% of patients with depression at high risk of psychosis (28.4±14.0 points), and 50% of patients with postpsychotic depression (8.9±9.7 points).

CONCLUSIONS

The group with post schizophrenic depression was characterized by lower basic symptom scale scores and percentage of eligible patients. Basic symptoms were common in a group of young female patients with depression who did not meet high-risk criteria. The score differentiates the high-risk group from the group of patients without risk symptoms.

Perceived Stress and Life Events in Patients Affected by Schizophrenia and Schizoaffective and Bipolar Disorder: Is There a Role for Self-Reported Basic Symptoms?

INTRODUCTION

The stress-diathesis model of psychotic disorders describes, in vulnerable individuals, the role of psychosocial stress in the onset and exacerbation of psychotic symptoms. Another interesting approach to the study of vulnerability in the development of psychosis is represented by the basic symptoms concept.

OBJECTIVE

The present study aims at proposing an integration between these two models and investigating possible associations between psychotic symptoms, basic symptoms, perceived stress, and life events in a sample of patients affected by schizophrenia (SZ), schizoaffective (SA), and bipolar disorder with and without psychotic symptoms.

METHODS

112 patients were recruited in two university hospitals. Severity of psychiatric symptoms (Positive and Negative Syndrome Scale, PANSS), basic symptoms (Frankfurt Complaint Questionnaire, FCQ), perceived stress (Stress-related Vulnerability Scale, SVS), and life events (Paykel's interview for recent life events) were assessed.

RESULTS

Patients affected by bipolar disorder (both with and without psychotic symptoms) showed a higher number of independent life events (p < 0.01) and tended to report more frequently at least 1 life event in the previous 6 months (p < 0.01) than patients affected by SZ or SA disorder. No differences emerged between the study groups in perceived stress nor in measures of basic symptoms. In the whole sample, a logistic regression analysis showed that the SVS total score (p < 0.05) and PANSS total score (p < 0.001) were associated with the presence of psychotic symptoms.

CONCLUSIONS

In the study sample, life events and basic symptoms did not play a major role in influencing psychotic symptoms, compared to the subjective perception of stress and the severity of psychopathology. Taken together, these results can be informative for rehabilitation therapies aimed at enhancing resilience and coping strategies in this vulnerable group of patients.

Markers of Psychosis Risk in the General Population

The categorical approach to defining schizophrenia spectrum disorders requires meeting established criteria. To advance early identification and intervention in young people, the field has progressed to studying help-seeking individuals who are at clinical high risk based on subthreshold psychosis spectrum symptoms, and criteria have been articulated for qualifying individuals as at risk. A broader dimensional examination of psychosis has been applied to population-based studies on non-help seekers. This review highlights the ascertainment and assessment approaches to such population-based studies. Most studies are cross-sectional and rely on questionnaires with limited overlap of tools. However, several consistent findings emerge on symptoms, neurocognitive deficits, and neuroimaging parameters and other biomarkers associated with emergence and persistence of psychotic features. The findings are consistent with the literature on abnormalities associated with schizophrenia, including the presence of neurocognitive deficits; abnormalities in brain structure, function, and connectivity that are related to distress; impairment; and functional outcome. These findings support the validity of studying psychosis experiences during development in a way that can chart the emergence of psychosis in the context of general psychopathology. Such studies are necessary for establishing developmental trajectories that characterize this emergence and for identifying risk and resilience biomarkers moderating or modulating the full range of schizophrenia-related manifestations. More community-based studies are needed, with better standardization and harmonization of measures and incorporating longitudinal follow-up, to establish mechanistic links between cellular-molecular aberrations and specific manifestations of psychosis as envisioned by the precision medicine agenda.

Characterization of children and adolescents with psychosis risk syndrome: The Children and Adolescents Psychosis Risk Syndrome (CAPRIS) study

AIM

Despite the interest in psychosis risk syndrome (PRS) in children and adolescents, information on the syndrome in this population is scarce.

METHODS

Prospective naturalistic multi-site study in which 10- to 17-year-old help-seeking subjects who met PRS criteria (positive or negative attenuated symptoms; brief limited intermittent psychotic symptoms; genetic risk or schizotypal personality disorder plus impairment in functioning) were included, along with 45 age and sex-matched healthy controls (HC). All subjects were clinically and functionally assessed.

RESULTS

Ninety-one PRS subjects (PRSS) with a mean age of 15.5 ± 1.4 met inclusion criteria (IC). Compared with HC, PRSS presented worse global and academic functioning in the previous year, had experienced more psychiatric and psychological problems, and presented gestational ages outside the normal range. More than 80% of PRSS met ≥2 IC, with 65.9% having one Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision diagnosis, and 61.7% of those having ≥2 diagnoses. Some 49.5% of PRSS had a first- or second-degree family history (FH) of psychosis. Patients with first- and second-degree FH do not differ in their clinical expression.

CONCLUSIONS

Children and adolescents with PRS are a patient group with a pattern of neurodevelopmental impairment and clinical complexity similar to patients with schizophrenia spectrum disorders, highlighting the importance of assessing these variables in child and adolescent samples. PRSS with first- and second-degree relatives with FH do not present differences in their clinical presentation, suggesting that including these two groups of patients in the genetic risk criteria would enrich knowledge of these criteria.

Basic symptoms in offspring of parents with mood and psychotic disorders

BACKGROUND

Basic symptoms, defined as subjectively perceived disturbances in thought, perception and other essential mental processes, have been established as a predictor of psychotic disorders. However, the relationship between basic symptoms and family history of a transdiagnostic range of severe mental illness, including major depressive disorder, bipolar disorder and schizophrenia, has not been examined.

AIMS

We sought to test whether non-severe mood disorders and severe mood and psychotic disorders in parents is associated with increased basic symptoms in their biological offspring.

METHOD

We measured basic symptoms using the Schizophrenia Proneness Instrument - Child and Youth Version in 332 youth aged 8-26 years, including 93 offspring of control parents, 92 offspring of a parent with non-severe mood disorders, and 147 offspring of a parent with severe mood and psychotic disorders. We tested the relationships between parent mental illness and offspring basic symptoms in mixed-effects linear regression models.

RESULTS

Offspring of a parent with severe mood and psychotic disorders (B = 0.69, 95% CI 0.22-1.16, P = 0.004) or illness with psychotic features (B = 0.68, 95% CI 0.09-1.27, P = 0.023) had significantly higher basic symptom scores than control offspring. Offspring of a parent with non-severe mood disorders reported intermediate levels of basic symptoms, that did not significantly differ from control offspring.

CONCLUSIONS

Basic symptoms during childhood are a marker of familial risk of psychopathology that is related to severity and is not specific to psychotic illness.

DECLARATION OF INTEREST

None.

A Public Health Perspective on Screening for Psychosis Within General Practice Clinics

Screening for major mental illness in adolescents and young adults has lagged behind screening for physical illness for a myriad of reasons. Existing pediatric behavioral health screening tools screen primarily for disorders of attention, disruptive behaviors, depression, and anxiety. A few also screen for substance use and suicide risk. Although it is now possible to reliably identify young people at imminent risk for a psychotic disorder, arguably the most severe of mental illnesses, general practitioners (GP) rarely screen for psychotic symptoms or recognize when to refer patients for a specialized risk assessment. Research suggests that barriers such as inadequate knowledge or insufficient access to mental health resources can be overcome with intensive GP education and the integration of physical and mental health services. Under the lens of two public health models outlining the conditions under which disease screening is warranted, we examine additional evidence for and against population-based screening for psychosis in adolescents and young adults. We argue that systematic screening within general health settings awaits a developmentally well-normed screening tool that includes probes for psychosis, is written at a sufficiently low reading level, and has acceptable sensitivity and, in particular, specificity for detecting psychosis and psychosis risk in both adolescents and young adults. As integrated healthcare models expand around the globe and psychosis-risk assessments and treatments improve, a stratified screening and careful risk management protocol for GP settings could facilitate timely early intervention that effectively balances the benefit/risk ratio of employing such a screening tool at the population level.

Adolescents at ultra-high risk of psychosis in Italian neuropsychiatry services: prevalence, psychopathology and transition rate

Studies in adolescents on ultra-high risk (UHR) and basic symptoms (BS) criteria for psychosis prediction are scarce. In Italy, early interventions in psychosis are less widespread than in other European countries. In the present study, we (1) assessed the clinical relevance of a UHR diagnosis [according to the comprehensive assessment of at-risk mental states (CAARMS) criteria] to promote the implementation of specific services for UHR adolescents into the Italian health care system; (2) described severity of positive, negative, general, and basic symptoms in UHR adolescents compared to adolescents with first-episode psychosis (FEP) and non-UHR adolescents (i.e., individuals who did not meet CAARMS criteria for UHR or FEP); and (3) investigated the predictive validity of UHR criteria in relation to BS criteria. Seventy-nine adolescents (aged 13-18 years) were assessed with the CAARMS, the positive and negative syndrome scale (PANSS), and the schizophrenia proneness instrument, child and youth version (SPI-CY). Both UHR (n = 25) and FEP (n = 11) had significantly higher PANSS subscale scores compared to non-UHR (n = 43). UHR had significantly lower PANSS-positive symptom scores than FEP, but similar global functioning and PANSS-negative symptoms and general psychopathology scores. Compared to non-UHR, both FEP and UHR had more severe thought and perception BS disturbances, and significantly more often met BS criteria. After 12 months, 2 of 20 (10%) UHR had transitioned to psychosis. They also met both BS criteria. Given the uncertain outcome of UHR adolescents, future research is needed to determine whether the combined assessment of BS with UHR symptoms can improve the accuracy of psychosis prediction in adolescence.

Self-Reported Visual Perceptual Abnormalities Are Strongly Associated with Core Clinical Features in Psychotic Disorders

BACKGROUND

Past studies using the Bonn Scale for the Assessment of Basic Symptoms (hereafter, Bonn Scale) have shown that self-reported perceptual/cognitive disturbances reveal which persons have or will soon develop schizophrenia. Here, we focused specifically on the clinical value of self-reported visual perceptual abnormalities (VPAs) since they are underexplored and have been associated with suicidal ideation, negative symptoms, and objective visual dysfunction.

METHOD

Using the 17 Bonn Scale vision items, we cross-sectionally investigated lifetime occurrence of VPAs in 21 first-episode psychosis and 22 chronic schizophrenia/schizoaffective disorder (SZ/SA) patients. Relationships were probed between VPAs and illness duration, symptom severity, current functioning, premorbid functioning, diagnosis, and age of onset.

RESULTS

Increased VPAs were associated with: earlier age of onset; more delusions, hallucinations, bizarre behavior, and depressive symptoms; and worse premorbid social functioning, especially in the childhood and early adolescent phases. SZ/SA participants endorsed more VPAs as compared to those with schizophreniform or psychotic disorder-NOS, especially in the perception of color, bodies, faces, object movement, and double/reversed vision. The range of self-reported VPAs was strikingly similar between first-episode and chronic patients and did not depend on the type or amount of antipsychotic medication. As a comparative benchmark, lifetime occurrence of visual hallucinations did not depend on diagnosis and was linked only to poor premorbid social functioning.

CONCLUSION

A brief 17-item interview derived from the Bonn Scale is strongly associated with core clinical features in schizophrenia. VPAs hold promise for clarifying diagnosis, predicting outcome, and guiding neurocognitive investigations.

Attenuated psychotic and basic symptom characteristics in adolescents with ultra-high risk criteria for psychosis, other non-psychotic psychiatric disorders and early-onset psychosis

While attenuated psychotic symptoms (APS) and basic symptoms (BS) are the main current predictors of psychosis in adults, studies in adolescents are scarce. Thus, we (1) described the prevalence and severity of positive, negative, disorganization, general, and basic symptoms in adolescent patients at ultra-high risk for psychosis (UHR), with other non-psychotic psychiatric disorders (PC) and with early-onset psychosis (EOP); and (2) investigated BS criteria in relation to UHR criteria. Sixty-nine 12-18-year-old adolescents (15.3 ± 1.7 years, female = 58.0 %, UHR = 22, PC = 27, EOP = 20) were assessed with the structured interview for prodromal syndromes (SIPS) and the schizophrenia proneness instrument-child and youth version (SPI-CY). Despite similar current and past 12-month global functioning, both UHR and EOP had significantly higher SIPS total and subscale scores compared to PC, with moderate-large effect sizes. Expectedly, UHR had significantly lower SIPS positive symptom scores than EOP, but similar SIPS negative, disorganized, and general symptom scores. Compared to PC, both EOP and UHR had more severe basic thought and perception disturbances, and significantly more often met cognitive disturbances criteria (EOP = 50.0 %, UHR = 40.9 %, PC = 14.8 %). Compared to UHR, both EOP and PC significantly less often met cognitive-perceptive BS criteria (EOP = 35.0 %, UHR = 68.2 %, PC = 25.9 %). BS were significantly more prevalent in both EOP and UHR than PC, and UHR were similar to EOP in symptom domains. Given the uncertain outcome of adolescents at clinical high-risk of psychosis, future research is needed to determine whether the combined assessment of early subjective disturbances with observable APS can improve the accuracy of psychosis prediction.

Disturbances of the Basic Self and Prodromal Symptoms Among Young Adolescents From the Community: A Pilot Population-Based Study

BACKGROUND AND GOAL

Recent findings have provided preliminary support for the notion that basic self-disturbances (SD) are related to prodromal symptoms among nonpsychotic help-seeking adolescents. As a sizable proportion of adolescents who are at risk do not seek help, this study attempts to assess the extent to which these findings can be generalized to the entire population of adolescents who are at risk for psychosis.

METHOD

The concurrent relationship between SD and prodromal symptoms was explored in a sample of 100 non-help-seeking adolescents (age 13-15) from the community. SD were assessed with the Examination of Anomalous Self-Experience (EASE); prodromal symptoms and syndromes were assessed with the Structured Interview for Prodromal Syndromes (SIPS); psychosocial functioning was assessed with the "Social and Role Global Functioning Scales"; and level of distress with the Mood and Anxiety States Questionnaire (MASQ).

RESULTS

SD significantly correlated with sub-clinical psychotic symptoms (r = .70, P < .0001). This correlation was significantly stronger than those of SD with mood symptoms and social functioning. Finally, SD was the single best concurrent predictor of prodromal symptoms and syndromes.

CONCLUSIONS

These results provide preliminary support for the generalizability of the association between SD and prodromal symptoms for the entire population of adolescents who are clinically at high risk for psychosis. In addition, they further support the notion that this association is both specific and unique.

Demographic and Environmental Factors Associated With Successful Day School Treatment Program Outcomes

In this study the authors examine the impact of admission characteristics of 105 students admitted to a day school treatment program on outcomes. Those who graduated, earned a general education diploma (GED), or were returned to a regular classroom setting were categorized as successful and those placed in a more restrictive settings (including detention), dropped out, or left the program with no known outcome were unsuccessful. The sample was largely male (n = 78, 74.3%), Caucasian (64%, n = 67), poor (53.4%), and entered in middle school or high school (73%). The majority (53.3%) had 4 or more prior educational placements before entering. They stayed in the program on average 2.5 years (SD = 2.17) with a range from 6 days through 10 years. Forty-three (41%) students were successfully discharged. Unsuccessfully discharged students dropped out (31.4%), placed in residential programs (19%), or were psychiatrically hospitalized (5.7%). At intake, 56 (53.3%) had a history of truancy, 38 (37.1%) had a PINS and 28 (26.7%) had been on probation. African Americans were approximately 73% less likely to succeed and were more likely to be from families meeting federal poverty guidelines and to live in single family households. Those who entered the program in grades K-6 or 10-12 were over 3 times more likely to succeed than students admitted in grades 7-9. Using logistic regression to assess the bivariate relationships of the demographic characteristics with successful discharge, race, admission while in grades 7-9, having both parents at home, and number of days in the program were significantly associated with success. Having externalizing behaviors, 5 or more prior placements, history of truancy, and contact with the juvenile justice system were associated with unsuccessful outcomes. Students with a history of being in the juvenile justice system were 87% less likely to succeed in the program. Implications for school social workers are discussed.

Patterns and correlates of expressed emotion, perceived criticism, and rearing style in first admitted early-onset schizophrenia spectrum disorders

The aim of this study was to assess patterns and correlates of family variables in 31 adolescents treated for their first episode of a schizophrenia spectrum disorder (early-onset schizophrenia [EOS]). Expressed emotion, perceived criticism, and rearing style were assessed. Potential correlates were patient psychopathology, premorbid adjustment, illness duration, quality of life (QoL), sociodemographic variables, patient and caregiver "illness concept," and caregiver personality traits and support. Families were rated as critical more frequently by patients than raters (55% vs. 13%). Perceived criticism was associated with worse QoL in relationship with parents and peers. An adverse rearing style was associated with a negative illness concept in patients, particularly with less trust in their physician. Future research should examine perceived criticism as a predictor of relapse and indicator of adolescents with EOS who need extended support and treatment. Rearing style should be carefully observed because of its link with patients' illness concept and, potentially, to service engagement and medication adherence.

Basic symptoms and psychotic symptoms: their relationships in the at risk mental states, first episode and multi-episode schizophrenia

In the field of the early psychosis two main approaches attempt to develop rating tools, one investigating the basic symptoms domain, and the other the attenuated psychotic symptoms. To explore the relationship between basic symptoms (BSs) and other symptom domains in different phases of the psychotic illness 32 at ultra-high risk (UHR), 49 first episode schizophrenia (FES), 42 multiple episode schizophrenia (MES), and 28 generalized anxiety disorder (GAD) patients were enrolled. Participants were assessed using the SIPS/SOPS and the FCQ scales. Analyses of covariance taking into account socio-demographic and clinical variables significantly different between groups were applied to compare FCQ and SOPS scores. Finally FCQ and SOPS principal component analysis was carried out in the schizophrenia spectrum group. SOPS scores were higher in the UHR, FES and MES groups compared to the GAD control group. Concordantly, FES and MES groups had a higher number of basic symptoms in comparison with the GAD group, whereas UHR did not differ from the control group. The largest number of correlations between BSs and psychotic symptoms was found in the GAD group. According to the principal component analysis (PCA) five factors were extracted, with the BSs loading on a unique factor. Our findings imply that the boundary between psychotic and non-psychotic conditions cannot be outlined on the basis of the presence/absence of basic and psychotic symptoms.

Executive functions and basic symptoms in adolescent antisocial behavior: a cross-sectional study on an Italian sample of late-onset offenders

Executive cognitive functions (ECFs) and other cognitive impairments, such as lower IQ and verbal deficits, have been associated with the pattern of antisocial and delinquent behavior starting in childhood (early-onset), but not with late-onset antisocial behavior. Beyond objective measures of ECF, basic symptoms are prodromal, subjectively experienced cognitive, perceptual, affective, and social disturbances, associated with a range of psychiatric disorders, mainly with psychosis. The goal of the present study was to examine ECF and basic symptoms in a sample of late-onset juvenile delinquents. Two-hundred nine male adolescents (aged 15-20 years) characterized by a pattern of late-onset delinquent behavior with no antecedents of Conduct Disorder, were consecutively recruited from the Social Services of the Department of Juvenile Justice of the city of Messina (Italy), and compared with nonantisocial controls matched for age, educational level, and socio-demographic features on measures for ECF dysfunction and basic symptoms. Significant differences between late-onset offenders (completers=147) and control group (n=150) were found on ECF and basic symptoms measures. Chi-square analysis showed that a significantly greater number of late-onset offending participants scored in the clinical range on several ECF measures. Executive cognitive impairment, even subtle and subclinical, along with subjective symptoms of cognitive dysfunction (basic symptom), may be contributing factor in the development and persistence of antisocial behaviors displayed by late-onset adolescent delinquents. The findings also suggest the need for additional research aimed to assess a broader range of cognitive abilities and specific vulnerability and risk factors for late-onset adolescent offenders.

Negative psychotic symptoms and impaired role functioning predict transition outcomes in the at-risk mental state: a latent class cluster analysis study

BACKGROUND

Many research groups have attempted to predict which individuals with an at-risk mental state (ARMS) for psychosis will later develop a psychotic disorder. However, it is difficult to predict the course and outcome based on individual symptoms scores.

METHOD

Data from 318 ARMS individuals from two specialized services for ARMS subjects were analysed using latent class cluster analysis (LCCA). The score on the Comprehensive Assessment of At-Risk Mental States (CAARMS) was used to explore the number, size and symptom profiles of latent classes.

RESULTS

LCCA produced four high-risk classes, censored after 2 years of follow-up: class 1 (mild) had the lowest transition risk (4.9%). Subjects in this group had the lowest scores on all the CAARMS items, they were younger, more likely to be students and had the highest Global Assessment of Functioning (GAF) score. Subjects in class 2 (moderate) had a transition risk of 10.9%, scored moderately on all CAARMS items and were more likely to be in employment. Those in class 3 (moderate-severe) had a transition risk of 11.4% and scored moderately severe on the CAARMS. Subjects in class 4 (severe) had the highest transition risk (41.2%), they scored highest on the CAARMS, had the lowest GAF score and were more likely to be unemployed. Overall, class 4 was best distinguished from the other classes on the alogia, avolition/apathy, anhedonia, social isolation and impaired role functioning.

CONCLUSIONS

The different classes of symptoms were associated with significant differences in the risk of transition at 2 years of follow-up. Symptomatic clustering predicts prognosis better than individual symptoms.

Psychometric properties of Peters et al. delusions inventory-21 in adolescence

We explored the psychometric properties of the Korean version of the Peters et al. delusions inventory-21 (PDI-21) and evaluated the item characteristics of the PDI-21 compared with the Magical Ideation Scale (MIS) in Korean community adolescents. Survey participants comprised 310 Year 10 students who were assessed with the following instruments: the PDI-21, the MIS, the Schizotypal Personality Scale (STA) and the symptom checklist-90-R (SCL-90-R). The item characteristics of the PDI-21 and MIS were also explored using item response theory (IRT). The PDI-21 exhibited good internal consistency and demonstrated significant correlations with the MIS, STA and all subscale scores of the SCL-90-R, indicating psychological distress in adolescents with high PDI-21 scores. We also found through IRT analysis that the PDI-21 provides more information at the lower range and the MIS at the higher range of delusion proneness. Our findings suggest that the PDI-21 is an effective and reliable self-report measure for assessment of delusion proneness and that the PDI-21 and the MIS may be used complementarily to assess a broad range of delusion proneness among community adolescents.

The Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY): practicability and discriminative validity

BACKGROUND

Basic symptom (BS) criteria have been suggested to complement ultra-high risk (UHR) criteria in the early detection of psychosis in adults and in children and adolescents. To account for potential developmental particularities and a different clustering of BS in children and adolescents, the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was developed.

AIMS

The SPI-CY was evaluated for its practicability and discriminative validity.

METHOD

The SPI-CY was administered to 3 groups of children and adolescents (mean age 16; range = 8-18; 61% male): 23 at-risk patients meeting UHR and/or BS criteria (AtRisk), 22 clinical controls (CC), and 19 children and adolescents from the general population (GPS) matched to AtRisk in age, gender, and education. We expected AtRisk to score highest on the SPI-CY, and GPS lowest.

RESULTS

The groups differed significantly on all 4 SPI-CY subscales. Pairwise post-hoc comparisons confirmed our expectations for all subscales and, at least on a descriptive level, most items. Pairwise subscale differences indicated at least moderate group effects (r ≥ 0.37) which were largest for Adynamia (0.52 ≤ r ≥ 0.70). Adynamia also performed excellent to outstanding in ROC analyses (0.813 ≤ AUC ≥ 0.981).

CONCLUSION

The SPI-CY could be a helpful tool for detecting and assessing BS in the psychosis spectrum in children and adolescents, by whom it was well received. Furthermore, its subscales possess good discriminative validity. However, these results require validation in a larger sample, and the psychosis-predictive ability of the subscales in different age groups, especially the role of Adynamia, will have to be explored in longitudinal studies.

Basic disturbances of information processing in psychosis prediction

The basic symptoms (BS) approach provides a valid instrument in predicting psychosis onset and represents moreover a significant heuristic framework for research. The term "basic symptoms" denotes subtle changes of cognition and perception in the earliest and prodromal stages of psychosis development. BS are thought to correspond to disturbances of neural information processing. Following the heuristic implications of the BS approach, the present paper aims at exploring disturbances of information processing, revealed by functional magnetic resonance imaging (fMRI) and electro-encephalographic as characteristics of the at-risk state of psychosis. Furthermore, since high-risk studies employing ultra-high-risk criteria revealed non-conversion rates commonly exceeding 50%, thus warranting approaches that increase specificity, the potential contribution of neural information processing disturbances to psychosis prediction is reviewed. In summary, the at-risk state seems to be associated with information processing disturbances. Moreover, fMRI investigations suggested that disturbances of language processing domains might be a characteristic of the prodromal state. Neurophysiological studies revealed that disturbances of sensory processing may assist psychosis prediction in allowing for a quantification of risk in terms of magnitude and time. The latter finding represents a significant advancement since an estimation of the time to event has not yet been achieved by clinical approaches. Some evidence suggests a close relationship between self-experienced BS and neural information processing. With regard to future research, the relationship between neural information processing disturbances and different clinical risk concepts warrants further investigations. Thereby, a possible time sequence in the prodromal phase might be of particular interest.

The significance of at-risk symptoms for psychosis in children and adolescents

The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided.

Adolescent attention deficit hyperactivity disorder and susceptibility to psychosis in adulthood: a review of the literature and a phenomenological case report

AIM

In contrast to affective disorders, some forms of personality disorders and drug addiction, schizophrenia is commonly not considered to be a sequela of attention deficit hyperactivity disorder. However, attention deficit hyperactivity disorder and the prodromal stages of schizophrenia spectrum disorders do exhibit a number of common central features. To facilitate the early treatment of schizophrenic symptoms, the detection of discrete and subtle alterations in the prodromal stages of incipient psychoses is particularly important.

METHODS

We review the literature on the prodromal symptoms of psychosis and present a case report, in which a phenomenological approach was used to identify subtle alterations linked to anomalous self-experience.

RESULTS

Using the Examination of Anomalous Self-Experience symptom checklist, the case report presented here reveals attention deficit hyperactivity disorder symptoms in adolescence as a precursor state of psychosis in adulthood.

CONCLUSIONS

The characteristics of this schizophrenia spectrum disorder case and its time course are derived from the specific distribution pattern of Examination of Anomalous Self-Experience items. When treating adolescent attention deficit hyperactivity disorder patients, the rare possibility of the development of schizophrenia spectrum disorder from attention deficit hyperactivity disorder like symptoms should be kept in mind.

[Early detection of psychosis in children and adolescents - have developmental particularities been sufficiently considered?]

The early detection and treatment of persons at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. The two current favored at-risk approaches, i.e., the «ultra high risk» and the «basic symptom» criteria, were developed mainly using adult samples. Initial evidence suggests, however, that they cannot simply be applied to children and adolescents. For «ultra-high risk» criteria, there is indication of some attenuated psychotic symptoms being potentially nonspecific in adolescents, and of brief limited intermittent symptoms being difficult to clinically classify in children when observable behavioral correlates are missing. For basic symptoms, too, only a preliminary indication of their usefulness in children and adolescents exists. Since developmental peculiarities in the assessment of basic symptoms should be considered, a child and youth version of the Schizophrenia Proneness Instrument (SPI-CY) was developed. In conclusion, research on the clinical-prognostic validity of the at-risk criteria and their potential adaption to the special needs of children and adolescents is needed. If a «Prodromal Risk Syndrome for Psychosis» or «Attenuated Psychotic Symptoms Syndrome» are included in the upcoming DSM-5, it should be highlighted that its suitability for children and adolescents is only insufficiently known.

Transition and remission in adolescents at ultra-high risk for psychosis

BACKGROUND

Future success of early intervention initiatives to prevent the onset of psychosis will rely on the validity of methods to predict clinical outcome. Proper identification is particularly essential for young adolescents, as psychotic-like symptoms are often transitory during this period and mislabeling can lead to early stigmatization and unnecessary treatment. This article presents results from a prospective, naturalistic 2-year follow-up study of a cohort of young adolescents putatively at ultra-high risk (UHR) for psychosis.

METHODS

Seventy-two adolescents between 12 and 18years were recruited, fulfilling either UHR criteria or the basic symptom-based criterion cognitive disturbances (COGDIS). Incidence of transition as well as the remission rate from UHR status was calculated. Individuals who made a transition (UHR-P) were compared to those who did not (UHR-NP) and to those who remitted (UHR-R) on socio-demographic and clinical characteristics.

RESULTS

Fifty-seven UHR individuals completed the 2-year follow-up assessment. The confirmed transition rate was 15.6% and 35.3% still met UHR criteria. The remaining 49.1% had remitted from an initial UHR status. The UHR subgroups did not differ on socio-demographic or clinical variables at baseline.

CONCLUSIONS

Half of young adolescents meeting UHR criteria continue to experience prodromal or psychotic symptoms after 2 years. However, they are at least three times more likely to have remitted from their UHR status than to have made a transition to psychosis. In addition, baseline characteristics are not indicative of clinical outcome at follow-up. Our results emphasize the need for further improvement and stratification of relative risk factors for psychosis.

Probably at-risk, but certainly ill--advocating the introduction of a psychosis spectrum disorder in DSM-V

Current criteria for an increased risk of developing first-episode psychosis are associated with conversion rates many times higher than the general incidence of psychosis. Yet, non-conversions still outnumber conversions, and conversion rates across and within centres vary considerably, fueling the ongoing debate about clinical and ethical justification of indicated prevention. This debate, however, almost exclusively focuses on the predictive validity of at-risk criteria, thereby widely disregarding the main general finding: persons meeting at-risk criteria already suffer from multiple mental and functional disturbances for those they seek help. Moreover, they exhibit various psychological and cognitive deficits along with morphological and functional cerebral changes. Thereby, the majority of help-seeking at-risk persons fulfils DSM-IV's general criteria for mental disorders (defined as a clinically significant behavioural or psychological syndrome associated with disability and/or severe distress) and clearly have to be considered as 'ill', i.e., as 'patients' with a need and right for treatment. Hence, the clinical picture defined by current at-risk criteria should be more adequately perceived as not only a still insufficient attempt to define the psychotic prodrome but a psychosis spectrum disorder in its own right - akin to ICD-10's schizotypal disorder - with conversion to psychosis just being one of several outcomes. Such a disorder, whose criteria are proposed and discussed, should initially be part of DSM-V research criteria. Following from this shift in the perception of current at-risk criteria, access to standard medical care would have to be granted, and diagnosis- or symptom- rather than conversion-related interventions would have to be developed.

Treatment implications of the schizophrenia prodrome

Schizophrenia is a debilitating neurodevelopmental disorder that strikes at a critical period of a young person's life. Early identification of individuals in the prodromal phase of a psychotic illness can lead to earlier treatment and perhaps prevention of many of the devastating effects of a first psychotic episode. International research efforts have demonstrated the success of community outreach and education regarding the schizophrenia prodrome and it is now possible to use empirically defined clinical and demographic criteria to identify individuals at a substantially increased risk for a psychotic illness. The development of clinical staging criteria for psychosis that incorporates type and severity of clinical symptoms, level of global and social functioning, family history, substance use, neurocognitive functioning, and perhaps neurobiological information, could help to specify appropriate treatment for vulnerable individuals at different phases of the prodrome. Preliminary psychosocial and pharmacologic treatment studies report initial success in reducing severity of prodromal symptoms in "at-risk" samples, but further work is needed to refine the prodromal criteria and perform well controlled treatment studies in adequately powered samples. Treatment algorithms can then be tailored to presenting symptoms, number of risk factors present, and evidence of progression of the illness, to assure appropriate, safe and effective interventions in the early stages of psychosis.