The near Babylonian speech confusion in early detection of psychosis

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

AIM

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

METHODS

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

RESULTS

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and modest harmonization for CHR-P criteria. The semi-structured interview, named Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

CONCLUSIONS

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

Aim

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

Methods

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

Results

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and partial harmonization for CHR-P criteria. The semi-structured interview, named P ositive SY mptoms and Diagnostic Criteria for the C AARMS H armonized with the S IPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

Conclusion

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Autism Spectrum Disorder and Clinical High Risk for Psychosis: A Systematic Review and Meta-analysis

Psychotic experiences can occur in autism spectrum disorders (ASD). Some of the ASD individuals with these experiences may fulfil Clinical High-Risk for Psychosis (CHR-P) criteria. A systematic literature search was performed to review the information on ASD and CHR-P. A meta-analysis of the proportion of CHR-P in ASD was conducted. The systematic review included 13 studies. The mean age of ASD individuals across the included studies was 11.09 years. The Attenuated Psychosis Syndrome subgroup was the most frequently reported. Four studies were meta-analysed, showing that 11.6% of CHR-P individuals have an ASD diagnosis. Symptoms of prodromal psychosis may be present in individuals with ASD. The transition from CHR-P to psychosis is not affected by ASD.

Comparisons between self-reported and interview-verified psychotic-like experiences in adolescents

AIM

The 15-item positive subscale of the Community Assessment of Psychic Experiences (CAPE-P15) has been widely used for measuring self-reported psychotic-like experiences (PLEs). However, its validity has not been well established. This study aimed to explore the consistency of self-reported PLEs (PLEs-S) and interview-verified PLEs (PLEs-I) based on the same items of the CAPE-P15.

METHODS

A total of 1255 college students completed the CAPE-P15 for measuring lifetime and current PLEs. Half of the students with high-risk scores and 5% of the rest were interviewed through telephone. Telephone interviews were based on the items of the CAPE-P15 using the symptom criteria for attenuated positive symptom syndrome.

RESULTS

When considering the presence of PLEs only, all κ values and correspondence rates (CRs) fell below the thresholds. However, there was adequate consistency for lifetime PLEs when associated distress was also considered in self-report (κ = .432, CR = 90.0%). Among three factors, only bizarre experiences (BEs) showed adequate diagnostic accuracy in detecting lifetime PLEs when combined with distress. Cut-off points of 1.30 (sensitivity of 89.2% and specificity of 92.3%) and 1.57 (sensitivity of 79.2% and specificity of 73.8%) for frequency scores were found to best identify genuine PLEs during lifetime and in the past month, respectively.

CONCLUSIONS

Although the validity of the CAPE-P15 for genuine PLEs is unsatisfactory, the scale showed much better diagnostic accuracy when combined with associated distress, especially for detecting lifetime PLEs. Self-report items on BEs may be more sensitive and specific when identifying PLEs in late adolescence.

Prodromal features in first-psychotic episodes of major affective and schizoaffective disorders

BACKGROUND

Study aims were to analyze psychopathological details of prodromes leading to first-lifetime psychotic episodes and apply them to improve prediction of final diagnoses.

METHODS

Comprehensive records of subjects with final diagnoses of bipolar I (BD-I; n = 216), schizoaffective (SzAffD; n = 71), or psychotic major-depressive (MDD; n = 42) disorders in the Harvard-McLean First-Psychotic Episode Project were analyzed to identify psychopathological details of prodromes leading to first-lifetime episodes with psychotic features and their ability to predict final diagnoses tested with multivariable logistic regression modeling.

RESULTS

While held blind to final diagnoses, we identified 84 distinct psychopathological characteristics of prodromes to first-psychotic episodes, including perceptual disturbances, affective symptoms, sleep disturbances, onset rate, and duration. Prevalence of 19 factors appeared to differ among final diagnoses, and were tested with multivariable regression modeling. Significantly and independently more associated with final diagnoses of MDD than BD-I were 7 features: suicidal ideation, somatic delusions, anorexia, lack of insomnia, older presenting age, depressive symptoms, and lack of impulsivity; 9 others were associated more with later SzAffD than MDD or BD-I: lack of insomnia, homicidal behavior, lack of excitement, visual hallucinations, command hallucinations, longer prodrome, male sex, responding to internal stimuli, and younger age at presentation.

LIMITATIONS

Historical-retrospective and prospective assessments may have misidentified some prodromal features, and subjects with final psychotic-MDD diagnosis were relatively few.

CONCLUSIONS

Psychopathological features identified during prodromes leading to first-episodes with psychotic features predicted and distinguished among final diagnoses of MDD, BD-I, and SzAffD. The findings add to growing impressions that early psychopathology has value in predicting final diagnoses of major affective and schizoaffective disorders.

Early Interventions for Clinical High-Risk State for Psychosis

The aim of this review was to discuss early intervention options for clinical high-risk states of psychosis, the limitations of the high-risk concept, and the importance of population-based approaches in preventing psychosis. Interventions for individuals at high risk of psychosis can be classified into two main categories: pharmacological and non-pharmacological. When selecting any of these intervention options, it should be taken into account that only a small proportion of individuals in the high-risk group will have a transition to clinical psychosis. Therefore, it is necessary to avoid aggressive interventions. Pharmacotherapies, particularly antipsychotics, are generally not considered as a treatment of choice for individuals at high risk of psychosis due to their potential side-effect profiles, whereas cognitive behavioral therapies and family-oriented therapies are the leading alternatives with virtually no side effects. However, meta-analyses have shown that none of the interventions are specifically more effective than needs-based treatment (including placebo) in preventing transition to psychosis. These interventions might not be effective in preventing transition to psychosis; however, they may improve the outcomes of psychosis. Accumulating evidence suggests that the targeted prevention approaches focusing on the clinical high risk of psychosis concept have major limitations in terms of the impact on reducing psychosis incidence in the general population compared to the population-based approaches. Recently, psychosis-focused prevention approaches have been replaced by easily accessible youth mental health centers that provide services for transdiagnostic conditions. Future studies on the efficacy of these community-based youth mental health services may provide guidance on how to prevent psychosis.

Changes in psychotic-like experiences and related influential factors in technical secondary school and college students during COVID-19

OBJECTIVE

Although students have been found to be at high risk of distress during the COVID-19 pandemic, little is known about the pandemic's impact on psychotic-like experiences (PLEs). We conducted a study in technical secondary school and college students before and during the pandemic to explore changes in PLEs and relevant influential factors.

METHODS

A total of 938 students completed both waves of the survey through electronic questionnaires. PLEs were assessed using the 15-item Positive Subscale of the Community Assessment of Psychic Experiences (CAPE-P15). Childhood trauma, perceived stress, resilience, and demographic factors were evaluated at baseline, and psychological status was measured during the pandemic.

RESULTS

The overall CAPE-P15 scores significantly decreased during the pandemic. Students with persistent PLEs showed the most severe COVID-19 related psychological symptoms, followed by new-onset and remitted individuals; those without PLEs exhibited the mildest symptoms (all p < .001). A single parent family (OR = 4.707), more childhood trauma (OR = 1.056), and a higher family income (OR = 1.658) were predictive of new-onset PLEs during the pandemic, while better resilience was a protective factor, associated with remission of previous PLEs (OR = 0.932).

CONCLUSIONS

Despite a downward trend in the prevalence of PLEs during the pandemic, PLEs predict greater serious psychological impact due to COVID-19, especially for students with persistent PLEs. Interventions that cultivate students' resilience are urgently needed to reduce PLEs and improve mental health, especially for students from single parent households or those who have experienced childhood trauma.

Delusions beyond beliefs: a critical overview of diagnostic, aetiological, and therapeutic schizophrenia research from a clinical-phenomenological perspective

Delusions are commonly conceived as false beliefs that are held with certainty and which cannot be corrected. This conception of delusion has been influential throughout the history of psychiatry and continues to inform how delusions are approached in clinical practice and in contemporary schizophrenia research. It is reflected in the full psychosis continuum model, guides psychological and neurocognitive accounts of the formation and maintenance of delusions, and it substantially determines how delusions are approached in cognitive-behavioural treatment. In this Review, we draw on a clinical-phenomenological framework to offer an alternative account of delusion that incorporates the experiential dimension of delusion, emphasising how specific alterations to self-consciousness and reality experience underlie delusions that are considered characteristic of schizophrenia. Against that backdrop, we critically reconsider the current research areas, highlighting empirical and conceptual issues in contemporary delusion research, which appear to largely derive from an insufficient consideration of the experiential dimension of delusions. Finally, we suggest how the alternative phenomenological approach towards delusion could offer new ways to advance current research and clinical practice.

Psychotic-Like Experiences: A Challenge in Definition and Assessment

Assuming a continuum between psychotic experiences and psychotic symptoms aligned between healthy individuals and patients with non-psychotic and psychotic disorders, recent research has focused on subclinical psychotic experiences. The wide variety of definitions, assessment tools, and concepts of psychotic-like experiences (PLEs) might contribute to the mixed findings concerning prevalence and persistence rates and clinical impact. In this narrative review, we address the panoply of terminology, definitions, and assessment tools of PLEs and associated concerns with this multitude. Moreover, the ambiguous results of previous studies regarding the clinical relevance of PLEs are described. In conclusion, we address clinical implications and highly suggest conceptual clarity and consensus concerning the terminology and definition of PLEs. The development of an agreed upon use of a "gold standard" assessment tool seems essential for more comparable findings in future research.

[The role of psychopathology and nosology in 'precision' psychiatry]

Psychopathology is the scientific exploration of abnormal mental experiences and behaviour that, for more than a century, has provided a Gestalt for psychiatric disorders and, thereby, the basis of psychiatric nosology. Having guided clinical and scientific progress in modern psychiatry, in consequence of considerable technical progress, psychopathology has been increasingly marginalised by neurobiological research. Albeit the precise, careful and qualified assessment of psychopathology has been a core skill of mental health professionals, today's curricula pay increasingly less attention to its training. However, because neurobiological models still have to prove their diagnostic superiority and despite all prophecies that psychopathology was doomed, psychiatric diagnoses in both DSM-5 and ICD-11 continue to rely exclusively on psychopathology. Their categorical nosology is also challenged by advances in computational psychiatry and an increasingly advocated personalised symptom-based approach to precision psychiatry. The current paper reviews the objectives of psychopathology and nosology, and the recent debate on their role in future precision psychiatry - from guiding neurobiological research by relating neurobiological changes to patients' experiences to giving a framework to the psychiatric encounter. It concludes that contemporary psychiatry does not need less but rather a more differentiated psychopathology and a likely reformed, possibly more dimensional nosology in order to develop approaches that adequately integrate patients' experiences and professional knowledge.

Cortical Volume Differences in Subjects at Risk for Psychosis Are Driven by Surface Area

In subjects at risk for psychosis, the studies on gray matter volume (GMV) predominantly reported volume loss compared with healthy controls (CON). However, other important morphological measurements such as cortical surface area (CSA) and cortical thickness (CT) were not systematically compared. So far, samples mostly comprised subjects at genetic risk or at clinical risk fulfilling an ultra-high risk (UHR) criterion. No studies comparing UHR subjects with at-risk subjects showing only basic symptoms (BS) investigated the differences in CSA or CT. Therefore, we aimed to unravel the contribution of the 2 morphometrical measures constituting the cortical volume (CV) and to test whether these groups inhere different morphometric features. We conducted a surface-based morphometric analysis in 34 CON, 46 BS, and 39 UHR to examine between-group differences in CV, CSA, and CT vertex-wise across the whole cortex. Compared with BS and CON, UHR individuals presented increased CV in frontal and parietal regions, which was driven by larger CSA. These groups did not differ in CT. Yet, at-risk subjects who later developed schizophrenia showed thinning in the occipital cortex. Furthermore, BS presented increased CSA compared with CON. Our results suggest that volumetric differences in UHR subjects are driven by CSA while CV loss in converters seems to be based on cortical thinning. We attribute the larger CSA in UHR to aberrant pruning representing a vulnerability to develop psychotic symptoms reflected in different levels of vulnerability for BS and UHR, and cortical thinning to a presumably stress-related cortical decomposition.

Lifetime and 12-month prevalence rates of sub-clinical psychosis symptoms in a community cohort of 50-year-old individuals

Background:

Estimation of prevalence rates of sub-clinical psychosis symptoms can vary considerably depending on the methodology used. Furthermore, discussions are ongoing how prevalence rates may differ across various syndromes.

Method:

We analyzed data from the prospective Zurich Study, assessing sub-clinical psychosis with a semi-structured clinical interview in a community cohort of 50 years old individuals. The higher-order factors of psychosis symptoms were analyzed with confirmatory factor analysis to validate the a priori specified symptom-structure. Further associations were examined with contingency tables and logistic regressions.

Results:

The confirmatory factor analysis was consistent with a structure with four higher-order syndromes. Those different syndromes were labeled “thought disorder” (lifetime prevalence = 10.6%), “ego disorder” (4.8%), “hallucination” (9.7%), and “schizotypy” (28.2%). A strong discrepancy was noted between the 12-month prevalence of any symptoms and those considered to be severe. Twelve-month prevalence rates of distressful syndromes ranged from 0.1% for hallucinations up to 6.6% for schizotypy. The most strongly interrelated syndromes were thought disorder and ego disorder (OR = 12.4).

Conclusion:

Our findings indicate a continuity of sub-clinical psychosis within the general population even though only a small proportion suffers from distressing symptoms. Our analyses showed that the syndromes identified here are similar to those found in full-blown schizophrenia, albeit in an attenuated form.

Schizotypy, social stress and the emergence of psychotic-like states - A case for benign schizotypy?

Schizotypy is a personality-organisation related to schizophrenia-liability as well as the emergence of psychotic symptoms and psychotic-like experiences (PLEs) in non-schizophrenic individuals. It has been suggested that some non-schizophrenic individuals may exhibit PLEs frequently, but in a fashion that is not distressing but life-enhancing ("benign schizotypy"). In schizophrenia and at-risk individuals, however, psychotic symptoms are not only distressing, but also triggered stress. To further investigate questions of causality and examine how PLEs may present as distressing symptoms in some individuals and as benign experiences in others, we explored how schizotypy-facets moderated PLEs-variability under experimentally induced social stress.We performed a standardised social stress-paradigm in 107 healthy adults (77 female, 30 male; average age 22,5 years), measuring changes in psychometrically assessed PLEs and the moderation of changes under stress through positive, negative and disorganised schizotypy. Results suggest two discrete effects: On the one hand, individuals high in disorganised and negative schizotypy showed stress-dependent increases in PLEs; without added effects of positive schizotypy. On the other, individuals low in negative and disorganised schizotypy showed higher levels of PLEs solely as a function of positive schizotypy but not stress. We discuss these findings in light of the fully-dimensional model of schizotypy and hypothesize that PLEs in individuals high in schizotypy-facets suggested to convey risk-for-schizophrenia (negative and disorganised) may reflect qualitatively different entities than PLEs in individuals with low values in these facets, but high expressions of positive schizotypy ("happy schizotypes"). Additionally, we emphasize the importance of not overlooking the disorganised schizotypy-facet in related research.

Delusions in the general population: A systematic review with emphasis on methodology

The presence of delusions is considered a key feature of psychosis, but despite the psychopathological centrality of the concept of delusion, its definition and comprehension is a matter of continuing debate. In recent years studies showing that delusions are common in the general population have accumulated and challenged the way we perceive psychotic illness. In this systematic review, we examine the basis of the psychosis continuum-hypothesis, by reviewing a representative section of the original literature that report measures of delusional ideation in the general population, focusing specifically on methodology. Three online databases were systematically searched for relevant studies. After applying criteria of inclusion and exclusion, 17 articles were included for comprehensive review. Estimates of the distribution of delusions in the general population vary substantially, as does the mode of assessment. The methodology relies with few exceptions exclusively on self-report and fully structured interview by lay person. We conclude that measures of delusions in the general population should be interpreted cautiously due to inherent difficulties in methodology. Hypothesizing a continuum of delusion between normality and full-blown psychosis is deemed premature based on the reviewed studies.

A Weighted Gene Co-expression Network Analysis Reveals lncRNA Abnormalities in the Peripheral Blood Associated With Ultra-High-Risk for Psychosis

Objective: The primary study aim was to identify long non-coding RNA (lncRNA) abnormalities associated with ultra-high-risk (UHR) for psychosis based on a weighted gene co-expression network analysis. Methods: UHR patients were screened by the structured interview for prodromal syndromes (SIPS). We performed a WGCNA analysis on lncRNA and mRNA microarray profiles generated from the peripheral blood samples in 14 treatment-seeking patients with UHR who never received psychiatric medication and 18 demographically matched typically developing controls. Gene Ontology (GO) analysis and canonical correlation analysis were then applied to reveal functions and correlation between lncRNAs and mRNAs. Results: The lncRNAs were organized into co-expressed modules by WGCNA, two modules of which were strongly associated with UHR. The mRNA networks were constructed and two disease-associated mRNA modules were identified. A functional enrichment analysis showed that mRNAs were highly enriched for immune regulation and inflammation. Moreover, a significant correlation between lncRNAs and mRNAs were verified by a canonical correlation analysis. Conclusion: We identified novel lncRNA modules related to UHR. These results contribute to our understanding of the molecular basis of UHR from the perspective of systems biology and provide a theoretical basis for early intervention in the assumed development of schizophrenia.

Psychosis and Schizophrenia-Spectrum Personality Disorders Require Early Detection on Different Symptom Dimensions

Psychotic disorders and schizophrenia-spectrum personality disorders (PD) with psychotic/psychotic-like symptoms are considerably linked both historically and phenomenologically. In particular with regard to schizotypal and schizotypal personality disorder (SPD), this is evidenced by their placement in a joint diagnostic category of non-affective psychoses in the InternationaI Classification of Diseases 10th Revision, (CD-10) and, half-heartedly, the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, (DSM-5). Historically, this close link resulted from observations of peculiarities that resembled subthreshold features of psychosis in the (premorbid) personality of schizophrenia patients and their biological relatives. These personality organizations were therefore called "borderline (schizophrenia)" in the first half of the 20th century. In the 1970s, they were renamed to "schizotypal" and separated from psychotic disorders on axis-I and from other PD on axis-II, including modern borderline PD, in the DSM. The phenomenological and historical overlap, however, has led to the common assumption that the main difference between psychotic disorders and SPD in particular was mainly one of severity or trajectory, with SPD representing a latent form of schizophrenia and/or a precursor of psychosis. Thus, psychosis proneness and schizotypy are often assessed using SPD questionnaires. In this perspective-piece, we revisit these assumptions in light of recent evidence. We conclude that schizotypy, SPD (and other schizophrenia-spectrum PD) and psychotic disorder are not merely states of different severity on one common but on qualitatively different dimensions, with the negative dimension being predictive of SPD and the positive of psychosis. Consequently, in light of the merits of early diagnosis, the differential early detection of incipient psychosis and schizophrenia-spectrum PD should be guided by the assessment of different schizotypy dimensions.

Individuals at high risk for psychosis experience more childhood trauma, life events and social support deficit in comparison to healthy controls

Evidence for psychological risk factors on prodromal state of psychosis remained limited and inconsistent. This study aimed to investigate childhood trauma, life events and social support in subjects with high risk for psychosis (HR), first episode psychosis with schizophrenia (FEP) and healthy control (HC). In the study, 56 FEP, 83 HR and 61 HC underwent face-to-face clinical interview and psychological assessment, including Childhood Trauma Questionnaire (CTQ), Life Events Scale (LES) and Perceived Social Support Scale (PSSS). The results showed that in univariate analysis, HR individuals had more childhood trauma, more recent life events and less social support than HC group, and these findings were also supported by ANCOVA analysis except for the results related to social support after taking age, education, marital and employment status as covariates. Logistic regression analysis revealed that HR group was significantly associated with more childhood trauma, poorer overall function and unmarried state than HC group after controlling the interfering factors. HR group was similar with FEP group in these assessments. In conclusion, HR individuals experienced more childhood trauma, life events and social support deficit than HC group, which may be risk factors of conversion to psychosis. Further explorations are warranted to develop optimal psychosocial interventions.

Measuring Psychotic-Like Experiences in the General Population

INTRODUCTION

The notion of a full psychosis continuum in which psychosis is seen on a continuum with normal experience rests heavily on studies showing that psychotic symptoms are common in the general population. However, the methods of assessment in the studies have been criticized.

OBJECTIVES

(1) to investigate how many from the general population who answered positively on a psychotic-like symptoms questionnaire and (2) to clinically assess a subset of those with psychotic-like experiences (PLE).

METHODS

A self-rating questionnaire concerning PLEs was given to individuals from the general population. A subsample of those, who scored positively for PLEs, was clinically assessed for psychosis.

RESULTS

Totally, 5.7% of the participants rated positive for PLEs according to the self-rating questionnaire. Forty of these were clinically assessed and 7 (17.5%) of them were found to have had a psychotic experience, 4 of them were already in psychiatric treatment.

CONCLUSION

The self-reported psychotic-like phenomena were more common in the general population than psychotic disorders. However, when assessed clinically, the experienced phenomena did correspond to psychotic phenomena except in a few patients, who were found to suffer from a psychotic disorder. Overall, we did not find support for the full psychosis continuum model.

Psychopathology-a Precision Tool in Need of Re-sharpening

Psychopathology is the scientific exploration of abnormal mental states that, for more than a century, has provided a Gestalt for psychiatric disorders and guided clinical as well as scientific progress in modern psychiatry. In the wake of the immense technical advances, however, psychopathology has been increasingly marginalized by neurobiological, genetic, and neuropsychological research. This ongoing erosion of psychiatric phenomenology is further fostered by clinical casualness as well as pressured health care and research systems. The skill to precisely and carefully assess psychopathology in a qualified manner used to be a core attribute of mental health professionals, but today's curricula pay increasingly less attention to its training, thus blurring the border between pathology and variants of the "normal" further. Despite all prophecies that psychopathology was doomed, and with neurobiological parameters having yet to show their differential-diagnostic superiority and value for differential indication, psychiatric diagnosis continues to rely exclusively on psychopathology in DSM-5 and ICD-11. Their categorical systematic, however, is equally challenged, and, supported by advances in machine learning, a personalized symptom-based approach to precision psychiatry is increasingly advocated. The current paper reviews the objectives of psychopathology and the recent debate on the role of psychopathology in future precision psychiatry-from guiding neurobiological research by relating neurobiological changes to patients' experiences to giving a framework to the psychiatric encounter. It concludes that contemporary research and clinic in psychiatry do not need less but rather more differentiated psychopathologic approaches in order to develop approaches that integrate professional knowledge and patients' experience.

Travel-related psychosis (TrP): a landscape analysis

BACKGROUND

Travel-related psychosis (TrP) can be difficult for both the traveller and treating clinician. This review focuses upon a particular subset of TrP occurring during travel to destinations with high religious, spiritual, cultural or aesthetic value (high valence destinations) because it is both interesting and informative.

METHOD

Psychiatric, occupational and travel medicine literature was reviewed using PubMed with search terms of 'travel' AND 'psychosis' and 'international travel' AND 'psychosis' from 1998 to the present. Articles were included if they dealt with psychosis in travellers to high valence destinations. Articles were excluded if they dealt primarily with psychosis in travellers due to drug or medication usage. French literature was obtained using the CH St. Anne Ey Medical Library, Paris, France.

RESULTS

Literature on TrP to high valence destinations is lacking many details. The range of high valence destinations is wide. Incidence and prevalence figures for TrP of any type do not exist although rough calculations as to incidence of psychiatric problems and psychosis in travellers are made based upon the articles reviewed and are discussed. Findings lead to several hypotheses with both medico-legal, diagnostic and epidemiological ramifications.

CONCLUSIONS

TrP to a number of high valence destinations is a real phenomenon worthy of further study. It is not clear that TrP is more likely to occur with such travel than to non-high valence destinations or not. First episode psychosis during travel to high valence and other destinations is reported and has medico-legal ramifications. Some TrP episodes likely are brief psychotic disorders and this hypothesis should be rigorously explored in future reports. A number of suggestions concerning further studies are made.

Prevalence and clinical relevance of interview-assessed psychosis-risk symptoms in the young adult community

BACKGROUND

An efficient indicated prevention of psychotic disorders requires valid risk criteria that work in both clinical and community samples. Yet, ultra-high risk and basic symptom criteria were recently recommended for use in clinical samples only. Their use in the community was discouraged for lack of knowledge about their prevalence, clinical relevance and risk factors in non-clinical, community settings when validly assessed with the same instruments used in the clinic.

METHODS

Using semi-structured telephone interviews with established psychosis-risk instruments, we studied the prevalence of psychosis-risk symptoms and criteria, their clinical relevance (using presence of a non-psychotic mental disorder or of functional deficits as proxy measures) and their risk factors in a random, representative young adult community sample (N=2683; age 16-40 years; response rate: 63.4%).

RESULTS

The point-prevalence of psychosis-risk symptoms was 13.8%. As these mostly occurred too infrequent to meet frequency requirements of psychosis-risk criteria, only 2.4% of participants met psychosis-risk criteria. A stepwise relationship underlay the association of ultra-high risk and basic symptoms with proxy measures of clinical relevance, this being most significant when both occurred together. In line with models of their formation, basic symptoms were selectively associated with age, ultra-high risk symptoms with traumatic events and lifetime substance misuse.

CONCLUSIONS

Psychosis-risk criteria were uncommon, indicating little risk of falsely labelling individuals from the community at-risk for psychosis. Besides, both psychosis-risk symptoms and criteria seem to possess sufficient clinical relevance to warrant their broader attention in clinical practice, especially if ultra-high risk and basic symptoms occur together.

Cannabis use related to early psychotic onset: Role of premorbid function

The present cross-sectional study investigates the relation between Cannabis and the development of a psychotic disorder. The main objective is to explore the relations between Cannabis use and psychosis onset, premorbid adjustment cognitive impairment and familiarity. Forty-three patients with a diagnosis of Psychotic Disorder were recruited and divided in two groups based on Cannabis use before onset: Cannabis-using patients (PCU, N=21) and Cannabis-free patients (PCF, N=22). Cognitive functioning was evaluated by Trail Making Test A and B (TMT), Rey-Osterrieth Complex Figure Test (ROCF), and the Rey Auditory-Verbal Learning Test (RAVLT). Premorbid functioning was assessed retrospectively through the Premorbid Adjustment Scale (PAS). PCU group showed earlier onset of the psychotic disorder compared to PCF (p=0.008). This finding was not influenced by age or positive family history for psychiatric illness. PCU subjects showed a worse premorbid functioning respect to PCF and this difference was found to impact on the early onset in the PCU group. In conclusion the present study suggests the hypothesis of an interactive role of Cannabis and poor premorbid school adjustment in the development of psychotic disorders.

Towards a Standard Psychometric Diagnostic Interview for Subjects at Ultra High Risk of Psychosis: CAARMS versus SIPS

Background. Several psychometric instruments are available for the diagnostic interview of subjects at ultra high risk (UHR) of psychosis. Their diagnostic comparability is unknown. Methods. All referrals to the OASIS (London) or CAMEO (Cambridgeshire) UHR services from May 13 to Dec 14 were interviewed for a UHR state using both the CAARMS 12/2006 and the SIPS 5.0. Percent overall agreement, kappa, the McNemar-Bowker χ (2) test, equipercentile methods, and residual analyses were used to investigate diagnostic outcomes and symptoms severity or frequency. A conversion algorithm (CONVERT) was validated in an independent UHR sample from the Seoul Youth Clinic (Seoul). Results. There was overall substantial CAARMS-versus-SIPS agreement in the identification of UHR subjects (n = 212, percent overall agreement = 86%; kappa = 0.781, 95% CI from 0.684 to 0.878; McNemar-Bowker test = 0.069), with the exception of the brief limited intermittent psychotic symptoms (BLIPS) subgroup. Equipercentile-linking table linked symptoms severity and frequency across the CAARMS and SIPS. The conversion algorithm was validated in 93 UHR subjects, showing excellent diagnostic accuracy (CAARMS to SIPS: ROC area 0.929; SIPS to CAARMS: ROC area 0.903). Conclusions. This study provides initial comparability data between CAARMS and SIPS and will inform ongoing multicentre studies and clinical guidelines for the UHR psychometric diagnostic interview.

Identifying children and adolescents at ultra high risk of psychosis in Italian neuropsychiatry services: a feasibility study

The past 20 years have seen the evolution of the construct of a clinical high-risk (hereafter, HR) state for psychosis. This construct is designed to capture the pre-psychotic phase. Some aspects of this approach, such as its feasibility in children and adolescents, are still under investigation. In the present study, we address the feasibility of implementing prodrome clinics for HR individuals within the framework of Italy's national child and adolescent neuropsychiatry services and the clinical relevance of a HR diagnosis in this population. Using the Comprehensive Assessment of At-Risk Mental States (CAARMS) to identify help-seeking patients meeting at least one HR criterion at baseline (HR+), we recruited 50 subjects for a feasibility study. The results obtained show that the Italian version of the CAARMS is easily administrable, causing patients no substantial discomfort. The prevalence of HR+ in our cohort was 44 %, which increased by an additional 18 % when negative symptoms were considered as an experimental inclusion criterion (HRNeg). The HR+ subjects were significantly more impaired in their social and occupational functioning than their HR- peers (subjects not at HR). The cumulative 1-year transition risk of psychosis of the HR+ group was 26.7 %. When the HRNeg group was added, the 1-year transition risk was 17.3 %. We suggest that administration of the CAARMS to children and adolescents with putative prodromal psychosis is feasible and that this assessment can easily be integrated into existing Italian neuropsychiatry services although clinicians should interpret results with caution as results in this age group still have to be replicated.

Lower functioning predicts identification of psychosis risk screening status in help-seeking adolescents

AIM

There is some previous evidence suggesting that the risk state for psychosis is associated with decreased functioning ability, health-related quality of life (QoL), anxiety and depression. The aim of this study is to identify which factors predict psychosis risk screening status.

METHODS

The data were collected in Helsinki University Central Hospital, Finland, by an early intervention team. One hundred eighty-one help-seeking adolescents (mean age 15.3 years) completed questionnaires of QoL (16D), alcohol consumption (Alcohol Use Disorders Identification Test), anxiety (Beck Anxiety Inventory), hopelessness (BBeck Hopelessness Scale) and depression (Beck Depression Inventory II). Functioning ability was assessed by the Global Assessment of Functioning, whereas the PROD-screen was used to interview and assess risk symptoms for psychosis.

RESULTS

In a logistic regression analysis, a lower functioning ability explained independently (P = 0.006) psychosis risk screening status after age, gender, alcohol consumption, QoL, anxiety, hopelessness and depression symptoms were adjusted.

CONCLUSIONS

The present results suggest that lower functioning ability is associated independently with psychosis risk screening status. Hence, therapeutic input for those at risk should focus upon improving functioning.

Utility of Scalp Hair Follicles as a Novel Source of Biomarker Genes for Psychiatric Illnesses

BACKGROUND

Identifying beneficial surrogate genetic markers in psychiatric disorders is crucial but challenging.

METHODS

Given that scalp hair follicles are easily accessible and, like the brain, are derived from the ectoderm, expressions of messenger RNA (mRNA) and microRNA in the organ were examined between schizophrenia (n for first/second = 52/42) and control subjects (n = 62/55) in two sets of cohort. Genes of significance were also analyzed using postmortem brains (n for case/control = 35/35 in Brodmann area 46, 20/20 in cornu ammonis 1) and induced pluripotent stem cells (n = 4/4) and pluripotent stem cell-derived neurospheres (n = 12/12) to see their role in the central nervous system. Expression levels of mRNA for autism (n for case/control = 18/24) were also examined using scalp hair follicles.

RESULTS

Among mRNA examined, FABP4 was downregulated in schizophrenia subjects by two independent sample sets. Receiver operating characteristic curve analysis determined that the sensitivity and specificity were 71.8% and 66.7%, respectively. FABP4 was expressed from the stage of neurosphere. Additionally, microarray-based microRNA analysis showed a trend of increased expression of hsa-miR-4449 (p = .0634) in hair follicles from schizophrenia. hsa-miR-4449 expression was increased in Brodmann area 46 from schizophrenia (p = .0007). Finally, we tested the expression of nine putative autism candidate genes in hair follicles and found decreased CNTNAP2 expression in the autism cohort.

CONCLUSIONS

Scalp hair follicles could be a beneficial genetic biomarker resource for brain diseases, and further studies of FABP4 are merited in schizophrenia pathogenesis.

New Targets for Prevention of Schizophrenia: Is It Time for Interventions in the Premorbid Phase?

A number of influences have converged that make this Special Theme Issue timely: "A New Direction: Considering Developmentally Sensitive Targets for Very Early Intervention in Schizophrenia". These factors include: 1. the substantial knowledge about premorbid developmental vulnerabilities to psychosis, especially regarding schizophrenia; 2. the promising results emerging from interventions during the clinical high-risk (CHR) phase of psychosis and; 3. the recognition that the CHR period is a relatively late phase of developmental derailment. These factors have together led to a perspective that even earlier intervention is warranted. This paper briefly summarizes the articles comprising the Special Theme including new data on early neurocognitive development, proposed potential targets for psychosocial and psychopharmacological interventions during the premorbid period as early as pregnancy, and ethical challenges. These thought experiments must be empirically tested, and the ethical challenges overcome as posed by the various interventions, which range from relatively low risk, supportive, psychosocial to higher risk, experimental, pharmacological interventions. All of the interventions proposed require careful study of ethics, safety, potential stigma, feasibility, efficacy and tolerability, and the meaning to the people involved.

The Stress of the Street for Patients With Persecutory Delusions: A Test of the Symptomatic and Psychological Effects of Going Outside Into a Busy Urban Area

BACKGROUND

For many patients with persecutory delusions, leaving home and going into crowded streets is a key clinical problem. In this study we aimed to inform treatment development by determining the psychological mechanisms whereby busy urban environments increase paranoia. In a randomized design with prespecified mediation analysis, we compared the effects on patients of going outside into a busy social environment with staying inside.

METHODS

Fifty-nine patients with current persecutory delusions, in the context of nonaffective psychosis, reporting fears when going outside were assessed on factors from a cognitive model of paranoia. They were then randomized either to enter a busy local shopping street or to complete a neutral task indoors. They were then reassessed on the measures.

RESULTS

Compared with staying inside, the street exposure condition resulted in significant increases in paranoia, voices, anxiety, negative beliefs about the self, and negative beliefs about others. There was also a decrease in positive thoughts about the self. There was no alteration in reasoning processes. There were indications that the increase in paranoia was partially mediated by increases in anxiety (45%), depression (38%), and negative beliefs about others (45%).

CONCLUSIONS

We found that increases in negative affect may form an important route by which social exposure in urban environments triggers paranoid thoughts. The study provides an illustration of how an experimental approach can be applied to help understand a specific difficulty for patients with psychosis. In future studies the effects of specific elements of the social environment could be tested.

Antidepressant, antipsychotic and psychological interventions in subjects at high clinical risk for psychosis: OASIS 6-year naturalistic study

BACKGROUND

Recent randomized controlled trials suggest some efficacy for focused interventions in subjects at high risk (HR) for psychosis. However, treating HR subjects within the real-world setting of prodromal services is hindered by several practical problems that can significantly make an impact on the effect of focused interventions.

METHOD

All subjects referred to Outreach and Support in South London (OASIS) and diagnosed with a HR state in the period 2001-2012 were included (n = 258). Exposure to focused interventions was correlated with sociodemographic and clinical characteristics at baseline. Their association with longitudinal clinical and functional outcomes was addressed at follow-up.

RESULTS

In a mean follow-up time of 6 years (s.d. = 2.5 years) a transition risk of 18% was observed. Of the sample, 33% were treated with cognitive behavioural therapy (CBT) only; 17% of subjects received antipsychotics (APs) in addition to CBT sessions. Another 17% of subjects were prescribed with antidepressants (ADs) in addition to CBT. Of the sample, 20% were exposed to a combination of interventions. Focused interventions had a significant relationship with transition to psychosis. The CBT + AD intervention was associated with a reduced risk of transition to psychosis, as compared with the CBT + AP intervention (hazards ratio = 0.129, 95% confidence interval 0.030-0.565, p = 0.007).

CONCLUSIONS

There were differential associations with transition outcome for AD v. AP interventions in addition to CBT in HR subjects. These effects were not secondary to baseline differences in symptom severity.

Subclinical psychosis syndromes in the general population: results from a large-scale epidemiological survey among residents of the canton of Zurich, Switzerland

Aims. Prevalence and covariates of subclinical psychosis have gained increased interest in the context of early identification and treatment of persons at risk for psychosis. Methods. We analysed 9829 adults representative of the general population within the canton of Zurich, Switzerland. Two psychosis syndromes, derived from the SCL-90-R, were applied: 'schizotypal signs' and 'schizophrenia nuclear symptoms'. Results. Only a few subjects (13.2%) reported no schizotypal signs. While 33.2% of subjects indicated mild signs, only a small proportion (3.7%) reported severe signs. A very common outcome was no 'schizophrenia nuclear symptoms' (70.6%). Although 13.5% of the participants reported mild symptoms, severe nuclear symptoms were very rare (0.5%). Because these two syndromes were only moderately correlated (r = 0.43), we were able to establish sufficiently distinct symptom clusters. Schizotypal signs were more closely connected to distress than was schizophrenia nuclear symptoms, even though their distribution types were similar. Both syndromes were associated with several covariates, such as alcohol and tobacco use, being unmarried, low education level, psychopathological distress and low subjective well-being. Conclusions. Subclinical psychosis symptoms are quite frequent in the general population but, for the most part, are not very pronounced. In particular, our data support the notion of a continuous Wald distribution of psychotic symptoms in the general population. Our findings have enabled us to confirm the usefulness of these syndromes as previously assessed in other independent community samples. Both can appropriately be associated with well-known risk factors of schizophrenia.

Neurocognitive profiles in help-seeking individuals: comparison of risk for psychosis and bipolar disorder criteria

BACKGROUND

Neurocognitive deficits are important aspects of the schizophrenic disorders because they have a strong impact on social and vocational outcomes. We expanded on previous research by focusing on the neurocognitive profiles of persons at high risk (HR) or ultra-high risk (UHR) for schizophrenic and affective psychoses. Our main aim was to determine whether neurocognitive measures are sufficiently sensitive to predict a group affiliation based on deficits in functional domains.

METHOD

This study included 207 help-seeking individuals identified as HR (n = 75), UHR (n = 102) or at high risk for bipolar disorder (HRBip; n = 30), who were compared with persons comprising a matched, healthy control group (CG; n = 50). Neuropsychological variables were sorted according to their load in a factor analysis and were compared among groups. In addition, the likelihood of group membership was estimated using logistic regression analyses.

RESULTS

The performance of HR and HRBip participants was comparable, and intermediate between the controls and UHR. The domain of processing speed was most sensitive in discriminating HR and UHR [odds ratio (OR) 0.48, 95% confidence interval (CI) 0.28-0.78, p = 0.004] whereas learning and memory deficits predicted a conversion to schizophrenic psychosis (OR 0.47, 95% CI 0.25-0.87, p = 0.01).

CONCLUSIONS

Performances on neurocognitive tests differed among our three at-risk groups and may therefore be useful in predicting psychosis. Overall, cognition had a profound effect on the extent of general functioning and satisfaction with life for subjects at risk of psychosis. Thus, this factor should become a treatment target in itself.

Self-reported attenuated psychotic-like experiences in help-seeking adolescents and their association with age, functioning and psychopathology

OBJECTIVE

Self-rated attenuated psychotic-like experiences (APLEs) are increasingly used to screen for ultra-high-risk (UHR) across all ages. However, self-rated psychotic-like experiences (PLEs), in particular perception-related ones, were more frequent in children and adolescents, in which they possessed less clinical significance. We therefore explored the prevalence of different factors of APLEs in help-seeking adolescents, and their relationship with age, functioning and psychopathology.

METHOD

As a part of the "Liberiamo il Futuro" project, help-seeking adolescents (N=171; 11-18 years, 53% male) were screened with the 92-item Prodromal Questionnaire (PQ-92). A factor analysis was performed on the PQ-92 positive items (i.e., APLEs) to identify different APLE-factors. These were assessed for their association with age, functioning and psychopathology using regression analyses.

RESULTS

APLEs were very common in help-seeking adolescents, and formed four factors: "Conceptual Disorganization and Suspiciousness", "Perceptual Abnormalities", "Bizarre Experiences", and "Magical Ideation". Associations with age and functioning but not psychopathology were found for "Perceptual Abnormalities" that was significantly more severe in 11-12-year-olds, while "Conceptual Disorganization and Suspiciousness" was significantly related to psychopathology.

CONCLUSION

In line with findings on PLEs, prevalence and clinical significance of APLEs, especially perception-related ones, might depend on age and thus neurodevelopmental stage, and may fall within the normal spectrum of experience during childhood. This should be considered when screening for UHR status in younger age groups.

Prevalence and clinical significance of DSM-5-attenuated psychosis syndrome in adolescents and young adults in the general population: the Bern Epidemiological At-Risk (BEAR) study

OBJECTIVE

Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists attenuated psychosis syndrome as a condition for further study. One important question is its prevalence and clinical significance in the general population.

METHOD

Analyses involved 1229 participants (age 16-40 years) from the general population of Canton Bern, Switzerland, enrolled from June 2011 to July 2012. "Symptom," "onset/worsening," "frequency," and "distress/disability" criteria of attenuated psychosis syndrome were assessed using the structured interview for psychosis-risk syndromes. Furthermore, help-seeking, psychosocial functioning, and current nonpsychotic axis I disorders were surveyed. Well-trained psychologists performed assessments using the computer-assisted telephone interviewing technique.

RESULTS

The symptom criterion was met by 12.9% of participants, onset/worsening by 1.1%, frequency by 3.8%, and distress/disability by 7.0%. Symptom, frequency, and distress/disability were met by 3.2%. Excluding trait-like attenuated psychotic symptoms (APS) decreased the prevalence to 2.6%, while adding onset/worsening reduced it to 0.3%. APS were associated with functional impairments, current mental disorders, and help-seeking although they were not a reason for help-seeking. These associations were weaker for attenuated psychosis syndrome.

CONCLUSIONS

At the population level, only 0.3% met current attenuated psychosis syndrome criteria. Particularly, the onset/worsening criterion, originally included to increase the likelihood of progression to psychosis, lowered its prevalence. Because progression is not required for a self-contained syndrome, a revision of the restrictive onset criterion is proposed to avoid the exclusion of 2.3% of persons who experience and are distressed by APS from mental health care. Secondary analyses suggest that a revised syndrome would also possess higher clinical significance than the current syndrome.

Current status specifiers for patients at clinical high risk for psychosis

BACKGROUND

Longitudinal studies of the clinical high risk (CHR) syndrome for psychosis have emphasized the conversion vs non-conversion distinction and thus far have not focused intensively on classification among non-converters. The present study proposes a system for classifying CHR outcomes over time when using the Structured Interview for Psychosis-risk Syndromes and evaluates its validity.

METHOD

The system for classifying CHR outcomes is referred to as "current status specifiers," with "current" meaning over the month prior to the present evaluation and "specifiers" indicating a set of labels and descriptions of the statuses. Specifiers for four current statuses are described: progression, persistence, partial remission, and full remission. Data from the North American Prodromal Longitudinal Study were employed to test convergent, discriminant, and predictive validity of the current status distinctions.

RESULTS

Validity analyses partly supported current status distinctions. Social and role functioning were more impaired in progressive and persistent than in remitted patients, suggesting a degree of convergent validity. Agreement between CHR current statuses and current statuses for a different diagnostic construct (DSM-IV Major Depression) was poor, suggesting discriminant validity. The proportion converting to psychosis within a year was significantly higher in cases meeting progression criteria than in those meeting persistence criteria and tended to be higher than in those meeting full remission criteria, consistent with a degree of predictive validity.

DISCUSSION

CHR syndrome current status specifiers could offer a potentially valid and useful description of current clinical status among non-converters. Study in additional samples is needed.

Evidence for an agitated-aggressive syndrome predating the onset of psychosis

BACKGROUND

Aggression and suicidality prior to the initiation of treatment are frequent phenomena in psychosis patients. Increased scores in the Brief Psychiatric Rating Scale Excited Component (BPRS-EC) have been shown to predict involuntary treatment, aggression, and suicide in first-episode psychosis (FEP) patients. However, it is unclear if an agitated-aggressive syndrome as measured with the BPRS-EC is already present in at-risk mental state (ARMS).

METHODS

BPRS-EC scores from 43 ARMS patients, 50 FEP patients, and 25 healthy controls (HC) were analyzed. Multivariate analyses were performed to review if group differences were mediated by potential confounders. In addition, the association of BPRS-EC scores with clinical variables was examined.

RESULTS

BPRS-EC scores were significantly different across diagnostic groups (H(2)=22.1; p<.001), and post-hoc analyses showed significantly higher BPRS-EC scores for ARMS (p=.001) and for FEP patients (p<.001) compared to HC. Differences remained significant after controlling for gender, years of education, and intelligence. No significant differences emerged between ARMS and FEP patients. BPRS-EC was significantly correlated with lower intelligence (r=-.27; p=.008), reduced level of functioning (r=-.44; p<.001), and with smoking behavior (r=.22; p=.019).

CONCLUSIONS

ARMS and FEP patients in our sample had significantly higher BPRS-EC scores compared to HC. This may constitute a correlate of an agitated-aggressive syndrome and an increased risk for aggression and suicidality.

Psychotische Störungen im DSM-5

Es wird eine Übersicht über die hauptsächlichen Änderungen des Kapitels «Schizophrenie-Spektrum und andere psychotische Störungen» von DSM-IV-TR zu DSM-5 gegeben, in dem erneut etwaigen Besonderheiten von Kindern und Jugendlichen nicht Rechnung getragen wird. Diese umfassen im Haupttext den Verzicht auf die klassischen Subtypen der Schizophrenie sowie die Aufgabe des besonderen Stellenwerts der Schneider’schen Erstrangsymptome und damit verbunden die Forderung von mindestens zwei Leitsymptomen (obligatorisch mindestens ein Positivsymptom) bei der Schizophrenie sowie Zulassung bizarrer Wahninhalte auch bei Wahnhaften Störungen. Neu sind zudem die Kodierung wahnhafter Zwangs-/Körperdysmorpher Störungen ausschließlich unter den Zwangsstörungen, die Präzisierung affektiver Episoden bei der Schizoaffektiven Störung und die Einführung einer eigenen Sektion «Katatonie» zur Beschreibung katatoner Symptome innerhalb verschiedendster Krankheitsbilder. In der Sektion III (Aufkommende Messmittel und Modelle) findet sich zudem der Vorschlag einer dimensionalen Beschreibung von Psychosen. Verwirrend ist die doppelte Einführung eines «Attenuated Psychosis» Syndromes: zum einen vage umschrieben unter die «Anderen spezifizierten Schizophrenie-Spektrum und anderen psychotischen Störungen» im Haupttext, zum anderen klar definiert unter die «Bedingungen mit weiterem Forschungsbedarf» der Sektion III. Mit dieser nicht spezifizierten Aufnahme des Attenuated Psychosis Syndromes in den Haupttext ist einer befürchteten Überdiagnostizierung subschwelliger psychotischer Symptome und deren frühzeitiger psychopharmakologischer Behandlung nun doch Tür und Tor geöffnet.

Self-reported psychotic-like experiences are a poor estimate of clinician-rated attenuated and frank delusions and hallucinations

BACKGROUND

One reason for the decision to delay the introduction of an Attenuated Psychosis Syndrome in the main text of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders was the concern that attenuated psychotic symptoms (APS) might in fact be common features in adolescents and young adults from the general population of no psychopathological significance in themselves. This concern was based on reports of high prevalence rates of psychotic-like experiences (PLEs) in the general population and the assumption that PLEs are a good estimate of APS. Although the criterion validity of self-reported PLEs had already been studied with respect to clinician-rated psychotic symptoms and found insufficient, it had been argued that PLEs might in fact be more comparable with mild, subclinical expressions of psychotic symptoms and, therefore, with APS. The present paper is the first to specifically study this assumption.

SAMPLING AND METHODS

The sample consisted of 123 persons seeking help at a service for the early detection of psychosis, of whom 54 had an at-risk mental state or psychosis, 55 had a nonpsychotic mental disorder and 14 had no full-blown mental disorder. PLEs were assessed with the Peters Delusion Inventory and the revised Launay-Slade Hallucination Scale, and psychotic symptoms and APS were assessed with the Structured Interview for Prodromal Syndromes.

RESULTS

At a level of agreement between the presence of any PLE (in 98.4% of patients) and any APS (in 40.7%) just exceeding chance (κ = 0.022), the criterion validity of PLEs for APS was insufficient. Even if additional qualifiers (high agreement or distress, preoccupation and conviction) were considered, PLEs (in 52.8%) still tended to significantly overestimate APS, and agreement was only fair (κ = 0.340). Furthermore, the group effect on PLE prevalence was, at most, moderate (Cramer's V ≤ 0.382).

CONCLUSIONS

The prevalence of APS cannot be deduced from studies of PLEs. Thus, the high population prevalence rate of PLEs does not allow the conclusion that APS are common features of no pathological significance and would lack clinical validity as an Attenuated Psychosis Syndrome in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Rather, the population prevalence rate of APS has to be assumed to be largely unknown at present but is likely lower than indicated by epidemiological studies of PLEs. Therefore, dedicated studies are warranted, in which APS are assessed in a way that equates to their clinical evaluation.

Prevalence of psychotic-like experiences in young adults with social anxiety disorder and correlation with affective dysregulation

Social anxiety disorder (SAD) is associated with psychotic-like experiences (PLEs) and is a frequent diagnosis in the prodromal phases of psychosis. We investigated whether psychopathological factors could discriminate which subjects with SAD are more likely to develop PLEs. A sample of 128 young adults with SAD was split into two subsamples according to the presence of clinically relevant PLEs. Correlations between PLEs and other psychopathological markers were explored. The SAD with PLEs group showed higher level of anxiety, depression, and intolerance of uncertainty (IU) compared with the SAD without PLEs group. A limitation of this study is that the cross-sectional design precluded the analysis of causality. In our sample, the presence of PLEs is related to higher levels of depression, anxiety, and IU. The current findings are consistent with hypotheses suggesting that cognitive disturbances, together with social anxiety, may result in PLEs.

"Early Psychosis" as a mirror of biologist controversies in post-war German, Anglo-Saxon, and Soviet Psychiatry

The English term "early psychosis" was coined in the 1930s to refer to feelings of irritability, loss of concentration, hypochondriac ideas, moodiness, and lassitude that were seen to precede the onset of clear-cut hallucinations and delusions. The history of thinking about "early psychosis" under names such as "latent," "masked," "mild," "simple" or "sluggish" schizophrenia before World War II and afterwards on the different sides of the Wall and the Iron Curtain reveals "early psychosis" as a mirror of quite aged international biologist controversies that are still alive today and to the same extent as they are misunderstood, are influential in their implications in today's psychiatry.

Season of birth effect on psychotic-like experiences in Japanese adolescents

A number of studies have investigated seasonality of birth in schizophrenia. Most of the studies have consistently observed an excess of winter births, often associated with decreased summer births. We postulated that psychotic-like experiences (PLEs), subclinical hallucinatory and delusional experiences, may also be affected by birth season. In the present study, we assessed the season of birth effect on the prevalence of PLEs using data from the cross-sectional survey of 19,436 Japanese adolescents. As a result, significant excess of winter births was observed in the prevalence of PLEs, accompanied by a decreased proportion of summer births. The odds ratios for the prevalence of PLEs were estimated to be 1.11, which was on the same order with those for the development of schizophrenia in the previous meta-analytic studies. To our knowledge, this is the first to show the seasonality of birth in the prevalence of PLEs and implicate the winter birth effect on subclinical stage of schizophrenia.

The Strauss and Carpenter Prognostic Scale in subjects clinically at high risk of psychosis

OBJECTIVE

To investigate the predictive value of the Strauss and Carpenter Prognostic Scale (SCPS) for transition to a first psychotic episode in subjects clinically at high risk (CHR) of psychosis.

METHOD

Two hundred and forty-four CHR subjects participating in the European Prediction of Psychosis Study were assessed with the SCPS, an instrument that has been shown to predict outcome in patients with schizophrenia reliably.

RESULTS

At 18-month follow-up, 37 participants had made the transition to psychosis. The SCPS total score was predictive of a first psychotic episode (P < 0.0001). SCPS items that remained as independent predictors in the Cox proportional hazard model were as follows: most usual quality of useful work in the past year (P = 0.006), quality of social relations (P = 0.006), presence of thought disorder, delusions or hallucinations in the past year (P = 0.001) and reported severity of subjective distress in past month (P = 0.003).

CONCLUSION

The SCPS could make a valuable contribution to a more accurate prediction of psychosis in CHR subjects as a second-step tool. SCPS items assessing quality of useful work and social relations, positive symptoms and subjective distress have predictive value for transition. Further research should focus on investigating whether targeted early interventions directed at the predictive domains may improve outcomes.

The psychosis high-risk state: a comprehensive state-of-the-art review

CONTEXT

During the past 2 decades, a major transition in the clinical characterization of psychotic disorders has occurred. The construct of a clinical high-risk (HR) state for psychosis has evolved to capture the prepsychotic phase, describing people presenting with potentially prodromal symptoms. The importance of this HR state has been increasingly recognized to such an extent that a new syndrome is being considered as a diagnostic category in the DSM-5.

OBJECTIVE

To reframe the HR state in a comprehensive state-of-the-art review on the progress that has been made while also recognizing the challenges that remain.

DATA SOURCES

Available HR research of the past 20 years from PubMed, books, meetings, abstracts, and international conferences.

STUDY SELECTION AND DATA EXTRACTION

Critical review of HR studies addressing historical development, inclusion criteria, epidemiologic research, transition criteria, outcomes, clinical and functional characteristics, neurocognition, neuroimaging, predictors of psychosis development, treatment trials, socioeconomic aspects, nosography, and future challenges in the field.

DATA SYNTHESIS

Relevant articles retrieved in the literature search were discussed by a large group of leading worldwide experts in the field. The core results are presented after consensus and are summarized in illustrative tables and figures.

CONCLUSIONS

The relatively new field of HR research in psychosis is exciting. It has the potential to shed light on the development of major psychotic disorders and to alter their course. It also provides a rationale for service provision to those in need of help who could not previously access it and the possibility of changing trajectories for those with vulnerability to psychotic illnesses.

'A rose is a rose is a rose', but at-risk criteria differ

BACKGROUND

Over the last 15 years, efforts to detect psychoses early in their prodromal states have greatly progressed; meanwhile, ultra-high risk (UHR) criteria have been the subject of such consensus that parts of them have been proposed for inclusion in DSM-5 in terms of an attenuated psychosis syndrome. However, it is frequently unacknowledged that the definitions and operationalizations of UHR-related at-risk criteria, including the relevant attenuated psychotic symptoms, vary considerably across centers and time and, thus, between prediction studies.

METHODS

These variations in UHR criteria are described and discussed with reference to the rates of transition to psychosis, their prevalence in the general population and the proposed new operationalization of the attenuated psychosis syndrome.

RESULTS

A comparison of samples recruited according to different UHR operationalizations reveals differences in the distribution of UHR criteria and transition rates as well as in the prevalence rates of at-risk criteria in the general population.

CONCLUSION

The evidence base for the introduction of such a new syndrome is weaker than the number of studies using supposedly equal UHR criteria would at first suggest. Thus, studies comparing the effects of different (sub-)criteria not only on transition rates and outcomes but also on other important aspects, such as neurocognitive performance and brain imaging results, are necessary. Meanwhile, the preliminary attenuated psychosis syndrome in DSM-5 should not follow an altogether new definition but, rather, the currently most reliable UHR definition, which must still demonstrate its reliability and validity outside specialized psychiatric services.

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

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

Psychotic-like or unusual subjective experiences? The role of certainty in the appraisal of the subclinical psychotic phenotype

The multi-dimensional features of Unusual Subjective Experiences (USEs) may be more accurate indicators of psychosis-proneness than simple frequency count. We tested whether subjective certainty or uncertainty of the occurrence of USEs can influence perceived wellbeing. Five hundred and four undergraduate students completed measures of delusion- and hallucination-proneness, general health and emotional processing. Participants' responses on the delusion- and hallucination-proneness scales were dichotomized on the basis of their certainty level. Results showed that, USEs rated with certainty were associated with poor self-perceived health and difficult emotional processing, while those rated with uncertainty were not. Certainty of USEs was associated with increased distress and may be important in characterizing psychopathological significance. Specific characteristics associated with USEs may be more important than their frequency in predicting psychosis risk.

Chances and risks of predicting psychosis

Prevention is currently regarded a promising strategy for fighting the unfavorable consequences of psychosis. Yet, for the error probability inherent in any predictive approach, benefits and costs must be carefully weighed against each other. False attribution of risk may unnecessarily provoke stress and anxiety, and lead to unwarranted intervention exposure. However, clinical risk samples already exhibit psychopathological symptoms, cognitive and functional impairments, and help-seeking for mental problems. Thus, the risk of futile interventions is low as long as preventive measures also provide treatment for current complaints. Differentiation between still normal and clinically relevant mental states is another challenge as psychotic-like phenomena occur frequently in the general population, especially in younger adolescents. Reported prevalence rates vary with age, and if severe in terms of frequency and persistence, these phenomena considerably increase risk of psychosis in clinical as well as general population samples. Stigmatization is another concern, though insufficiently studied. Yet, at least more severe states of risk, which are accompanied by changes in thinking, feeling, and behavior, might lead to unfavorable, (self-) stigmatizing effects already by themselves, independent of any diagnostic "label," and to stress and confusion for the lack of understanding of what is going on. To further improve validity of risk criteria, advanced risk algorithms combining multi-step detection and risk stratification procedures should be developed. However, all prediction models possess a certain error probability. Thus, whether a risk model justifies preventive measures can only be decided by weighing the costs of unnecessary intervention and the benefits of avoiding a potentially devastating outcome.