Social functioning deficits in young people at risk for schizophrenia

Psychological and social difficulties in young non-help-seeking adolescents at risk for psychosis: insights from a large cohort study

Background

This study used data from the Norwegian Mother, Father, and Child Cohort Study (MoBa), and explored the psychological and social challenges of 14-year-olds who report psychotic symptoms. Research on help-seeking youths indicates comorbid symptoms of depression, anxiety, and social deterioration, but less is known about non-help-seeking individuals who may not use healthcare services, possibly skewing comorbidity profiles. Also, findings suggest that adolescents manifesting psychotic symptoms refrain from pursuing help. This gap underscores the necessity of studying non-help-seeking adolescents to better understand their needs and the risks they face without intervention.

Methods

We analyzed responses from adolescents who completed the 14-year questionnaire in MoBa (N = 127), identifying those as at risk by their high scores on psychosis-risk items, within the top 0.4% (N = 58). Comparative analyses were conducted against matched controls to assess differences in psychological and social functioning (N = 69).

Results

Results indicated that the at-risk adolescents experience significantly more depression and anxiety and have lower self-esteem and poorer social functioning than controls. Social functioning parameters, including leisure activities, social competence, quality of parental relationship, and sense of school belonging, were significantly worse than those observed in controls. The results indicate a pronounced vulnerability among non-help-seeking adolescents at-risk, similar to issues seen in help-seeking youths.

Conclusion

These findings highlight the importance of early identification and intervention strategies that reach beyond traditional clinical settings, suggesting the efficacy of population or community-based screenings to prevent long-term adverse outcomes. The study proposes a broader understanding of psychosis risk, stressing the importance of inclusive approaches to support at-risk adolescents effectively.

Psychosocial stress, interpersonal sensitivity, and social withdrawal in clinical high risk for psychosis: a systematic review

Stress has repeatedly been implicated in the onset and exacerbation of positive symptoms of psychosis. Increasing interest is growing for the role of psychosocial stress in the development of psychosis symptoms in individuals at Clinical High Risk (CHR) for psychosis. A systematic review was therefore conducted to summarize the existing evidence base regarding psychosocial stress, interpersonal sensitivity, and social withdrawal in individuals at CHR for psychosis. An electronic search of Ovid (PsychINFO, EMBASE, MEDLINE, and GLOBAL HEALTH) was conducted until February 2022. Studies that examined psychosocial stress in CHR were included. Twenty-nine studies were eligible for inclusion. Psychosocial stress, interpersonal sensitivity, and social withdrawal were higher in CHR individuals compared to healthy controls and there was some evidence of their association with positive symptoms of psychosis. Two types of psychosocial stressors were found to occur more frequently with CHR status, namely daily stressors, and early and recent trauma, while significant life events did not appear to be significant. Greater exposure to psychosocial stress, emotional abuse, and perceived discrimination significantly increased risk of transition to psychosis in CHR. No studies examined the role of interpersonal sensitivity on transition to psychosis in CHR. This systematic review provides evidence for the association of trauma, daily stressors, social withdrawal, and interpersonal sensitivity with CHR status. Further studies investigating the impact of psychosocial stress on psychosis symptom expression in individuals at CHR and its effects on transition to psychosis are therefore warranted.

Scenario-specific aberrations of social reward processing in dimensional schizotypy and psychopathy

The feelings of reward associated with social interaction help to motivate social behaviour and influence preferences for different types of social contact. In two studies conducted in a general population sample, we investigated self-reported and experimentally-assessed social reward processing in personality spectra with prominent interpersonal features, namely schizotypy and psychopathy. Study 1 (n = 154) measured social reward processing using the Social Reward Questionnaire, and a modified version of a Monetary and Social Incentive Delay Task. Study 2 (n = 42; a subsample of Study 1) investigated social reward processing using a Social Reward Subtype Incentive Delay Task. Our results show that schizotypy (specifically Cognitive-Perceptual dimension) and psychopathy (specifically Lifestyle dimension) are associated with diverging responses to social scenarios involving large gatherings or meeting new people (Sociability), with reduced processing in schizotypy and heightened processing in psychopathy. No difference, however, occurred for other social scenarios-with similar patterns of increased antisocial (Negative Social Potency) and reduced prosocial (Admiration, Sociability) reward processing across schizotypy and psychopathy dimensions. Our findings contribute new knowledge on social reward processing within these personality spectra and, with the important exception of Sociability, highlight potentially converging patterns of social reward processing in association with schizotypy and psychopathy.

Deficits in adolescent social functioning, dysfunctional family processes and genetic risk for schizophrenia spectrum disorders as risk factors for later psychiatric morbidity of adoptees

Social functioning deficits during adolescence are associated with later psychiatric morbidity, particularly in offspring at high genetic risk for schizophrenia spectrum disorders. However, a shortcoming of earlier study findings is the lack of control of the impact of the family rearing environment. The study was aimed to examine the association of adoptees' social functioning during adolescence, adoptive family functioning, and adoptees' high (HR) or low (LR) genetic risk for schizophrenia spectrum disorders with adoptees' later psychiatric morbidity. The present subsample from the nationwide Finnish Adoptive Family Study of Schizophrenia included 57 HR and 60 LR adoptees. Adolescent social functioning was assessed using UCLA Social Attainment Survey (UCLA SAS). Adoptive family functioning was based on Global Family Ratings (GFRs) and psychiatric disorders on DSM-III-R criteria. The results indicated that, after controlling for adoptive family functioning and genetic risk for schizophrenia spectrum disorders, deficits in peer relationships during adolescence were associated with an increased likelihood of psychiatric morbidity of adoptees. Our findings highlight social functioning deficits during adolescence, specifically in peer relationships, as plausible independent risk factors for later psychiatric disorders. These results can be utilized in identifying possible at-risk groups and targets for prevention and in developing preventive strategies.

Treatments for Social Interaction Impairment in Animal Models of Schizophrenia: A Critical Review and Meta-analysis

BACKGROUND

While pharmacological treatments for positive symptoms of schizophrenia are widely used, their beneficial effect on negative symptoms, particularly social impairment, is insufficiently studied. Therefore, there is an increasing interest in preclinical research of potentially beneficial treatments, with mixed results. The current review aims to evaluate the efficacy of available treatments for social deficits in different animal models of schizophrenia.

STUDY DESIGN

A systematic literature search generated 145 outcomes for the measures "total time" and "number" of social interactions. Standardized mean differences (SMD) and 95% confidence interval (CI) were calculated, and heterogeneity was tested using Q statistics in a random-effect meta-analytic model. Given the vast heterogeneity in effect sizes, the animal model, treatment group, and sample size were all examined as potential moderators.

STUDY RESULTS

The results showed that in almost all models, treatment significantly improved social deficit (total time: SMD = 1.24; number: SMD = 1.1). The moderator analyses discovered significant subgroup differences across models and treatment subgroups. Perinatal and adult pharmacological models showed the most substantial influence of treatments on social deficits, reflecting relative pharmacological validity. Furthermore, atypical antipsychotic drugs had the highest SMD within each model subgroup.

CONCLUSIONS

Our findings indicate that the improvement in social interaction behaviors is dependent on the animal model and treatment family used. Implications for the preclinical and clinical fields are discussed.

Development of social responsiveness and theory of mind in children of parents with schizophrenia or bipolar disorder

Social impairments are suggested as vulnerability markers for schizophrenia and bipolar disorder. Therefore, we investigated the development of social responsiveness and theory of mind (ToM) in children at familial high-risk of schizophrenia (FHR-SZ) or bipolar disorder (FHR-BP).

This study is part of The Danish High Risk and Resilience Study, a longitudinal cohort study of children at FHR-SZ or FHR-BP and population-based controls (PBC). Social responsiveness was measured with the Social Responsiveness Scale (SRS-2), completed by teachers and primary caregivers. ToM was measured using The Animated Triangles Task (ATT). Both SRS-2 and ATT were applied at age 7 and 11. A total of 520 children participated (FHR-SZ, n = 201; FHR-BP, n = 119; PBC, n = 200).

Results showed no significant time by group interactions. At follow-up, children at FHR-SZ exhibited impaired social responsiveness compared with PBC regardless of the informant. At both timepoints, a higher proportion of children at FHR-SZ were rated at a clinically significant level, implying inference in everyday social interactions. Compared with PBC, primary caregivers reported impairments in social responsiveness in children at FHR-BP at follow-up. The three groups did not differ in ToM at follow-up.

Social responsiveness and ToM do not develop differently in children at FHR-SZ, FHR-BP and PBC from age 7 to 11, but impairments in social responsiveness remain stable and may constitute a vulnerability marker particularly in children at FHR-SZ, but also FHR-BP. ToM abilities seem to improve and remain intact, but ToM development and ToM task properties should be taken into consideration.

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No developmental differences in social abilities in children at familial high-risk

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Children at familial high-risk exhibit impaired social responsiveness.

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Social responsiveness impairments are detectable already at an early age.

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Impairments in social responsiveness may constitute a vulnerability marker.

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11-Year-olds at familial high-risk have intact theory of mind.

Psychiatric Assessment of Social Impairment Across the Lifespan

Although autism spectrum disorder (ASD) is the prototypical psychiatric disorder of social impairment, several if not most psychiatric disorders are characterized by prominent impairments in social functioning. A challenge in clinically assessing and describing social impairment is that it has been variably defined and can be difficult to measure. In this article we consider the psychiatric differential diagnosis of social impairment within the DSM-5 framework. We describe the features of social impairment in 13 DSM-5 disorders from a developmental perspective and highlight diagnostic factors that differentiate among the disorders, including the main features of social impairment, verbal communication, nonverbal communication, course of social impairment, social cognition, and key features of accompanying neuropsychiatric symptoms. We conclude by describing an approach for assessing social impairment across the lifespan.

Relationship of negative symptom severity with cognitive symptoms and functioning in subjects at ultra-high risk for psychosis

AIM

Negative symptoms and cognition are related with functioning in schizophrenia. However, it is not clear whether they have a similar effect in individuals at ultra-high risk (UHR) for psychosis. In this study, we aimed to explore relationship of negative symptoms with cognition and functioning cross-sectionally in people with UHR for psychosis.

METHODS

In total, 107 people participated in this study. We assessed negative symptoms with Scale for Negative Symptoms (SANS). We applied a cognitive battery including seven tests. We evaluated functioning by using Global Assessment of Functioning Scale and work/study status as an indicator of role functioning.

RESULTS

SANS scores were correlated to global functioning cross-sectionally. SANS total score was correlated to cognitive test scores related to cognitive flexibility and attention. Only Trail Making Test B (TMT B) was negatively correlated to global functioning. SANS-affective blunting and SANS-avolition scores were independently related to global functioning. There was a significant indirect effect of the TMT B and composite attention scores on global functioning through negative symptoms indicating a complete mediation.

CONCLUSION

Our findings suggest that negative symptoms, particularly avolition have an impact on functioning and the association of cognition with functioning was mediated by negative symptoms in UHR.

Neurocognition and Social Cognition- Possibilities for Diagnosis and Treatment in Ultra-High Risk for Psychosis State

In recent decades, clinicians have developed the construct of ultra-high risk (UHR) for psychosis to characterize the prodromal phase of psychosis or classify people with weakly expressed psychotic symptoms. In this conceptual analysis, we have gathered up-to-date data about the clinical picture of neurocognition and social cognition in people at UHR for psychosis. We also discuss treatment options. A well-chosen therapeutic approach can help to deal with difficulties and delay or even prevent the development of full-blown psychotic disorders in the UHR group. Despite much evidence supporting the benefits of therapy, early interventions are still not as widely used as they should be. Thus, a better understanding of the UHR state is very important for all healthcare workers.

Negative symptoms in the clinical high-risk state for psychosis: Connection with cognition and primacy in impacting functioning

AIM

In the clinical high-risk (CHR) state for psychosis, both negative symptoms and lower cognitive function have been associated with poorer daily functioning. Recent evidence suggests that negative symptoms share overlapping variability with cognition and may partially mediate the relationship between cognition and functioning. However, the nature of this overlap is unknown, and the reverse mediation model remains untested leaving the precise nature of these associations unclear.

METHODS

In order to clarify these relationships, a sample of community-dwelling youth meeting CHR criteria was collected from a specialty CHR clinic (n = 91, mean age = 21, 63% male). Bootstrapping methods were then applied in a mediation analysis to test both negative symptoms and cognition as independent variables and mediating variables predicting social and role functioning in CHR individuals. Canonical correlation analysis was used to characterize the overlapping variability between negative symptoms and cognition.

RESULTS

Support for a primary role of negative symptoms in predicting functioning and cognition was observed. Canonical correlation revealed a single dimension of overlap between the two symptom types (r = .62), represented by a strong correlation between negative symptoms in general and tasks involving verbal working memory, vigilance and social cognition specifically. A single cognitive factor composed primarily of these tasks was found to predict role functioning (adjusted R ² = .04).

CONCLUSIONS

The results highlight the importance of considering specific cognitive mechanisms overlapping with negative symptoms in research and rehabilitative practice in CHR populations, as well as the primary importance of targeting negative symptoms.

Adolescent social functioning in offspring at high risk for schizophrenia spectrum disorders in the Finnish Adoptive Family Study of Schizophrenia

BACKGROUND

Children and adolescents with a genetic risk for schizophrenia are often found to have poorer social functioning compared to their controls. However, less is known about high-risk offspring who have not been reared by a biological parent with schizophrenia. The purpose of this study was to examine deficits in social functioning in adolescence as a possible factor related to genetic vulnerability to schizophrenia spectrum disorders, and also to examine possible gender differences in these associations.

METHOD

The present sample consisted of 88 genetic high-risk (HR) adoptees whose biological mothers were diagnosed with schizophrenia spectrum disorders and 83 genetic low-risk (LR) adoptees with biological mothers with non-schizophrenia spectrum disorders or no psychiatric disorders. Adoptees' social functioning at ages 16-20 was assessed using the UCLA Social Attainment Survey.

RESULTS

Compared to LR adoptees, HR adoptees displayed statistically significant deficits in their peer relationships, involvement in activities and overall social functioning during adolescence. HR males were distinguished from LR males by their significantly poorer overall social functioning. Compared to HR females, HR males showed significant deficits in their romantic relationships. Of marginal significance was that HR females displayed more social functioning deficits relative to LR females, mainly in the areas of peer relationships, involvement in activities and overall social functioning.

CONCLUSIONS

These results from the adoption and high-risk study design suggest that deficits in social functioning in adolescence may be related to genetic vulnerability to schizophrenia spectrum disorders and that some of these deficits may be gender-specific.

Negative Symptoms and Functioning in Youth at Risk of Psychosis: A Systematic Review and Meta-analysis

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Evaluate the relationship between negative symptoms and functioning in youth at clinical high risk for psychosis.

AIM

Youth at CHR for psychosis often demonstrate significant negative symptoms and poor functioning, though the magnitude and direction of the relationship between the two remains unknown. The objective of this systematic review is to summarize the relationship between negative symptoms and functioning in CHR samples.

METHOD

Electronic databases CINAHL, EBM, Embase, MEDLINE, and PsycINFO were searched from inception. Studies were selected if they included any study that reported a relationship between negative symptoms and functioning in youth at clinical high risk (CHR). The correlation coefficient r was converted to Cohen's d, and all random-effects meta-analyses were performed using the transformed values.

RESULTS

Forty-one studies met the inclusion criteria, including a total of 4574 individuals at CHR for psychosis. Negative symptom total scores were significantly associated with poorer global functioning (d, -1.40; 95% CI, -1.82 to -0.98; I = 79.4%; p < .001 [9 studies, n = 782]), social functioning (d, -1.10; 95% CI, -1.27 to -0.93; I = 10.40%; p < .001 [12 studies, n = 811]), and role functioning (d, -0.96; 95% CI, -1.17 to -0.76; I = 41.1%; p < .001 [9 studies, n = 881]). In addition, negative symptoms were consistently associated with poor premorbid functioning. When examining negative symptom domains, avolition, anhedonia, and blunted affect were each significantly and independently associated with poorer social functioning and role functioning. In terms of prediction models, negative symptoms contributed to the prediction of lower functioning across multiple studies.

CONCLUSION

This meta-analysis demonstrates a strong relationship between negative symptoms and functioning in youth at clinical high risk for psychosis.

Social functioning and subclinical psychosis in adolescence: a longitudinal general adolescent population study

OBJECTIVES

To investigate the longitudinal relationship between subclinical psychotic symptoms and social functioning in a representative general population sample of adolescents.

METHOD

Data were derived from a routine general health screening of 1909 adolescents in a circumscribed region. Baseline measurement was in the second grade of secondary school (T0), and follow-up occurred approximately 2 years later (T1). Social functioning and subclinical psychotic symptoms of hallucinations and delusions were assessed at both time points.

RESULTS

Baseline (T0) social problems preceded follow-up (T1) subclinical delusions, but not T1 subclinical hallucinations. Similarly, T0 delusions preceded social problems at T1, but T0 hallucinations did not.

CONCLUSION

This longitudinal general population study demonstrated a bidirectional association between social problems and delusions, but found no link between social problems and hallucinations. This may reflect a downward negative spiral where delusional thoughts and social problems reinforce each other.

Learning to trust: social feedback normalizes trust behavior in first-episode psychosis and clinical high risk

BACKGROUND

Psychosis is characterized by problems in social functioning that exist well before illness onset, and in individuals at clinical high risk (CHR) for psychosis. Trust is an essential element for social interactions that is impaired in psychosis. In the trust game, chronic patients showed reduced baseline trust, impaired response to positive social feedback, and attenuated brain activation in reward and mentalizing areas. We investigated whether first-episode psychosis patients (FEP) and CHR show similar abnormalities in the neural and behavioral mechanisms underlying trust.

METHODS

Twenty-two FEP, 17 CHR, and 43 healthy controls performed two trust games, with a cooperative and an unfair partner in the fMRI scanner. Region of interest analyses were performed on mentalizing and reward processing areas, during the investment and outcome phases of the games.

RESULTS

Compared with healthy controls, FEP and CHR showed reduced baseline trust, but like controls, learned to trust in response to cooperative and unfair feedback. Symptom severity was not associated with baseline trust, however in FEP associated with reduced response to feedback. The only group differences in brain activation were that CHR recruited the temporo-parietal junction (TPJ) more than FEP and controls during investment in the unfair condition. This hyper-activation in CHR was associated with greater symptom severity.

CONCLUSIONS

Reduced baseline trust may be associated with risk for psychotic illness, or generally with poor mental health. Feedback learning is still intact in CHR and FEP, as opposed to chronic patients. CHR however show distinct neural activation patterns of hyper-activation of the TPJ.

Social Mindfulness and Psychosis: Neural Response to Socially Mindful Behavior in First-Episode Psychosis and Patients at Clinical High-Risk

Background: Psychosis is characterized by problems in social functioning and trust, the assumed glue to positive social relations. But what helps building trust? A prime candidate could be social mindfulness: the ability and willingness to see and consider another person’s needs and wishes during social decision making. We investigated whether first-episode psychosis patients (FEP) and patients at clinical high-risk (CHR) show reduced social mindfulness, and examined the underlying neural mechanisms.

Methods: Twenty FEP, 17 CHR and 46 healthy controls, aged 16–31, performed the social mindfulness task (SoMi) during fMRI scanning, spontaneously and after the instruction “to keep the other’s best interest in mind.” As first of two people, participants had to choose one out of four products, of which three were identical and one was unique, differing in a single aspect (e.g., color).

Results: FEP tended to choose the unique item (unmindful choice) more often than controls. After instruction, all groups significantly increased the number of mindful choices compared to the spontaneous condition. FEP showed reduced activation of the caudate and medial prefrontal cortex (mPFC) during mindful, and of the anterior cingulate cortex (ACC), mPFC, and left dorsolateral prefrontal cortex (dlPFC) during unmindful decisions. CHR showed reduced activation of the ACC compared to controls.

Discussion: FEP showed a trend toward more unmindful choices. A similar increase of mindful choices after instruction indicated the ability for social mindfulness when prompted. Results suggested reduced sensitivity to the rewarding aspects of social mindfulness in FEP, and reduced consideration for the other player. FEP (and CHR to a lesser extent) might perceive unmindful choices as less incongruent with the automatic mindful responses than controls. Reduced socially mindful behavior in FEP may hinder the building of trust and cooperative interactions.

Psychopathology and social functioning of 42 subjects from a Danish ultra high-risk cohort

AIM

To make a thorough characterization of the co-morbidity, psychopathology and demographics in the first Danish ultra high-risk (UHR) sample.

METHOD

Forty-two UHR subjects went through comprehensive interviews assessing their psychopathology, psychiatric disorders, substance use and family history of psychiatric disorders.

RESULTS

All UHR subjects met the criteria of at least 1 axis I diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and met on average four diagnoses (both axis I and II), mostly within the areas of depression, anxiety and substance abuse. A total of 48% had schizotypal personality disorder and 19% had borderline personality disorder. Level of functioning was low with a mean score on the Social and Occupational Functioning Assessment Scale corresponding to "major impairment in several areas," and mean scores in the Global Functioning: Social and Role scales between "moderate impairment in social functioning" and "very serious impairment independently." Forty-seven percent were unemployed and 29% on sick leave. Fifty-five percent relied financially on public support.

CONCLUSION

As seen in previous UHR populations, Danish UHR subjects had low function socio-economically and met criteria of several psychiatric diagnoses, suggesting that they require pharmacological and non-pharmacological psychiatric treatment as well as vocational and educational guidance and support.

Impact of rurality and substance use on young people at ultra high risk for psychosis

BACKGROUND

Longitudinal research into early intervention for youth at ultra high risk (UHR) for psychosis demonstrates beneficial outcomes including increased treatment compliance and greater participation in education and the workforce. Despite known barriers for rural youth accessing mental health services, research comparing urban and rural UHR youth is lacking. The study included an examination of the impact of substance use on functioning of UHR youth.

METHODS

Youth aged 12 to 25 years were recruited from the urban area of Newcastle or the rural area of Orange, New South Wales, Australia, and identified as UHR by the Comprehensive Assessment of At Risk Mental States. Rural and urban youth were compared on clinical profiles, social and occupational functioning and substance use.

RESULTS

The rural youth showed different help-seeking behaviours and had greater functional impairment than urban youth. Substance use was common across the sample of 57 youth (mean age 16.5 years, 56% female) and a history of hazardous substance use was associated with higher levels of depression. Rural youth (n = 32) were more likely than urban youth to be taking antidepressants at baseline (44% compared with 16%).

CONCLUSION

Different patterns of help seeking by rural UHR youth suggest a need for greater access to psychosis informed primary care early intervention services. Interventions should target functional decline to prevent adverse outcomes such as reduced community participation and unemployment. In addition, interventions for substance use should be a priority for UHR youth, who should also be screened and monitored for depressive symptoms and treated for depression if indicated.

Metacognitive beliefs as psychological predictors of social functioning: An investigation with young people at risk of psychosis

Poor social functioning has been found to be present in those at risk for psychosis. This study aimed to examine metacognitive beliefs as potential predictors of structured activity (measure of social functioning) in those with an At Risk Mental State (ARMS). Regression and correlation analyses were conducted. The sample included 109 young people. Age was found to be positively correlated to structured activity. Metacognitive beliefs concerning uncontrollability and danger of worry were found to negatively predict structured activity. This was after controlling for age, gender, treatment allocation, cognitive schemas, positive symptom severity, social anxiety, and depression. Metacognitive danger items were most important. Age was the only control variable found to be an independent predictor of structured activity in the regression model, despite negative bi-variate relationships with structured activity found across three cognitive schema subscales and social anxiety. This is the first study to find that higher negative metacognitive beliefs about uncontrollability and danger predict lower social functioning in an ARMS sample, and that the perception of thoughts being dangerous was of particular importance. Psychological interventions should consider targeting this metacognitive dimension to increase social functioning. Future longitudinal research is required to strengthen findings in this area.

Facial affect recognition and social functioning among individuals with varying degrees of schizotypy

Facial affect recognition (FAR) accuracy is impaired in schizophrenia and, to a lesser extent, in individuals at-risk for psychosis. Reduced reaction time and negative bias on FAR tasks are also evident in schizophrenia, though few studies have examined these measures in at-risk samples. Social dysfunction is associated with FAR deficits in schizophrenia and at-risk individuals. We aimed to elucidate the nature of FAR and social functioning among individuals from a non-clinical population reporting a range of schizotypal traits (i.e., risk for psychosis), and to examine whether FAR mediates the relationship between schizotypal traits and social functioning. Participants completed self-report measures assessing schizotypal traits and social functioning, and a computerized FAR task remotely via the Internet. High schizotypy individuals performed significantly worse than low schizotypy individuals on FAR total and neutral accuracy, demonstrated a negative bias, and reported significantly worse social functioning. Schizotypal traits were also negatively correlated with FAR performance and social functioning in the total sample. FAR accuracy did not mediate the direct relationship between schizotypal traits and social functioning. FAR may be an important social-cognitive endophenotype of psychosis risk with implications for understanding etiology of psychotic spectrum disorders, improving ways of identifying at-risk individuals, and developing preventive strategies.

Deconstructing Vulnerability for Psychosis: Meta-Analysis of Environmental Risk Factors for Psychosis in Subjects at Ultra High-Risk

Background

Subjects at ultra high-risk (UHR) for psychosis have an enhanced vulnerability to develop the disorder but the risk factors accounting for this accrued risk are undetermined.

Method

Systematic review of associations between genetic or environmental risk factors for psychosis that are widely established in the literature and UHR state, based on comparisons to controls.

Results

Forty-four studies encompassing 170 independent datasets and 54 risk factors were included. There were no studies on association between genetic or epigenetic risk factors and the UHR state that met the inclusion criteria. UHR subjects were more likely to show obstetric complications, tobacco use, physical inactivity, childhood trauma/emotional abuse/physical neglect, high perceived stress, childhood and adolescent low functioning, affective comorbidities, male gender, single status, unemployment and low educational level as compared to controls.

Conclusions

The increased vulnerability of UHR subjects can be related to environmental risk factors like childhood trauma, adverse life events and affective dysfunction. The role of genetic and epigenetic risk factors awaits clarification.

What drives poor functioning in the at-risk mental state? A systematic review

BACKGROUND

Transition to psychotic disorder has been the traditional outcome of interest for research in the at-risk mental state (ARMS). However, there is growing recognition that individuals with ARMS may function poorly regardless of whether they develop psychosis. We aimed to review the literature to determine whether there are specific factors associated with, or predictive of, functional impairment in the ARMS population.

METHOD

An electronic database search of MEDLINE, PsycINFO and Embase from inception until May 2014 was conducted using keyword search terms synonymous with the at-risk mental state and functioning. Eligible studies were original peer-reviewed English language research articles with populations that met validated at-risk diagnostic criteria and examined the cross-sectional or longitudinal association between any variable and a measure of functioning.

RESULTS

Seventy-two eligible studies were identified. Negative symptoms and neurocognitive impairment were associated with poor functioning in cross-sectional studies. Negative and disorganised symptoms, neurocognitive deficits and poor functioning at baseline were predictive of poor functional outcome in longitudinal studies. Positive symptoms were unrelated to functioning in both cross-sectional and longitudinal studies. Functional disability was persistent and resistant to current treatments.

CONCLUSIONS

Negative and disorganised symptoms and cognitive deficits pre-date frank psychotic symptoms and are risk factors for poor functioning. This is consistent with a subgroup of ARMS individuals potentially having neurodevelopmental schizophrenia. Treatments aimed at improving functioning must be considered a priority on par with preventing transition to psychosis in the development of future interventions in the ARMS group.

Mental health recovery and quilting: evaluation of a grass-roots project in a small, rural, Australian Christian church

A small project in a rural community church setting was undertaken to promote mental health recovery for one person and to develop a positive conversation about mental health amongst the wider group. Social capital within the group of people was successfully harnessed so that a warm and supportive recovery environment might be fostered within the broader community. The goals of the project were to reduce mental health stigma and to foster recovery. This was achieved as a mental health nurse, quilt maker, and a team of sewers came together to produce a quilt as a tangible expression of care and support for both the quilt recipient and each other. This project, as a case study, demonstrates how a church faith community and mental health care can be combined and yield positive outcomes. This article outlines how the project proceeded and presents the results of a post-project evaluation survey.

Psychosis-proneness and neural correlates of self-inhibition in theory of mind

Impaired Theory of Mind (ToM) has been repeatedly reported as a feature of psychotic disorders. ToM is crucial in social interactions and for the development of social behavior. It has been suggested that reasoning about the belief of others, requires inhibition of the self-perspective. We investigated the neural correlates of self-inhibition in nineteen low psychosis prone (PP) and eighteen high PP subjects presenting with subclinical features. High PP subjects have a more than tenfold increased risk of developing a schizophrenia-spectrum disorder. Brain activation was measured with functional Magnetic Resonance Imaging during a ToM task differentiating between self-perspective inhibition and belief reasoning. Furthermore, to test underlying inhibitory mechanisms, we included a stop-signal task. We predicted worse behavioral performance for high compared to low PP subjects on both tasks. Moreover, based on previous neuroimaging results, different activation patterns were expected in the inferior frontal gyrus (IFG) in high versus low PP subjects in self-perspective inhibition and simple response inhibition. Results showed increased activation in left IFG during self-perspective inhibition, but not during simple response inhibition, for high PP subjects as compared to low PP subjects. High and low PP subjects showed equal behavioral performance. The results suggest that at a neural level, high PP subjects need more resources for inhibiting the self-perspective, but not for simple motor response inhibition, to equal the performance of low PP subjects. This may reflect a compensatory mechanism, which may no longer be available for patients with schizophrenia-spectrum disorders resulting in ToM impairments.

Efficacy of social cognition remediation programs targeting facial affect recognition deficits in schizophrenia: a review and consideration of high-risk samples and sex differences

Schizophrenia patients suffer from significant social functioning deficits. Social cognition, particularly facial affect recognition (FAR), is an important predictor of functional outcome. Recently, investigators developed numerous social cognition remediation programs targeting FAR deficits with the goal of improving social functioning and quality of life in schizophrenia patients. This article builds on Horan et al.'s (2008) comprehensive review and Kurtz and Richardson's (2012) meta-analysis of a broad range of social cognition remediations, by systematically reviewing efficacy of empirically based remediations in schizophrenia specifically targeting FAR (across 23 studies), and their potential functional benefits. We describe each FAR-based social cognition remediation program, which may aid clinical scientists and clinicians in selecting programs for further study and practice. We critically evaluate limitations of FAR remediation programs and applications. Our review concludes FAR remediation programs are strongly efficacious in improving FAR performance and functional status in schizophrenia. Importantly, we provide rationale for and recommend that future research consider (as yet underexplored) sexual dimorphisms in FAR remediation effects, and examine FAR remediation in clinical high-risk for psychosis populations. The goal is to mitigate deficits, perhaps hinder illness onset, and individually tailor treatments across the psychosis continuum in a way that maximally aids those in greatest need.

Personality disorders and accentuations in at-risk persons with and without conversion to first-episode psychosis

AIM

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Cluster A personality disorders (PDs), particularly schizotypal PD, are considered a part of the schizophrenia spectrum and a risk factor of psychosis. The role of PDs and personality accentuations (PAs) in predicting conversion to psychosis was studied in patients symptomatically considered at risk, assuming a major role of the schizotypal subtype.

METHODS

PDs and PAs, assessed at baseline with a self-report questionnaire, were compared between risk-, gender- and age-matched at-risk patients with (n = 50) and without conversion to psychosis (n = 50).

RESULTS

Overall, Cluster A-PDs were the least frequent cluster (14%), and schizotypal PD was rare (7%). Yet, PDs in general were frequent (46%), especially Cluster B- (31%) and C-PDs (23%). Groups did not differ in frequencies of PDs, yet converters tended to have a higher expression of schizoid (P = 0.057) and Cluster A-PAs (P = 0.027). In regression analyses, schizoid PA was selected as sole but weak predictor of conversion (OR = 1.685; 95% CIs: 1.134/2.504).

CONCLUSIONS

Unexpectedly, schizotypal PD was infrequent and did not predict conversion. Conversion was best predicted by schizoid PA, indicating more severe, persistent social deficits already at baseline in later converters. This corresponds to premorbid social deficits reported for genetic high-risk children and low social functioning in at-risk patients later converting to psychosis. Further, PDs occurred frequently in at-risk patients irrespective of conversion. As psychopathology and personality relate closely to one another, this result highlights that, beyond the current narrow focus on schizotypal PD, personality-related factors should be considered more widely in the prevention of psychosis.

Neuromagnetic auditory response and its relation to cortical thickness in ultra-high-risk for psychosis

BACKGROUND

Higher cognitive dysfunction, lower perceptual disturbance and its relation to the structures that implicate such processes have been considered as key features in patients with schizophrenia. However, little is known about the relationship between perceptual processing and structural deficits in ultra-high-risk for psychosis.

METHODS

We investigated the dipole moment of M100 auditory evoked response using a magnetoencephalography in 18 patients with schizophrenia, 16 ultra-high-risk for psychosis and 16 healthy controls, and their relation to cortical thinning on Heschl's gyrus and planum temporale.

RESULTS

The auditory evoked M100 dipole moment was decreased in the ultra-high-risk subjects and in the patients with schizophrenia. Ultra-high-risk subjects showed impaired right M100 dipole magnitude, similar to patients with schizophrenia. Robust correlations between the cortical thickness of left Heschl's gyrus and the left M100 dipole moment were found in patients with schizophrenia. Moreover, correlations were also evident between right Heschl's gyrus and right M100 in subjects at ultra-high-risk for psychosis.

CONCLUSIONS

The primary feature of auditory perception in ultra-high-risk subjects and schizophrenia patients is an encoding deficit that manifests as a reduced M100 dipole moment. The relationship between abnormal M100, thinning of cortical generators and their symptomatology were shown to exist prior to the onset of overt psychosis and progressively worsen over time. Therefore, they may be a potential indicator of the development of schizophrenia.

Modeling resilience to schizophrenia in genetically modified mice: a novel approach to drug discovery

Complex psychiatric disorders, such as schizophrenia, arise from a combination of genetic, developmental, environmental and social factors. These vulnerabilities can be mitigated by adaptive factors in each of these domains engendering resilience. Modeling resilience in mice using transgenic approaches offers a direct path to intervention, as resilience mutations point directly to therapeutic targets. As prototypes for this approach, we discuss the three mouse models of schizophrenia resilience, all based on modulating glutamatergic synaptic transmission. This motivates the broader development of schizophrenia resilience mouse models independent of specific pathophysiological hypotheses as a strategy for drug discovery. Three guiding validation criteria are presented. A resilience-oriented approach should identify pharmacologically tractable targets and in turn offer new insights into pathophysiological mechanisms.

Early intervention in psychosis: Insights from Korea

Subjects at clinical high risk (CHR) for psychosis have been the focus of clinical attention in psychiatry for the last 15 years, leading to the development of valid and reliable diagnostic instruments to detect these individuals early in the course of their illness. These efforts have resulted in research into optimal preventive measures. Our experiences at and data from the Seoul Youth Clinic support the validity of the CHR concept and its underlying neurobiological basis and provide valuable information related to the determination of appropriate clinical interventions. The limitations of the current criteria for CHR, such as the relatively low transition rates to psychosis and the "false-positive" problem, are also common critical issues in Korea. Additionally, concerns about social stigmatization and the potential side effects of pharmacotherapy render individuals at CHR reluctant to visit clinical settings. Therefore, further investigations using a combination of predictive markers based on clinical and neurobiological studies of those at CHR are needed to refine the diagnostic criteria, overcome their current limitations including ethical issues, and develop phase-specific and individualized therapeutic interventions.

Theory of Mind in patients at clinical high risk for psychosis

BACKGROUND

Patients with schizophrenia have a decreased ability to interpret the intentions of other individuals, called Theory of Mind (ToM). As capacity for ToM normally advances with brain maturation, research on ToM in individuals at heightened clinical risk for psychosis may reveal developmental differences independent of disease based differences.

METHODS

We examined ToM in at clinical high risk and schizophrenia patients as well as healthy controls: 1) 63 clinical high risk (CHR) patients and 24 normal youths ascertained by a CHR program; and 2) in 13 schizophrenia cases and 14 normal adults recruited through a schizophrenia program. ToM measures included first- and second-order false belief cartoon tasks (FBT) and two "higher order" tasks ("Strange Stories Task" (SST) and the "Reading the Mind in the Eyes" task). In the first study, CHR patients and normal youths were also assessed for cognition, "prodromal" symptoms and social function.

RESULTS

Errors on first- and second-order false belief tasks were made primarily by patients. CHR patients and their young comparison group had equivalent performance on higher order ToM, which was not significantly different from the worse ToM performance of schizophrenia patients and the higher performance of normal adult controls. In the combined dataset from both studies, all levels of ToM were associated with IQ, controlling for age and sex. ToM bore no relation to explicit memory, prodromal symptoms, social function, or later transition to psychosis.

CONCLUSIONS

Higher order ToM capacity was equally undeveloped in high risk cases and younger controls, suggesting that performance on these tasks is not fully achieved until adulthood. This study also replicates the association of IQ with ToM performance described in previous studies of schizophrenia.

Longitudinal patterns of social functioning and conversion to psychosis in subjects at ultra-high risk

OBJECTIVE

Impaired social functioning is one of the defining features of patients with schizophrenia and subjects at ultra-high risk (UHR) for psychosis. This prospective study aimed to investigate the course of social dysfunction in UHR subjects and to examine its relationship with later conversion to psychosis. The effect of pharmacotherapy on the course of social dysfunction was also examined.

METHOD

A total of 57 UHR subjects and 58 healthy controls participated in this study. The Social Functioning Scale (SFS) was used to assess social functioning of UHR subjects at baseline and at the 1 year follow up. The changes in social functioning of UHR subjects have been examined to compare the social functioning of those who later converted to psychosis ('converters') with those who did not ('non-converters'). The effect of pharmacotherapy on longitudinal change in social functioning was also evaluated.

RESULTS

Subjects at UHR for psychosis showed more impaired social functioning at baseline than did healthy controls. Moreover, the course of social dysfunction of the converter and non-converter groups differed during the 1 year follow up period. The converters showed decreases in SFS average (F (1,32) = 7.85, p = 0.009) and interpersonal behaviour (F (1,32) = 10.43, p = 0.003) scores over time, whereas the non-converters showed increased scores. Additionally, we found that pharmacological treatment was associated with increased prosocial activities score (F (1,32) = 4.66, p = 0.038).

CONCLUSIONS

We found that the social functioning of converters was impaired before the onset of the psychosis and further declined during the at-risk phase. A series of social functioning indices in the longitudinal course may be helpful in predicting conversion to psychosis in subjects at UHR. Appropriate pharmacotherapy can offer clinical benefits by improving social functioning in UHR individuals.

Cortical thickness reduction in individuals at ultra-high-risk for psychosis

Although schizophrenia is characterized by gray matter (GM) abnormalities, particularly in the prefrontal and temporal cortices, it is unclear whether cerebral cortical GM is abnormal in individuals at ultra-high-risk (UHR) for psychosis. We addressed this issue by studying cortical thickness in this group with magnetic resonance imaging (MRI). We measured cortical thickness of 29 individuals with no family history of psychosis at UHR, 31 patients with schizophrenia, and 29 healthy matched control subjects using automated surface-based analysis of structural MRI data. Hemispheric mean and regional cortical thickness were significantly different according to the stage of the disease. Significant cortical differences across these 3 groups were found in the distributed area of cerebral cortices. UHR group showed significant cortical thinning in the prefrontal cortex, anterior cingulate cortex, inferior parietal cortex, parahippocampal cortex, and superior temporal gyrus compared with healthy control subjects. Significant cortical thinning in schizophrenia group relative to UHR group was found in all the regions described above in addition with posterior cingulate cortex, insular cortex, and precentral cortex. These changes were more pronounced in the schizophrenia group compared with the control subjects. These findings suggest that UHR is associated with cortical thinning in regions that correspond to the structural abnormalities found in schizophrenia. These structural abnormalities might reflect functional decline at the prodromal stage of schizophrenia, and there may be progressive thinning of GM cortex over time.

The relationship of social function to depressive and negative symptoms in individuals at clinical high risk for psychosis

BACKGROUND

Social dysfunction is a hallmark symptom of schizophrenia which commonly precedes the onset of psychosis. It is unclear if social symptoms in clinical high-risk patients reflect depressive symptoms or are a manifestation of negative symptoms.

METHOD

We compared social function scores on the Social Adjustment Scale-Self Report between 56 young people (aged 13-27 years) at clinical high risk for psychosis and 22 healthy controls. The cases were also assessed for depressive and 'prodromal' symptoms (subthreshold positive, negative, disorganized and general symptoms).

RESULTS

Poor social function was related to both depressive and negative symptoms, as well as to disorganized and general symptoms. The symptoms were highly intercorrelated but linear regression analysis demonstrated that poor social function was primarily explained by negative symptoms within this cohort, particularly in ethnic minority patients.

CONCLUSIONS

Although this study demonstrated a relationship between social dysfunction and depressive symptoms in clinical high-risk cases, this association was primarily explained by the relationship of each of these to negative symptoms. In individuals at heightened risk for psychosis, affective changes may be related to a progressive decrease in social interaction and loss of reinforcement of social behaviors. These findings have relevance for potential treatment strategies for social dysfunction in schizophrenia and its risk states and predict that antidepressant drugs, cognitive behavioral therapy and/or social skills training may be effective.

Structural brain alterations in individuals at ultra-high risk for psychosis: a review of magnetic resonance imaging studies and future directions

Individuals at ultra-high-risk (UHR) for psychosis have become a major focus for research designed to explore markers for early detection of and clinical intervention in schizophrenia. In particular, structural magnetic resonance imaging studies in UHR individuals have provided important insight into the neurobiological basis of psychosis and have shown the brain changes associated with clinical risk factors. In this review, we describe the structural brain abnormalities in magnetic resonance images in UHR individuals. The current accumulated data demonstrate that abnormalities in the prefrontal and temporal cortex and anterior cingulate cortex occur before illness onset. These regions are compatible with the regions of structural deficits found in schizophrenia and first-episode patients. In addition, the burgeoning evidence suggests that such structural abnormalities are potential markers for the transition to psychosis. However, most findings to date are limited because they are from cross-sectional rather than longitudinal studies. Recently, researchers have emphasized neurodevelopmental considerations with respect to brain structural alterations in UHR individuals. Future studies should be conducted to characterize the differences in the brain developmental trajectory between UHR individuals and healthy controls using a longitudinal design. These new studies should contribute to early detection and management as well as provide more predictive markers of later psychosis.

The case for including Attenuated Psychotic Symptoms Syndrome in DSM-5 as a psychosis risk syndrome

The American Psychiatric Association Task Force on DSM-5 has recently proposed consideration of Attenuated Psychotic Symptoms Syndrome as a new diagnosis, based on nearly 15 years of prospective research in centers across the globe. The condition is also known as "psychosis risk syndrome," "at-risk mental state," "ultra-high risk," and "putative prodrome." We review evidence favoring its inclusion as a new diagnosis in DSM-5 and report new preliminary findings on DSM-IV diagnoses in current clinical use for these patients and on results of diagnostic interviews in unselected volunteers. The main evidence supporting inclusion is: (1) the patients are currently ill, (2) the patients are at high risk for getting worse, (3) no DSM-IV diagnosis accurately captures their current illness or future risk, (4) the diagnosis has been made with reliability and validity in the research setting, and (5) placement in DSM-5 would help promote the needed treatment and prevention research to enable articulation of a standard of care to benefit these patients and their families. Potential harms can be minimized by patient, family, and provider education. It will be important to demonstrate through well-designed field trials whether the diagnostic criteria can be used with reliability in everyday clinical practice.

Reduced intra-amygdala activity to positively valenced faces in adolescent schizophrenia offspring

Studies suggest that the affective response is impaired in both schizophrenia and adolescent offspring of schizophrenia patients. Adolescent offspring of patients are developmentally vulnerable to impairments in several domains, including affective responding, yet the bases of these impairments and their relation to neuronal responses within the limbic system are poorly understood. The amygdala is the central region devoted to the processing of emotional valence and its sub-nuclei including the baso-lateral and centro-medial are organized in a relative hierarchy of affective processing. Outputs from the centro-medial nucleus converge on regions involved in the autonomous regulation of behavior, and outputs from the baso-lateral nucleus modulate the response of reward processing regions. Here using fMRI we assessed the intra-amygdala response to positive, negative, and neutral valenced faces in a group of controls (with no family history of psychosis) and offspring of schizophrenia parents (n=44 subjects in total). Subjects performed an affective continuous performance task during which they continually appraised whether the affect signaled by a face on a given trial was the same or different from the previous trial (regardless of facial identity). Relative to controls, offspring showed reduced activity in the left centro-medial nucleus to positively (but not negatively or neutral) valenced faces. These results were independent of behavioral/cognitive performance (equal across groups) suggesting that an impaired affective substrate in the intra-amygdala response may lie at the core of deficits of social behavior that have been documented in this population.

Altered resting-state connectivity in subjects at ultra-high risk for psychosis: an fMRI study

Background

Individuals at ultra-high risk (UHR) for psychosis have self-disturbances and deficits in social cognition and functioning. Midline default network areas, including the medial prefrontal cortex and posterior cingulate cortex, are implicated in self-referential and social cognitive tasks. Thus, the neural substrates within the default mode network (DMN) have the potential to mediate self-referential and social cognitive information processing in UHR subjects.

Methods

This study utilized functional magnetic resonance imaging (fMRI) to investigate resting-state DMN and task-related network (TRN) functional connectivity in 19 UHR subjects and 20 matched healthy controls. The bilateral posterior cingulate cortex was selected as a seed region, and the intrinsic organization for all subjects was reconstructed on the basis of fMRI time series correlation.

Results

Default mode areas included the posterior/anterior cingulate cortices, the medial prefrontal cortex, the lateral parietal cortex, and the inferior temporal region. Task-related network areas included the dorsolateral prefrontal cortex, supplementary motor area, the inferior parietal lobule, and middle temporal cortex. Compared to healthy controls, UHR subjects exhibit hyperconnectivity within the default network regions and reduced anti-correlations (or negative correlations nearer to zero) between the posterior cingulate cortex and task-related areas.

Conclusions

These findings suggest that abnormal resting-state network activity may be related with the clinical features of UHR subjects. Neurodevelopmental and anatomical alterations of cortical midline structure might underlie altered intrinsic networks in UHR subjects.

Social skill and social cognition in adolescents at genetic risk for psychosis

Adolescents at genetic high risk (GHR) for schizophrenia have shown social skill impairments and there is some evidence to suggest they have Theory of Mind (ToM) deficits; however no research has used a standardized, performance-based behavioral measure to assess social functioning in this population nor evaluated ToM with a well-validated measure. We evaluated the psychometric properties of a new, theoretically-derived assessment of social functioning in GHR adolescents: the "High-Risk Social Challenge" task (HiSoC). The second aim was to explore whether GHR adolescents would show social skill and ToM deficits as compared to a non-psychiatric control (NPC) group. The present study evaluated social functioning with the HiSoC and ToM with the Eyes Test in 23 GHR adolescents and 31 NPCs. The HiSoC demonstrated high levels of reliability and validity. The GHR adolescents showed social skill impairments, but not ToM deficits. The results suggest that the HiSoC is a potentially useful new measure of social functioning in GHR adolescents. Furthermore, the findings add to the current body of literature that indicates that social skill impairments are related to schizophrenia vulnerability.

Genetic modelling of childhood social development and personality in twins and siblings with schizophrenia

BACKGROUND

Abnormalities in early social development and personality are present in patients with schizophrenia and their unaffected relatives. This study aimed to establish the degree to which these childhood and adolescent developmental abnormalities are genetically determined.

METHOD

We used a combined twin and family study design (n=531) to assess childhood and adolescent social adjustment and schizotypal personality traits in 98 twin pairs (n=196) varying in their zygosity and concordance for schizophrenia and 156 sibling clusters (n=335) varying in their concordance for schizophrenia.

RESULTS

Schizophrenia was significantly associated with childhood and adolescent deficits in social adjustment and personality, with additive genetic effects being the main source of these phenotypic correlations.

CONCLUSIONS

Abnormalities of social adjustment and personality are present in children and adolescents who later develop schizophrenia, reflecting the influence of common genetic risk.

What factors are related to delayed treatment in individuals at high risk for psychosis?

BACKGROUND

Previous studies have shown that the individuals at high risk for psychosis suffer from depression, anxiety, and deficits in social functioning. The present report describes help-seeking behaviours, baseline psychopathology, and duration of attenuated psychotic symptoms (DUAPS) and their associations with other variables.

METHODS

Using the Comprehensive Assessment of At-Risk Mental States (CAARMS), we conducted systematic evaluations of individuals at high risk for psychosis. Help-seeking behaviours, current Axis I diagnoses, DUAPS, and baseline psychopathology were investigated. Demographic and clinical characteristics of short and long DUAPS groups were compared.

RESULTS

Thirty-eight subjects were recruited from nine centres. Participants seldom sought psychiatric services at their first help-seeking contact, and the mean DUAPS was 22.00 +/- 28.59 months. Most participants had current Axis I diagnoses, and depressive disorder NOS was the most common of these. Higher levels of depression, anxiety, obsessive-compulsive symptoms, and functional impairment were also identified. We found no significant differences between short and long DUAPS groups in baseline psychopathology. However, we observed significantly lesser distressing intensity of thought contents and significantly greater social impairment in the long-DUAPS group.

CONCLUSION

These findings suggest that high-risk subjects frequently received delayed treatment despite symptomatic distress and functional impairment. No direct evidence supporting the delayed effect of the DUAPS on baseline psychopathology was found.

Research in people with psychosis risk syndrome: a review of the current evidence and future directions

After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of 'prodromal' or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as 'clinical high risk' (CHR), or 'ultra-high risk' (UHR), or 'prodromal'. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, 'multisite' projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non-antipsychotic, neuroprotective and low-risk pharmacologic and non-pharmacologic interventions; 3) testing of potentially phase-specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow-up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia-spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.

Social dysfunction predicts two years clinical outcome in people at ultra high risk for psychosis

The experience of a first psychotic episode is associated with a marked impairment in psychosocial functioning. However, the decline may be already evident in the pre-psychotic phases and play a significant role in the etiopathology of the disease onset. A sample of subjects at ultra high clinical risk for psychosis ("At Risk Mental State", ARMS, n=152) was compared with a demographically-matched general population (n=98,072) on different measures of psychosocial functioning. The proportion of subjects with an ARMS living in communal establishments or living at home with their parents was significantly higher than that of the local population (p<0.001). Subjects with an ARMS showed also higher rates of unemployment as compared to the general population (p<0.001). GAF scores at baseline were significantly lower in unemployed ARMS as compared to students and employed ARMS (p=0.002). ARMS subjects living in communal establishments presented higher rates of co-morbid psychiatric conditions (p=0.007) and lower GAF scores at baseline (p=0.017). Finally, baseline unemployment and living in a communal establishment were associated with an increased risk of developing a psychotic episode within the following two years (p<0.05). We concluded that the "At Risk Mental State" is a clinical condition which is characterized by marked psychosocial impairment and by an increased vulnerability to psychosis. Unemployment at the first contact with the prodromal service may be a risk factor for the development of a psychotic episode.

Premorbid cognitive deficits in young relatives of schizophrenia patients

Neurocognitive deficits in schizophrenia (SZ) are thought to be stable trait markers that predate the illness and manifest in relatives of patients. Adolescence is the age of maximum vulnerability to the onset of SZ and may be an opportune "window" to observe neurocognitive impairments close to but prior to the onset of psychosis. We reviewed the extant studies assessing neurocognitive deficits in young relatives at high risk (HR) for SZ and their relation to brain structural alterations. We also provide some additional data pertaining to the relation of these deficits to psychopathology and brain structural alterations from the Pittsburgh Risk Evaluation Program (PREP). Cognitive deficits are noted in the HR population, which are more severe in first-degree relatives compared to second-degree relatives and primarily involve psychomotor speed, memory, attention, reasoning, and social-cognition. Reduced general intelligence is also noted, although its relationship to these specific domains is underexplored. Premorbid cognitive deficits may be related to brain structural and functional abnormalities, underlining the neurobiological basis of this illness. Cognitive impairments might predict later emergence of psychopathology in at-risk subjects and may be targets of early remediation and preventive strategies. Although evidence for neurocognitive deficits in young relatives abounds, further studies on their structural underpinnings and on their candidate status as endophenotypes are needed.