Symptom dimensions and subgroups in childhood-onset schizophrenia

Neurocognitive dysfunctions in childhood-onset schizophrenia: A systematic review

Objective

To conduct a systematic review of neurocognitive dysfunctions in patients with childhood-onset schizophrenia (COS), a neuropsychiatric disorder that occurs before age 13 and is rarer and more severe than adult-onset schizophrenia.

Method

A search was made in the PubMed database. Sixty-seven studies (out of 543) which analyzed Intellectual Quotient (IQ), attentional, memory and executive functions were selected by two independent researchers. Study's appraisal was done according to the Mixed Methods Appraisal Tool (MMAT). This systematic review was registered on PROSPERO (CRD42024548945).

Result

COS shows neurocognitive dysfunction in IQ with mean scores ranging from one to two standard deviation lower than normative data. Attentional deficits are observed with longer reaction time, more errors of omission and commission and slower processing speed than controls. In addition, working memory and executive functions, such as planification and flexibility are impaired. COS exhibit significantly more neurocognitive deficits than adolescent and adult-onset forms and display deterioration in intellectual functioning between premorbid period and after onset of psychosis.

Conclusion

COS is characterized by major cognitive impairments, both before the onset of the disease and throughout its course. As in adult-onset schizophrenia, generalized cognitive impairment is found without the emergence of a specific profile, providing further support for the continuum hypothesis between early-onset and adult-onset schizophrenia. Collaborative research on a larger scale (including meta-analyses) and using complementary approaches (dimensional and multimodal) is needed to gain a better understanding of the cognitive impact of COS and pave the way for more precise and targeted cognitive remediation.

Deciphering the Heterogeneity of Schizophrenia: A Multimodal and Multivariate Neuroimaging Framework for Unveiling Brain-Symptom Relationships and Underlying Subtypes

BACKGROUND AND HYPOTHESIS

Schizophrenia manifests large heterogeneities in either symptoms or brain abnormalities. However, the neurobiological basis of symptomatic diversity remains poorly understood. We hypothesized that schizophrenia's diverse symptoms arise from the interplay of structural and functional alterations across multiple brain regions, rather than isolated abnormalities in a single area.

STUDY DESIGN

A total of 495 schizophrenia patients and 507 healthy controls from 8 sites were recruited. Five symptomatic dimensions of schizophrenia patients were derived from the Positive and Negative Syndrome Scale. Multivariate canonical correlation analysis was introduced to identify symptom-related multimodal magnetic resonance imaging composite indicators (MRICIs) derived from gray matter volume, functional connectivity strength, and white matter fractional anisotropy. The intergroup differences in MRICIs were compared, and the paired-wise correlations between symptom dimensions and MRICIs were resolved. Finally, K-means clustering was used to identify the underlying biological subtypes of schizophrenia based on MRICIs.

STUDY RESULTS

Canonical correlation analysis identified 15 MRICIs in schizophrenia that were specifically contributed by the neuroimaging measures of multiple regions, respectively. These MRICIs can effectively characterize the complexity of symptoms, showing correlations within and across symptom dimensions, and were consistent across both first-episode and chronic patients. Additionally, some of these indicators could moderately differentiate schizophrenia patients from healthy controls. K-means clustering identified 2 schizophrenia subtypes with distinct MRICI profiles and symptom severity.

CONCLUSIONS

Symptom-guided multimodal and multivariate MRICIs could decode the symptom heterogeneity of schizophrenia patients and might be considered as potential biomarkers for schizophrenia.

The diagnostic conundrum of late-onset developmental regression in child psychiatry: case series

BACKGROUND

Developmental regression in children, in the absence of neurological damage or trauma, presents a significant diagnostic challenge. The complexity is further compounded when it is associated with psychotic symptoms.

METHOD

We discuss a case series of ten children aged 6-10 years, with neurotypical development, presenting with late-onset developmental regression (>6 years of age), their clinical course and outcome at 1 year. A comprehensive clinical evaluation, laboratory investigations and neuroimaging ruled out any identifiable neurological cause.

RESULTS

Mean age at regression was 7.65 (s.d. 1.5) years and mean illness duration was 10.1 (s.d. 8.5) months. The symptom domains included regression (in more than two domains - cognitive, socio-emotional, language, bowel and bladder incontinence), emotional disturbances, and hallucinatory and repetitive behaviours. Response to treatment was gradual over 6 months to 1 year. At 1-year follow-up, nine children did not attain pre-regression functioning, and residual symptoms included not attaining age-appropriate speech and language, socio-emotional reciprocity and cognitive abilities.

CONCLUSIONS

These cases demonstrate a unique pattern of regression with psychiatric manifestations, distinct from autism spectrum disorder and childhood-onset schizophrenia. The diagnostic dilemma arises from the overlap of symptoms with childhood disintegrative disorder (CDD), childhood-onset schizophrenia and autism. This study underscores the diagnostic intricacies of this clinical presentation and highlights the need for longitudinal follow-up to unravel the transitions in phenomenology, course and outcome. For severe manifestations such as developmental regression, where the illness is still evolving, considering CDD as a non-aetiological and transitory/tentative diagnosis would aid against premature diagnostic categorisation and provide scope for ongoing aetiological search.

Clinical features and comorbidity in very early-onset schizophrenia: a systematic review

Background

Very early-onset schizophrenia (VEOS) is a form of schizophrenia that manifests before the age of 13 years and is characterized by the presence of positive, negative, and disorganized symptoms. The condition is exceptionally rare and, to date, limited studies have been conducted, resulting in incomplete information about its clinical features.

Methods

The present study involves a systematic review of the existing literature regarding the clinical features and comorbidities of VEOS.

Results

The first search retrieved 384 studies. Of these, 366 were removed following the application of exclusion criteria, resulting in 18 studies for the final set.

Conclusion

The results highlight that VEOS shares similarities with early-onset and adult-onset schizophrenia but also exhibits distinct and recognizable characteristics, including a more severe clinical profile (particularly in females), increased visual hallucinations, and high comorbidities with neurodevelopmental disorders. These findings may support clinicians in formulating early diagnoses and developing effective treatment strategies for pediatric and adolescent patients with psychosis.

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).

Early-onset schizophrenia: studying the links between cognitive and clinical dimensions

BACKGROUND

Early-onset schizophrenia (EOS), a rare and severe chronic psychiatric condition, is defined by an onset of schizophrenia symptoms before the age of 18. Core symptoms also include cognitive impairments. However, little is known about links between psychiatric symptoms of EOS and cognitive abilities.

OBJECTIVE

To explore the clinical and neurocognitive profiles of EOS patients and their links.

METHOD

EOS patients have been phenotyped using standardised psychiatric assessments for DSM-5 diagnoses (K-SADS-PL) and for symptoms (PANSS and SANS), together with neurocognitive evaluations.

RESULTS

The EOS sample (n = 27, 12.4 +/-3.2 years) presented hallucinations (83%), negative symptoms (70%) and delusion (59%). 81% of patients presented comorbidities such as anxiety disorders (33%), autism spectrum disorder (26%) and attention-deficit hyperactivity disorder (26%). Patients presented borderline intellectual deficiency (total IQ = 72.5 +/-4.7), with low performances in working memory subtest. We highlight a positive correlation between the IQ and intensity of positive symptoms (PANSS) and between the IQ and a first treatment being administered at an older age. We also highlight a negative correlation between the IQ and attention items of SANS.

CONCLUSION

Cognitive skills are correlated with symptom intensity in EOS patients. An older age of onset seems to be a protective factor for cognitive development.

Exploring negative symptoms heterogeneity in patients diagnosed with schizophrenia and schizoaffective disorder using cluster analysis

BACKGROUND

Dissecting the heterogeneity of schizophrenia may help foster progress in understanding its etiology and lay the groundwork for the development of new treatment options for primary or enduring negative symptoms (NS). In this regard, the present study aimed to: (1) to use cluster analysis to identify subgroups of Lebanese patients diagnosed with either schizophrenia or schizoaffective disorder based on NS clusters, and (2) to relate the statistically-derived subgroups to clinically relevant external validators (including measures if state and trait depression, stigma, insight, loneliness, social support).

METHOD

A total of 202 adult long-stay, chronic, and clinically remitted patients (166 diagnosed with schizophrenia and 36 with schizoaffective disorder) were enrolled. A cluster analysis approach was adopted to classify patients based on the five NS domains social withdrawal, emotional withdrawal, alogia, avolition and anhedonia.

RESULTS

A three-cluster solution was obtained based on unique NS profiles, and divided patients into (1) low NS (LNS; 42.6%) which characterized by the lowest mean scores in all NS domains, (2) moderate NS (MNS; 25.7%), and (3) high NS (HNS; 31.7%). Post-hoc comparisons showed that depression (state and trait), loneliness and social support could accurately distinguish the schizophrenia subgroups. Additionally, individuals in the HNS cluster had longer duration of illness, longer duration of hospitalization, and were given higher dosages of antipsychotic medication compared to those in the other clusters, but these differences did not achieve the statistical significance.

CONCLUSION

Findings provide additional support to the categorical model of schizophrenia by confirming the existence of three alternate subtypes based on NS. The determination of distinct NS subgroups within the broad heterogeneous population of people diagnosed with schizophrenia may imply that each subgroup possibly has unique underlying mechanisms and necessitates different treatment approaches.

Impact on the Risk and Severity of Childhood Onset Schizophrenia of Schizophrenia Risk Genetic Variants at the DRD2 and ZNF804A Loci

The study explored whether schizophrenia risk alleles of the DRD2 rs2514218 and ZNF804A rs1344706 polymorphisms also influenced the risk and severity of childhood-onset schizophrenia (COS) and differentiated it from autism spectrum disorders (ASD). We compared 75 children with COS to 75 children with ASD, 150 patients with adult-onset schizophrenia and 150 healthy individuals. Frequency of the DRD2 T-allele, assumed to be protective against schizophrenia overall, was higher in COS compared to adult-onset schizophrenia and healthy controls. The risk allele A of ZNF804A was associated with greater severity of negative symptoms in COS. The latter result is consistent with the involvement of ZNF804A in the development of severe forms of schizophrenia. The findings regarding DRD2 suggest that the same genetic variants may play different roles in schizophrenia with childhood and adult onset. This warrants further research, since D2 receptor blockade is a general pharmacodynamic property of antipsychotics.

Treatment resistant psychosis in children and adolescents and clozapine: Nuances

With proliferation in research on high-risk psychosis spectrum diseases, it is crucial to distinguish a prodrome or psychosis-like episode in children and adolescents from true psychosis. The limited role of psychopharmacology in such circumstances is well-documented, underlining the difficulties in diagnosing treatment resistance. To add to the confusion is emerging data on the head-to-head comparison trials for treatment-resistant and treatment-refractory schizophrenia. Clozapine, the gold-standard drug for resistant schizophrenia and other psychotic psychopathology, lacks FDA or manufacturer guidelines for use in the pediatric population. Possibly due to developmental pharmacokinetic (PK) considerations, clozapine-related side effects are more commonly seen in children than adults. Despite evidence of an increased risk for seizures and hematological problems in children, clozapine is widely used off-label. Clozapine reduces the severity of resistant childhood schizophrenia, aggression, suicidality, and severe non-psychotic illness. There is inconsistent prescribing, administration, and monitoring of clozapine, and limited database evidence-backed guidelines. Despite the overwhelming efficacy, problems remain regarding unambiguous indications of use and risk-benefits assessments. This article reviews the nuances in the diagnosis of treatment resistance psychosis in childhood and adolescents and its management, in particular highlighting the evidence base for clozapine in this population group.

Affective symptom dimensions in early-onset psychosis over time: a principal component factor analysis of the Young Mania Rating Scale and the Hamilton Depression Rating Scale

Early-onset psychosis (EOP) is a complex disorder characterized by a wide range of symptoms, including affective symptoms. Our aim was to (1) examine the dimensional structure of affective symptoms in EOP, (2) evaluate the predominance of the clinical dimensions and (3) assess the progression of the clinical dimensions over a 2-year period. STROBE-compliant prospective principal component factor analysis of Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale-21 (HDRS-21) at baseline, 6-months, 1-year and 2-year follow-up. We included 108 EOP individuals (mean age = 15.5 ± 1.8 years, 68.5% male). The factor analysis produced a four-factor model including the following dimensions: mania, depression/anxiety, sleep and psychosis. It explained 47.4% of the total variance at baseline, 60.6% of the total variance at 6-months follow-up, 54.5% of the total variance at 1-year follow-up and 49.5% of the total variance at 2-year follow-up. According to the variance explained, the mania factor was predominant at baseline (17.4%), 6-month follow-up (23.5%) and 2-year follow-up (26.1%), while the depression/anxiety factor was predominant at 1-year follow-up (23.1%). The mania factor was the most stable; 58.3% items that appeared in this factor (with a load > 0.4) at any time point appeared in the same factor at ≥ 3/4 time points. Affective symptoms are frequent and persistent in EOP. Mania seems to be the most predominant and stable affective dimension. However, depression and anxiety may gain predominance with time. A comprehensive evaluation of the dimensional structure and the progression of affective symptoms may offer clinical and therapeutic advantages.

Cluster analysis of negative symptoms identifies distinct negative symptom subgroups

The heterogeneity of schizophrenia has been acknowledged for decades because of the diverse presentation of symptoms, illness course, and treatment response noted between individuals diagnosed with the disorder. Cluster analysis has been used as a statistical method to determine whether schizophrenia subgroups might be identified based on symptom heterogeneity. However, there is very limited research examining whether heterogeneity in negative symptoms might be useful in establishing schizophrenia subtypes, particularly research examining newer models of negative symptoms based on five latent constructs including anhedonia, asociality, avolition, blunted affect, and alogia. The Brief Negative Symptom Scale was used to assess the five negative symptoms domains in a sample of 220 outpatients diagnosed with schizophrenia or schizoaffective disorder. Cluster analysis supported a four-cluster solution, comprising clusters of subjects with low negative symptoms (LNS), severe negative symptoms (SNS), and two clusters with moderate negative symptoms, one with predominantly elevated blunted affect (BA) and one with elevated avolition (AV). The LNS, SNS, BA, and AV clusters significantly differed on external validators including clinical characteristics, neurocognition, and functional outcome. Findings suggest that schizophrenia heterogeneity can be parsed according to negative symptom subtypes that have distinct clinical and neuropsychological profiles. Implications for diagnosis and treatment are discussed.

A systematic review and narrative synthesis of data-driven studies in schizophrenia symptoms and cognitive deficits

To tackle the phenotypic heterogeneity of schizophrenia, data-driven methods are often applied to identify subtypes of its symptoms and cognitive deficits. However, a systematic review on this topic is lacking. The objective of this review was to summarize the evidence obtained from longitudinal and cross-sectional data-driven studies in positive and negative symptoms and cognitive deficits in patients with schizophrenia spectrum disorders, their unaffected siblings and healthy controls or individuals from general population. Additionally, we aimed to highlight methodological gaps across studies and point out future directions to optimize the translatability of evidence from data-driven studies. A systematic review was performed through searching PsycINFO, PubMed, PsycTESTS, PsycARTICLES, SCOPUS, EMBASE and Web of Science electronic databases. Both longitudinal and cross-sectional studies published from 2008 to 2019, which reported at least two statistically derived clusters or trajectories were included. Two reviewers independently screened and extracted the data. In this review, 53 studies (19 longitudinal and 34 cross-sectional) that conducted among 17,822 patients, 8729 unaffected siblings and 5520 controls or general population were included. Most longitudinal studies found four trajectories that characterized by stability, progressive deterioration, relapsing and progressive amelioration of symptoms and cognitive function. Cross-sectional studies commonly identified three clusters with low, intermediate (mixed) and high psychotic symptoms and cognitive profiles. Moreover, identified subgroups were predicted by numerous genetic, sociodemographic and clinical factors. Our findings indicate that schizophrenia symptoms and cognitive deficits are heterogeneous, although methodological limitations across studies are observed. Identified clusters and trajectories along with their predictors may be used to base the implementation of personalized treatment and develop a risk prediction model for high-risk individuals with prodromal symptoms.

Developmental and symptom profiles in early-onset psychosis

Psychotic disorders in children are more heterogeneous than is captured by categorical diagnoses. In a new cohort of children and adolescents, we evaluated the relationships among age at onset (AAO), clinical symptoms and developmental impairments. Patients with schizophrenia and other "spectrum" psychotic diagnoses (N = 88; AAO 6-17, mean 12.6) were evaluated with diagnostic interviews, a new clinical scale (Lifetime Dimensions of Psychosis Scale-Child and Adolescent), and neuropsychological and medical evaluations. Key findings were replicated in an adult cohort of 2420 cases, including 127 with retrospective AAO<13. Factor and cluster analyses were carried out to identify clinical profiles. Five clinical factors were identified in each cohort: Positive, Bizarre Positive, Negative/Formal Thought Disorder, Depression and Mania. Earlier AAO predicted severity of bizarre positive symptoms in children and of bizarre and other symptoms in adults. Four clinical clusters in the child cohort were characterized by: more severe bizarre positive symptoms (N = 31); negative symptoms (N = 15); premorbid autism spectrum features and developmental delay (N = 12); and depressive symptoms with heterogeneous diagnoses and mild positive/negative symptoms (N = 25). Previous factor-analytic studies of childhood psychosis did not specifically consider bizarre positive symptoms. Here, bizarre positive symptoms emerged as clinical markers of severe, childhood-onset psychosis similar to adult schizophrenia. The four clusters are clinically meaningful and useful for treatment planning and potentially for biological research. Childhood-onset cases are rare and thus difficult to study, but additional, larger cohorts may be useful in dissecting the biological and developmental heterogeneity of psychotic disorders.

[Cross-sectional data of inpatient residents of a rehabilitation center with schizophrenic psychosis diagnosis]

Cross-sectional data of inpatient residents of a rehabilitation center with schizophrenic psychosis diagnosis Abstract.

OBJECTIVE

The objective of this study is to evaluate the level of neuropsychological functioning, quality of life, content of treatment, abnormal psychology as well as the level of functioning and medication in children and adolescents who suffer from a schizophrenia spectrum disorder, treated as rehabilitation inpatients.

METHODS

Forty-two patients could be examined, therefore, the IRAOS, the WAIS-IV, the TMT-A/-B, the FBB-P (patient's version), the ILK-P, the SANS/SAPS, the BPRS, the BSCL, the GAF, the CGAS, and the CGI were used.

RESULTS

Patients' average age at onset of the disorder was 14.49 years (± 2.90). The total value of IQ was 87.00 (± 15.02), the value of TMT-A was 73.05 (± 14.51), and of the TMT-B 75.62 (± 15.15). The value for the content of treatment in the summary-score of the FBB-P was 3.05 (± 0.49). The value of the total-score in ILK-P was 2.10 (± 0.70). The summary-score of the SANS was 5.00 (± 2.90) and of the SAPS 3.00 (± 2.70). The BPRS-summary-score's value was 30.70 (± 7.80), the BSCL-GSI's value was 0.90 (± 0.50). GAF and CGAS were at 48.30 (± 12.80), respectively 51.00 (± 12.30). Clozapin has been prescribed in 25.0 % of the cases as first or second neuroleptic medication.

CONCLUSION

We investigated patients with VEOS and EOS living in a rehabilitation center. Usually, the course of their illness is much more severe and chronic than it is seen in a common department for child and adolescent psychiatry. Findings indicate a clear impairment in the level of neuropsychological and global functioning in contrast to rather low to moderate burden of positive/negative deficits. Satisfactory results of treatment and quality of life could be evaluated in spite of the aforementioned impairments. Medication did not conform to current guidelines, especially concerning Clozapin. Findings of the subsequent follow-up will show, if the impairment will improve under inpatient rehabilitation conditions.