Development and Validation of the Negative Symptom Inventory-Psychosis Risk

Longitudinal clinical outcomes based on cognitive and hippocampal clusters of first episode psychosis

BACKGROUND

In first episode psychosis (FEP), cognitive impairments are core features contributing to clinical and functional heterogeneity. Significant impairment indicates greater clinical severity throughout the course of the illness, particularly for negative symptoms. Hippocampal volume is smaller in FEP than in healthy controls (notably subfields like Cornu Ammonis 1-3 and subiculum), and is related to cognitive impairments and negative symptoms. The aim of this study was to compare the clinical and functional trajectories of FEP subgroups as a function of cognitive performance and hippocampal volumes.

METHODS

One hundred FEP patients and sixty healthy controls initially assessed using the CogState research battery, underwent 3 T MRI to extract hippocampal subfields and adjacent structures using the MAGeT brain algorithm. Clinical assessments were carried out for negative (Motivational and Pleasure - MAP, and diminished expression - EXP) and depressive symptoms, and global functioning. Measurements were taken at 4 time points (3, 9, 15, 21 months following program entry). Based on available first timepoint standardized cognitive and hippocampal features, using healthy controls as reference, clusters were determined by a hierarchical ascending classification. Their clinical and functional longitudinal trajectories were analyzed using linear mixed-effects models.

RESULTS

Three baseline clusters were revealed: normal-range hippocampal volume with low attention, working and verbal memory (FEP 0), small hippocampus with low verbal memory and social cognition (FEP 1), and large hippocampus with low verbal memory (FEP 2). At baseline, the clusters did not differ on symptoms severity and global functioning. Longitudinally, MAP, EXP and depressive symptoms decreased over time in FEP 0. Global functioning improved in FEP 0 and FEP 1, while FEP 2 was clinically and functionally stable over time. Longitudinal inter-group comparisons did not yield any significant differences.

CONCLUSION

The clusters were dissociated between hippocampus and cognition, but their trajectories suggest the importance of hippocampal integrity in the clinical and/or functional outcome. Future studies are needed to understand intervention efficiency depending on hippocampal integrity.

Digital phenotyping evidence for the reduced positivity offset as a mechanism underlying anhedonia among individuals at clinical high-risk for psychosis

Prior studies suggest that the "anhedonia paradox" in schizophrenia (i.e., discrepant results indicating intact hedonic reactivity despite reduced frequency of pleasure-seeking activity) can be explained by a reduction in the "positivity offset" (i.e., a reduction in the normative tendency to experience greater positive than negative affect during low arousal neutral contexts that promote reward-seeking behavior). In the current study, we examined whether the positivity offset is relevant to explaining anhedonia and liability for psychosis among individuals at clinical high-risk for psychosis (CHR) (i.e., individuals exhibiting attenuated hallucinations or delusions that cause distress and functional decline). Mathematical modeling approaches from Cacioppo's Evaluative Space Model were applied to six days of digital phenotyping data collected in daily life among 100 individuals at CHR and 57 healthy controls (CN). Participants reported levels of positive emotion, negative emotion, and arousal throughout the day via ecological momentary assessment (EMA) surveys while accelerometry was passively recorded. EMA surveys were used to calculate the positivity offset and examine associations with real-world motivated behavior. Results indicated that the positivity offset was present among individuals at CHR, but diminished compared to CN. Importantly, smaller positivity offset scores were associated with greater clinically rated anhedonia, particularly among CHR cases with comorbid mood disorder diagnoses. Findings suggest that reductions in the positivity offset are a mechanism underlying anhedonia across phases of psychotic illness and represent a novel treatment target that is relevant for the treatment of negative symptoms and prevention of psychotic disorders.

Enabling FAIR data stewardship in complex international multi-site studies: Data Operations for the Accelerating Medicines Partnership® Schizophrenia Program

Modern research management, particularly for publicly funded studies, assumes a data governance model in which grantees are considered stewards rather than owners of important data sets. Thus, there is an expectation that collected data are shared as widely as possible with the general research community. This presents problems in complex studies that involve sensitive health information. The latter requires balancing participant privacy with the needs of the research community. Here, we report on the data operation ecosystem crafted for the Accelerating Medicines Partnership® Schizophrenia project, an international observational study of young individuals at clinical high risk for developing a psychotic disorder. We review data capture systems, data dictionaries, organization principles, data flow, security, quality control protocols, data visualization, monitoring, and dissemination through the NIMH Data Archive platform. We focus on the interconnectedness of these steps, where our goal is to design a seamless data flow and an alignment with the FAIR (Findability, Accessibility, Interoperability, and Reusability) principles while balancing local regulatory and ethical considerations. This process-oriented approach leverages automated pipelines for data flow to enhance data quality, speed, and collaboration, underscoring the project's contribution to advancing research practices involving multisite studies of sensitive mental health conditions. An important feature is the data's close-to-real-time quality assessment (QA) and quality control (QC). The focus on close-to-real-time QA/QC makes it possible for a subject to redo a testing session, as well as facilitate course corrections to prevent repeating errors in future data acquisition. Watch Dr. Sylvain Bouix discuss his work and this article: https://vimeo.com/1025555648 .

Sample ascertainment and clinical outcome measures in the Accelerating Medicines Partnership® Schizophrenia Program

Clinical ascertainment and clinical outcome are key features of any large multisite study. In the ProNET and PRESCIENT research networks, the Accelerating Medicines Partnership® Schizophrenia (AMP®SCZ) Clinical Ascertainment and Outcome Measures Team aimed to establish a harmonized clinical assessment protocol across these two research networks and to define ascertainment criteria and primary and secondary endpoints. In addition to developing the assessment protocol, the goals of this aspect of the AMP SCZ project were: (1) to implement and monitor clinical training, ascertainment of participants, and clinical assessments; (2) to provide expert clinical input to the Psychosis Risk Evaluation, Data Integration and Computational Technologies: Data Processing, Analysis, and Coordination Center (PREDICT-DPACC) for data collection, quality control, and preparation of data for the analysis of the clinical measures; and (3) to provide ongoing support to the collection, analysis, and reporting of clinical data. This paper describes the (1) protocol clinical endpoints and outcomes, (2) rationale for the selection of the clinical measures, (3) extensive training of clinical staff, (4) preparation of clinical measures for a multisite study which includes several sites where English is not the native language; and (5) the assessment of measure stability over time in the AMP SCZ observational study comparing clinical ratings at baseline and at the 2-month follow up. Watch Dr. Jean Addington discuss her work and this article: https://vimeo.com/1040425281 .

Digital Phenotyping Measurement of Smartphone Social Behavior is Associated with Illness Progression Risk Scores in Young People at Clinical High Risk for Psychosis

BACKGROUND

Young people at clinical high risk for psychosis (CHR-p) commonly experience social impairment, which contributes to functional decline and predicts transition to psychotic illness. Although the use of smart phone technology and social media platforms for social interaction is widespread among today's youth, it is unclear whether aberrant digital social interactions contribute to risk for conversion and functional impairment in CHR-p. The current study sought to characterize the nature of social smartphone and social media use in a CHR-p sample and determine its association with clinical symptoms and risk for conversion to psychosis.

STUDY DESIGN

CHR-p (n = 132) and HC (n = 61) participants completed clinical interviews and 6 days of digital phenotyping that monitored total smartphone use, ratio of outgoing to incoming text messages and phone calls, social media use, and ecological momentary assessment surveys focused on in-person and electronic social interactions. Study Results: CHR-p did not differ from HC in total smartphone use for social communication or active social media use. However, CHR-p participants reported significantly less daily passive social media use compared to HC peers, and decreased text message reciprocity predicted 1- and 2-year conversion risk.

CONCLUSIONS

Results demonstrate a nuanced digital social landscape with divergent relationships from in-person social behavior and suggest online socialization has implications for high-precision identification and intervention strategies among the CHR-p population.

Cognitive-Behavioural Social Skills Training: Mediation of Treatment Outcomes in a Randomized Controlled Trial for Youth at Risk of Psychosis: L'entraînement aux compétences sociales cognitivo-comportementales : variables médiatrices des résultats thérapeutiques dans le cadre d'un essai clinique randomisé pour les jeunes présentant un risque de psychose

OBJECTIVES

Currently, there are no effective treatments for functional outcomes (i.e., role and social) and negative symptoms for youth at clinical high-risk (CHR) for psychosis. Investigations into possible mechanisms that may contribute to the improvement of functioning and negative symptoms are needed in CHR research to help inform psychosocial treatments. The present study examined whether functioning and negative symptoms were mediated by asocial beliefs, defeatist beliefs, self-efficacy, maladaptive schemas, anxiety, depression, social cognition, or attenuated psychotic symptoms (APS) in a large clinical trial.

METHODS

CHR participants (n = 203; 104 females; 99 males) were recruited as part of a three-site randomized control trial comparing group cognitive-behavioural social skills training (CBSST) versus a supportive therapy group. Mediation analyses were conducted to test the relationships between treatment group, mediators (asocial beliefs, defeatist beliefs, self-efficacy, maladaptive schemas, anxiety, depression, social cognition, and APS), and outcome (social and role functioning, and negative symptoms). The mediation analyses employed conditional process path analysis via ordinary least squares regression.

RESULTS

At the end of treatment, but not 12-month follow-up, more severe APS were found to mediate the impact of treatment on negative symptoms, and social and role functioning. The greater the severity of APS, the less likely that CBSST would result in improvement in negative symptoms and social and role functioning. Many of the other variables showed significant associations with social (less for role) functioning and negative symptoms but did not mediate the effect of treatment on these outcomes at the end of treatment or 12-month follow-up.

CONCLUSIONS

There were no significant mediators except for APS at the end of treatment. Since more severe APS may result in participants being unable to fully participate in therapy and thus limit their gains, clinical implications may include offering some individual therapy to prepare these young people to benefit from the group treatment.

Probabalistic reinforcement learning impairments predict negative symptom severity and risk for conversion in youth at clinical high-risk for psychosis

BACKGROUND

Elucidation of transphasic mechanisms (i.e., mechanisms that occur across illness phases) underlying negative symptoms could inform early intervention and prevention efforts and additionally identify treatment targets that could be effective regardless of illness stage. This study examined whether a key reinforcement learning behavioral pattern characterized by reduced difficulty learning from rewards that have been found to underlie negative symptoms in those with a schizophrenia diagnosis also contributes to negative symptoms in those at clinical high-risk (CHR) for psychosis.

METHODS

CHR youth (n = 46) and 51 healthy controls (CN) completed an explicit reinforcement learning task with two phases. During the acquisition phase, participants learned to select between pairs of stimuli probabilistically reinforced with feedback indicating receipt of monetary gains or avoidance of losses. Following training, the transfer phase required participants to select between pairs of previously presented stimuli during the acquisition phase and novel stimuli without receiving feedback. These test phase pairings allowed for inferences about the contributions of prediction error and value representation mechanisms to reinforcement learning deficits.

RESULTS

In acquisition, CHR participants displayed impaired learning from gains specifically that were associated with greater negative symptom severity. Transfer performance indicated these acquisition deficits were largely driven by value representation deficits. In addition to negative symptoms, this profile of deficits was associated with a greater risk of conversion to psychosis and lower functioning.

CONCLUSIONS

Impairments in positive reinforcement learning, specifically effectively representing reward value, may be an important transphasic mechanism of negative symptoms and a marker of psychosis liability.

Deconstructing the nature of emotion regulation impairments at the identification, selection, and implementation stages in individuals at clinical high-risk for psychosis

BACKGROUND

Psychotic disorders are characterized by emotion regulation abnormalities that predict greater symptom severity and poor functional outcomes. However, it is unclear whether these abnormalities also occur in individuals at clinically high risk for psychosis (CHR). The current study used ecological momentary assessment (EMA) to address this question and examined the nature of abnormalities at three stages of emotion regulation (identification, selection, implementation).

METHODS

Participants included 120 CHR and 59 CN who completed 1 week of EMA surveys evaluating emotional experience, emotion regulation, context, and symptoms. Multi-level models examined concurrent and time-lagged effects.

RESULTS

CHR evidenced elevated state negative affect and abnormalities at all three stages of emotion regulation. At the identification stage (i.e., determining the need to regulate), regulatory attempts were made too frequently and with too much effort at low levels of negative affect and not frequently enough and with insufficient effort at high levels of negative affect. Selection stage abnormalities (i.e., choosing the exact strategy to attempt based on context) were characterized by increased frequency of selecting individual strategies and greater polyregulation (i.e., use of multiple strategies concurrently). Implementation stage (i.e., executing the selected strategy) abnormalities were indicated by being less effective at decreasing the intensity of negative affect from time t to t + 1.

CONCLUSIONS

It is not only heightened stress reactivity that confers risk for psychosis, but also abnormalities in applying emotion regulation strategies to control the stress response. The profile of abnormalities observed in CHR is similar to schizophrenia, suggesting treatment targets that transcend phases of psychotic illness.

A generalized reward processing deficit pathway to negative symptoms across diagnostic boundaries

BACKGROUND

Negative symptoms are a key feature of several psychiatric disorders. Difficulty identifying common neurobiological mechanisms that cut across diagnostic boundaries might result from equifinality (i.e., multiple mechanistic pathways to the same clinical profile), both within and across disorders. This study used a data-driven approach to identify unique subgroups of participants with distinct reward processing profiles to determine which profiles predicted negative symptoms.

METHODS

Participants were a transdiagnostic sample of youth from a multisite study of psychosis risk, including 110 individuals at clinical high-risk for psychosis (CHR; meeting psychosis-risk syndrome criteria), 88 help-seeking participants who failed to meet CHR criteria and/or who presented with other psychiatric diagnoses, and a reference group of 66 healthy controls. Participants completed clinical interviews and behavioral tasks assessing four reward processing constructs indexed by the RDoC Positive Valence Systems: hedonic reactivity, reinforcement learning, value representation, and effort-cost computation.

RESULTS

k-means cluster analysis of clinical participants identified three subgroups with distinct reward processing profiles, primarily characterized by: a value representation deficit (54%), a generalized reward processing deficit (17%), and a hedonic reactivity deficit (29%). Clusters did not differ in rates of clinical group membership or psychiatric diagnoses. Elevated negative symptoms were only present in the generalized deficit cluster, which also displayed greater functional impairment and higher psychosis conversion probability scores.

CONCLUSIONS

Contrary to the equifinality hypothesis, results suggested one global reward processing deficit pathway to negative symptoms independent of diagnostic classification. Assessment of reward processing profiles may have utility for individualized clinical prediction and treatment.

The Negative Symptom Inventory-Psychosis Risk (NSI-PR): Psychometric Validation of the Final 11-Item Version

BACKGROUND AND HYPOTHESES

The lack of psychometrically validated assessment tools designed specifically to assess negative symptoms in individuals at clinical high risk (CHR) for psychosis represents a significant barrier to the early identification and prevention of psychosis. To address this need, the Negative Symptom Inventory-Psychosis Risk (NSI-PR) was developed based on the iterative, data-driven approach recommended by the National Institute of Mental Health consensus conference on negative symptoms.

STUDY DESIGN

This manuscript reports the results of the second study phase that psychometrically validates the final 11-item version of the scale in data collected across 3 sites. A total of 222 participants (144 CHR and 78 clinical help-seeking controls) completed the NSI-PR, 1 week of ecological momentary assessment (EMA), and additional convergent and discriminant validity measures.

STUDY RESULTS

Structural analyses replicated the previously reported strong fit for the 5-factor (anhedonia, avolition, asociality, alogia, and blunted affect) and hierarchical structures (2 super-ordinate dimensions and 5 lower-level domains). The 5 domains and 2 dimensions generally demonstrated good internal consistency, temporal stability, and interrater reliability. Convergent validity was demonstrated in relation to the 16-item beta version of the NSI-PR, Structured Interview for Psychosis-risk Syndromes negative subscale, Global Functioning Scale social and role, and EMA measures. Discriminant validity was supported by low correlations with positive, disorganized, and general psychiatric symptoms.

CONCLUSIONS

Findings indicate the final 11-item version of the NSI-PR has sound psychometric properties. The scale, which is designed specifically for CHR individuals, is brief and appropriate for use in research and clinical contexts. Accompanying training materials have been developed to support its use in multisite trials.

The Complex Latent Structure of Attenuated Psychotic Symptoms: Hierarchical and Bifactor Models of SIPS Symptoms Replicated in Two Large Samples at Clinical High Risk for Psychosis

BACKGROUND AND HYPOTHESIS

The Structured Interview for Psychosis-Risk Syndromes (SIPS) and other assessments of psychosis risk define clinical high risk for psychosis (CHR) by the presence of attenuated psychotic symptoms. Despite extensive research on attenuated psychotic symptoms, substantial questions remain about their internal psychometric structure and relationships to comorbid non-psychotic symptoms.

STUDY DESIGN

Hierarchical and bifactor models were developed for the SIPS in a large CHR sample (NAPLS-3, N = 787) and confirmed through preregistered replication in an independent sample (NAPLS-2, N = 1043). Criterion validity was tested through relationships with CHR status, comorbid symptoms/diagnoses, functional impairment, demographics, neurocognition, and conversion to psychotic disorders.

STUDY RESULTS

Most variance in SIPS items (75%-77%) was attributable to a general factor. Hierarchical and bifactor models included a general factor and five specific/lower-order factors (positive symptoms, eccentricity, avolition, lack of emotion, and deteriorated thought process). CHR participants were elevated on the general factor and the positive symptoms factor. The general factor was associated with depressive symptoms; functional impairment; and mood, anxiety, and schizotypal personality diagnoses. The general factor was the best predictor of psychotic disorders (d ≥ 0.50). Positive symptoms and eccentricity had specific effects on conversion outcomes. The deteriorated thought process was least meaningful/replicable.

CONCLUSIONS

Attenuated psychotic symptoms, measured by the SIPS, have a complex hierarchical structure with a strong general factor. The general factor relates to internalizing symptoms and functional impairment, emphasizing the roles of general psychopathological distress/impairment in psychosis risk. Shared symptom variance complicates the interpretation of raw symptom scores. Broad transdiagnostic assessment is warranted to model psychosis risk accurately.

Persistent negative symptoms in young people at clinical high risk of psychosis treated with an Italian early intervention program: a longitudinal study

Negative symptoms in CHR-P people are generally not responsive to treatments and commonly related to poorer functional outcome. However, less research attention has been dedicated to Persistent Negative Symptoms (PNS), defined as clinically stable negative symptoms of moderate severity evident for at least 6 months. This study aims to (a) determine the prevalence of PNS in a sample of young people at CHR-P; (b) investigate any association of PNS with functioning and clinical features; (c) examine longitudinal course of PNS across 2 years of follow-up and changes in PNS severity levels with specialized treatments. One Hundred Eighty CHR-P participants were recruited and were divided into CHR-P/PNS + and CHR-P/PNS- subgroups. The clinical assessments were based on the PANSS and the GAF and were conducted at baseline and every 12 months during the follow-up. Twenty four participants showed PNS at entry. Of them, 21 concluded the 2-year follow-up period. At baseline, the CHR-P/PNS + participants showed more educational and employment deficits, and more social and functioning impairment. During the follow-up, the CHR-P/PNS + subgroup had a significant longitudinal decrease in negative symptoms, which was specifically related to antidepressant treatment. CHR-P/PNS + subjects also showed a higher incidence of new hospitalization and a lower functional recovery over time. Our findings support that the persistence of negative symptoms in CHR-P people is longitudinally related to worse daily functioning and more severe clinical conditions that are at higher risk of hospitalization and are less responsive to specialized treatments.

Diminished differentiation of rewards in individuals at clinical high-risk for psychosis

Reward processing is impaired in people with schizophrenia, which may begin in the clinical high-risk (CHR) for psychosis period. The Monetary Incentive Delay (MID) task has been important in understanding the neural correlates of reward processing deficits in various psychiatric disorders. Previous research has found that CHR individuals have an imprecise mental representation of rewards, which leads to a diminished differentiation between rewards, though this has not been observed behaviorally. A total of 19 CHR individuals and 20 controls were given a novel variant of the MID task, designed to examine how modulating reward context may impact responses to reward cues, a process often referred to as "adaptive coding." Both groups appeared to update their behavior in response to the rewards available in this adaptive task. However, when compared to controls who showed a more graded decrease in response time to increasing reward contexts, CHR individuals appeared to have a sharp decrease in response time in the low reward context that is nearly stable across higher reward contexts. This is largely driven by the exponential component of the response time distribution, which is often interpreted to be more cognitively or effortfully influenced. Response times are related to negative symptoms, but not positive symptoms, disorganized symptoms, or estimated intelligence. Although an adaptive coding effect was not observed, these results provide novel insight into the reward processing mechanisms and volitional processes in the CHR population, as this was the first study to observe the diminished differentiation of rewards behaviorally.

Comparing a Computerized Digit Symbol Test to a Pen-and-Paper Classic

Background and Hypothesis

Processing speed dysfunction is a core feature of psychosis and predictive of conversion in individuals at clinical high risk (CHR) for psychosis. Although traditionally measured with pen-and-paper tasks, computerized digit symbol tasks are needed to meet the increasing demand for remote assessments. Therefore we: (1) assessed the relationship between traditional and computerized processing speed measurements; (2) compared effect sizes of impairment for progressive and persistent subgroups of CHR individuals on these tasks; and (3) explored causes contributing to task performance differences.

Study Design

Participants included 92 CHR individuals and 60 healthy controls who completed clinical interviews, the Brief Assessment of Cognition in Schizophrenia Symbol Coding test, the computerized TestMyBrain Digit Symbol Matching Test, a finger-tapping task, and a self-reported motor abilities measure. Correlations, Hedges' g, and linear models were utilized, respectively, to achieve the above aims.

Study Results

Task performance was strongly correlated (r = 0.505). A similar degree of impairment was seen between progressive (g = -0.541) and persistent (g = -0.417) groups on the paper version. The computerized task uniquely identified impairment for progressive individuals (g = -477), as the persistent group performed similarly to controls (g = -0.184). Motor abilities were related to the computerized version, but the paper version was more related to symptoms and psychosis risk level.

Conclusions

The paper symbol coding task measures impairment throughout the CHR state, while the computerized version only identifies impairment in those with worsening symptomatology. These results may be reflective of sensitivity differences, an artifact of existing subgroups, or evidence of mechanistic differences.