The relationship of premorbid functioning to illness course in schizophrenia and psychotic mood disorders during two years following first hospitalization

GDNF and miRNA-29a as biomarkers in the first episode of psychosis: uncovering associations with psychosocial factors

Aim

Schizophrenia involves complex interactions between biological and environmental factors, including childhood trauma, cognitive impairments, and premorbid adjustment. Predicting its severity and progression remains challenging. Biomarkers like glial cell line-derived neurotrophic factor (GDNF) and miRNA-29a may bridge biological and environmental aspects. The goal was to explore the connections between miRNAs and neural proteins and cognitive functioning, childhood trauma, and premorbid adjustment in the first episode of psychosis (FEP).

Method

This study included 19 FEP patients who underwent clinical evaluation with: the Childhood Trauma Questionnaire (CTQ), the Premorbid Adjustment Scale (PAS), the Positive and Negative Syndrome Scale (PANSS), and the Montreal Cognitive Assessment Scale (MoCA). Multiplex assays for plasma proteins were conducted with Luminex xMAP technology. Additionally, miRNA levels were quantitatively determined through RNA extraction, cDNA synthesis, and RT-qPCR on a 7500 Fast Real-Time PCR System.

Results

Among miRNAs, only miR-29a-3p exhibited a significant correlation with PAS-C scores (r = -0.513, p = 0.025) and cognitive improvement (r = -0.505, p = 0.033). Among the analyzed proteins, only GDNF showed correlations with MoCA scores at the baseline and after 3 months (r = 0.533, p = 0.0189 and r = 0.598, p = 0.007), cognitive improvement (r = 0.511, p = 0.025), and CTQ subtests. MIF concentrations correlated with the PAS-C subscale (r = -0.5670, p = 0.011).

Conclusion

GDNF and miR-29a-3p are promising as biomarkers for understanding and addressing cognitive deficits in psychosis. This study links miRNA and MIF to premorbid adjustment and reveals GDNF's unique role in connection with childhood trauma.

Premorbid adjustment as predictor of long-term functionality: Findings from a 10-year follow-up study in the PAFIP-cohort

The literature indicates that patients with schizophrenia spectrum disorders often show deficits in premorbid adjustment. Additionally, these impairments have been correlated with critical disease parameters, evident in both early and advanced stages. The principal objective of this study was to investigate the association between premorbid adjustment and functional outcomes a decade following the initial episode of psychosis. A cluster analysis was performed to group patients according to their premorbid adjustment scores as assessed with the Premorbid Adjustment Scale (PAS). The measurements of The Disability Assessment Scale (DAS), The Global Assessment of Function (GAF) scale, ​​and The Quality of Life Scale (QLS) were used to compare the functionality of the groups at a 10-year follow-up. A total of 231 patients were classified into three groups based on their premorbid adjustment: "good PAS", "deteriorating PAS", and "chronically poor PAS". The three groups differed significantly in their sociodemographic and cognitive baseline characteristics. At the 10-year follow-up, "good PAS" group had better scores than the other groups in the variables of functionality and quality of life. The relationship found between premorbid adjustment and long-term functional results in patients with psychosis can help us predict the evolution of patients and act accordingly.

Premorbid functioning in schizophrenia spectrum disorders with comorbid substance use: A systematic review

Premorbid functioning has been related with several clinical features and prognosis of schizophrenia spectrum disorders. Comorbidity with substance use is highly prevalent and usually hinders clinical improvement in this kind of psychiatric disorders. This systematic review analyzes the differences in the premorbid functioning of subjects with a schizophrenia spectrum disorder with substance use (SSD+, dual psychosis) or without it (SSD-). A systematic review (PRISMA guidelines), including search in electronic databases (MEDLINE, Web of Science, and Cochrane Library), was performed. 118 published works were considered of which only 20 met our inclusion criteria. Although there is a great variability in methodologies, diagnoses included, and substances used, studies using the Premorbid Functioning Scale to assess the academic and/or social domains found that SSD+ subjects had a poorer academic but better social premorbid functioning than those with SSD-. Current evidence is not conclusive, so additional studies are required to integrate intervening factors in order to clarify the clinical implications of premorbid functioning to improve the course and therapeutic response of patients.

Premorbid adjustment amongst outpatients with schizophrenia in a Nigerian psychiatric facility

BACKGROUND

Studies from developed countries have shown that poor premorbid adjustment in patients with schizophrenia is associated with poor outcome. However, similar studies in developing countries like Nigeria are few despite the stability of schizophrenia prevalence across cultures.

AIM

The aim of this study was to assess the prevalence and correlates of poor premorbid adjustment amongst outpatients with schizophrenia.

SETTING

The Neuropsychiatric Hospital, Abeokuta in Ogun State, Nigeria.

METHODS

The premorbid adjustment of 300 outpatients with schizophrenia was assessed using the premorbid adjustment scale. Pattern and severity of psychosis, overall illness severity, global assessment of functioning and socio-demographic factors were investigated as correlates of premorbid functioning.

RESULTS

About half (53.3%) of the respondents had poor premorbid adjustment and most of them were males (56.9%). Poor premorbid adjustment was associated with male gender (χ 2 = 7.81, p = 0.005) whilst good premorbid adjustment was associated with no or borderline illness severity (χ 2 = 8.26, p = 0.016) as well as no or mild impairment in functioning (χ 2 = 7.01, p = 0.029) amongst the respondents. Positive, negative and general symptomatology were predicted by premorbid adjustment at different developmental stages.

CONCLUSION

Consistent with existing literature, poor premorbid adjustment was prevalent amongst patients with schizophrenia in this study and was associated with male gender, poorer clinical outcomes and greater illness severity. Mental health promotion and other preventative approaches are recommended as possible early intervention strategies in dealing with schizophrenia.

Familial and socioeconomic contributions to premorbid functioning in psychosis: Impact on age at onset and treatment response

Background.

Premorbid adjustment (PA) abnormalities in psychotic disorders are associated with an earlier age at onset (AAO) and unfavorable clinical outcomes, including treatment resistance. Prior family studies suggest that familial liability, likely reflecting increased genetic risk, and socioeconomic status (SES) contribute to premorbid maladjustment. However, their joint effect possibly indicating gene–environment interaction has not been evaluated.

Methods.

We examined whether family history of psychosis (FHP) and parental SES may predict PA and AAO in unrelated cases with first-episode psychosis (n = 108) and schizophrenia (n = 104). Premorbid academic and social functioning domains during childhood and early adolescence were retrospectively assessed. Regression analyses were performed to investigate main effects of FHP and parental SES, as well as their interaction. The relationships between PA, AAO, and response to antipsychotic medication were also explored.

Results.

Positive FHP associated with academic PA difficulties and importantly interacted with parental SES to moderate social PA during childhood (interaction p = 0.024). Positive FHP and parental SES did not predict differences in AAO. Nevertheless, an earlier AAO was observed among cases with worse social PA in childhood (β = −0.20; p = 0.005) and early adolescence (β = −0.19; p = 0.007). Further, confirming evidence emerged for an association between deficient childhood social PA and poor treatment response (p = 0.04).

Conclusions.

Familial risk for psychosis may interact with parental socioeconomic position influencing social PA in childhood. In addition, this study supports the link between social PA deviations, early psychosis onset, and treatment resistance, which highlights premorbid social functioning as a promising clinical indicator.

Premorbid academic and social functioning in patients with schizophrenia and its associations with negative symptoms and cognition

OBJECTIVE

The study aimed to explore premorbid academic and social functioning in patients with schizophrenia, and its associations with the severity of negative symptoms and neurocognitive impairment.

METHOD

Premorbid adjustment (PA) in patients with schizophrenia was compared to early adjustment in unaffected first-degree relatives and healthy controls. Its associations with psychopathology, cognition, and real-life functioning were investigated. The associations of PA with primary negative symptoms and their two factors were explored.

RESULTS

We found an impairment of academic and social PA in patients (P ≤ 0.000001) and an impairment of academic aspects of early adjustment in relatives (P ≤ 0.01). Patients with poor PA showed greater severity of negative symptoms (limited to avolition after excluding the effect of depression/parkinsonism), working memory, social cognition, and real-life functioning (P ≤ 0.01 to ≤0.000001). Worse academic and social PA were associated with greater severity of psychopathology, cognitive impairment, and real-life functioning impairment (P ≤ 0.000001). Regression analyses showed that worse PA in the academic domain was mainly associated to the impairment of working memory, whereas worse PA in the social domain to avolition (P ≤ 0.000001).

CONCLUSION

Our findings suggest that poor early adjustment may represent a marker of vulnerability to schizophrenia and highlight the need for preventive/early interventions based on psychosocial and/or cognitive programs.

The role of premorbid adjustment in schizophrenia: Focus on cognitive remediation outcome

Premorbid adjustment has been associated with several outcomes in schizophrenia and has been proposed as an index of cognitive reserve. This study aims to comprehensively analyse the relation between premorbid adjustment and clinical, neurocognitive, socio-cognitive and functional assessments, as well as to investigate the effect of premorbid adjustment on cognitive improvements after a cognitive remediation therapy protocol. Seventy-nine clinically stabilised outpatients with schizophrenia underwent a combined intervention consisting of cognitive remediation therapy added to standard rehabilitation therapy. All patients were assessed at baseline for psychopathology, premorbid adjustment, intellectual level, cognition and functioning. Cognitive evaluations were also repeated after the intervention. At baseline, significant correlations were observed between premorbid adjustment and working memory. The global cognitive improvement after treatment was significantly predicted by age and premorbid adjustment. This study confirms the association between premorbid adjustment and cognitive impairment and is the first to highlight the possible role of premorbid adjustment on the capacity to recover from cognitive deficits through a cognitive remediation therapy protocol. The data suggest that cognitive remediation may be particularly effective for people in the early course and that the assessment of premorbid adjustment could be of value to design individualised interventions.

Social and academic premorbid adjustment domains predict different functional outcomes among youth with first episode mania

BACKGROUND

Premorbid characteristics may help predict the highly variable functional and illness outcomes of young people with early stage Bipolar Disorder (BD). We sought to examine the relationships between premorbid adjustment and short to medium-term outcomes after a first treated episode of mania.

METHODS

We examined the baseline and 18-month follow-up characteristics of 117 participants with first episode of mania, treated at two tertiary early intervention services in Melbourne, Australia. The baseline demographic, family history, diagnoses, comorbidity and clinical features were determined using unstructured questionnaires and structured diagnostic interviews. Premorbid adjustment was determined using the Premorbid Adjustment Scale (PAS), the components of which were identified using a principal component analysis. Eighteen-month follow-up outcome measures included the Clinical Global Impressions scale, Social and Occupational Functioning Assessment Scale and the Heinrichs' Quality of Life Scale (QLS). Correlations and linear regressions were utilised to examine the relationships between component scores and outcomes, while controlling for baseline and follow-up confounders.

RESULTS

The social adjustment component of the PAS correlated with the interpersonal relations (r_s = -0.46, p<0.001) domain of QLS while the academic adjustment component of the PAS correlated with the vocational functioning domain of QLS (r_s =-0.39, p = 0.004). Premorbid adjustment did not predict illness severity or objective functioning.

LIMITATIONS

Lack of information on cognition, personality factors and prodromal symptoms limited the assessment of their impact on outcomes.

CONCLUSIONS

Impairments in domains of premorbid adjustment may be early markers of persistent difficulties in social and vocational functioning and may benefit from targeted interventions.

Characterization of premorbid functioning during childhood in patients with deficit vs. non-deficit schizophrenia and in their healthy siblings

Impaired premorbid adjustment has been reported in patients with schizophrenia, generally in association with unfavorable aspects of the illness (e.g., poor outcome and severe negative symptoms). Several studies attempted to define the domains of premorbid dysfunction associated with negative symptoms and poor outcome; however, most of them assessed broadly defined negative symptoms. The present study was aimed to characterize premorbid functioning in a group of patients with deficit schizophrenia (DS), characterized by the presence of at least two primary and persistent negative symptoms (PPNS), and one of patients with a diagnosis of schizophrenia who did not meet criteria for DS (NDS). The presence of emotional/behavioral problems during childhood was investigated using the Childhood Behavior Checklist (CBCL) in both patient groups and in their respective healthy siblings. The Premorbid Adjustment Scale (PAS) was also used to assess premorbid functioning during childhood in the two patient groups. PPNS were also treated as a continuous variable and correlated with the indices of premorbid functioning regardless the DS/NDS categorization. DS patients, as compared to NDS, showed higher scores on the CBCL subscale "Withdrawn". Both DS and NDS patients showed, as compared to their healthy siblings, a greater impairment on almost all CBCL subscales. PAS findings revealed that DS patients had poorer premorbid adjustment than NDS. No significant correlation between premorbid functioning and PPNS was observed. These findings support the hypothesis that DS has a different developmental trajectory with respect to NDS, and that premorbid adjustment is one of the essential aspects of its characterization.

Trajectory and predictors of quality of life in first episode psychotic mania

BACKGROUND

Little is known about the trajectory of quality of life (QoL) following a first episode of psychotic mania in bipolar disorder (BD). This 18-month longitudinal study investigated the trajectory of QoL, and the influence of premorbid adjustment and symptoms on 18-month QoL in a cohort of young people experiencing a first episode of psychotic mania.

METHODS

As part of an overarching clinical trial, at baseline, sixty participants presenting with a first episode of psychotic mania (BD Type 1 - DSM-IV) completed symptomatic and functional assessments in addition to the Premorbid Adjustment Scale - General Subscale. Symptom measures were repeated at 18-month follow up. QoL was rated using the Quality of Life Scale (QLS) at designated time points.

RESULTS

Mean QLS scores at initial measurement (8 weeks) were 61% of the maximum possible score, increasing significantly to 70% at 12 months, and 71.2% at 18-month follow-up. Premorbid adjustment and 18-month depressive symptoms were significantly associated with QoL at 18-month follow-up.

LIMITATIONS

Study limitations include the small sample size, inclusion of participants with psychotic mania only, use of measures originally designed for use with schizophrenia spectrum disorders, and lack of premorbid or baseline measurement of QoL.

CONCLUSIONS

Results suggest that QoL can be maintained early in BD, and reinforce the importance of assertively treating depressive symptoms throughout the course of this disorder. The emergence of a link between premorbid adjustment and poorer QoL in this cohort highlights the importance of assessing facets of adjustment when planning psychological interventions.

Patterns of premorbid functioning in individuals at clinical high risk of psychosis

In schizophrenia, four typical patterns of premorbid functioning have been observed: stable-good, stable-intermediate, poor-deteriorating and deteriorating. However, it is unknown whether similar patterns exist in those who are at clinical high risk (CHR) of psychosis. The aim of this study was to examine patterns of premorbid functioning in a large sample of individuals at CHR of psychosis and its association with symptoms, functioning, and conversion to psychosis. One-hundred sixty people at CHR of psychosis were assessed on premorbid functioning using the Premorbid Adjustment Scale. Poorer premorbid functioning was significantly correlated with worse negative symptom severity and lower social functioning. Cluster analysis was used to identify patterns of premorbid functioning. Results indicated three patterns of premorbid functioning in our CHR sample: stable-intermediate, stable-good, and deteriorating. The deteriorating group had more severe disorganization, worse negative symptoms, and poorer social functioning than the other groups. Participants who made the conversion to psychosis had significantly poorer premorbid functioning during adolescence compared to those who did not convert. These results suggest that those at a clinical high risk for psychosis display similar patterns in premorbid functioning as have been observed in those with a psychotic illness and that poor premorbid functioning may be a predictor of psychosis.

Trajectories of premorbid childhood and adolescent functioning in schizophrenia-spectrum psychoses: A first-episode study

Evidence of social and behavioral problems preceding the onset of schizophrenia-spectrum psychoses is consistent with a neurodevelopmental model of these disorders. Here we predict that individuals with a first episode of schizophrenia-spectrum psychoses will evidence one of three patterns of premorbid adjustment: an early deficit, a deteriorating pattern, or adequate or good social adjustment. Participants were 164 (38% female; 31% black) individuals ages 15-50 with a first episode of schizophrenia-spectrum psychoses. Premorbid adjustment was assessed using the Cannon-Spoor Premorbid Adjustment Scale. We compared the fit of a series of growth mixture models to examine premorbid adjustment trajectories, and found the following 3-class model provided the best fit with: a "stable-poor" adjustment class (54%), a "stable-good" adjustment class (39%), and a "deteriorating" adjustment class (7%). Relative to the "stable-good" class, the "stable-poor" class experienced worse negative symptoms at 1-year follow-up, particularly in the social amotivation domain. This represents the first known growth mixture modeling study to examine premorbid functioning patterns in first-episode schizophrenia-spectrum psychoses. Given that the stable-poor adjustment pattern was most prevalent, detection of social and academic maladjustment as early as childhood may help identify people at increased risk for schizophrenia-spectrum psychoses, potentially increasing feasibility of early interventions.

Functional outcome in major psychiatric disorders and associated clinical and psychosocial variables: A potential cross-diagnostic phenotype for further genetic investigations?

OBJECTIVES

Functional outcome has recently become of interest for cross-diagnostic subphenotype approaches in psychiatric genetics. Therefore, it is crucial to know about clinical, demographic and psychosocial variables that correlate with long-term functioning. Unfortunately, there is a lack of studies that directly compare the importance of correlates for functional outcome between different disorders.

METHODS

Applying regression models to samples of patients with schizophrenia (SZ, n = 238), bipolar disorder (BD, n = 533) and major depressive disorder (MDD, n = 398), we compared the magnitude of association of potential correlates with functional outcome, measured by the Global Assessment of Functioning (GAF) score.

RESULTS

Shared correlates for worse functional outcome were poor premorbid functioning, insidious illness onset and poor premorbid work or social adjustment in all three disorders, and negative symptomatology in SZ and BD. Disorder-specific correlates for SZ were longer duration of illness, lower functioning during episodes and being life-time single, for BD substance abuse and suicidality, and for MDD premorbid unemployment and having a premorbid personality disorder.

CONCLUSIONS

We found different patterns of correlates for long-term functioning in SZ, BD and MDD. Knowledge of these patterns may improve the quality of genetic investigations focussing on functional outcome.

Premorbid functional development and conversion to psychosis in clinical high-risk youths

Deterioration in premorbid functioning is a common feature of schizophrenia, but sensitivity to psychosis conversion among clinical high-risk samples has not been examined. This study evaluates premorbid functioning as a predictor of psychosis conversion among a clinical high-risk sample, controlling for effects of prior developmental periods. Participants were 270 clinical high-risk individuals in the North American Prodrome Longitudinal Study-I, 78 of whom converted to psychosis over the next 2.5 years. Social, academic, and total maladjustment in childhood, early adolescence, and late adolescence were rated using the Cannon-Spoor Premorbid Adjustment Scale. Early adolescent social dysfunction significantly predicted conversion to psychosis (hazard ratio = 1.30, p = .014), independently of childhood social maladjustment and independently of severity of most baseline positive and negative prodromal symptoms. Baseline prodromal symptoms of disorganized communication, social anhedonia, suspiciousness, and diminished ideational richness mediated this association. Early adolescent social maladjustment and baseline suspiciousness together demonstrated moderate positive predictive power (59%) and high specificity (92.1%) in predicting conversion. Deterioration of academic and total functioning, although observed, did not predict conversion to psychosis. Results indicate early adolescent social dysfunction to be an important early predictor of conversion. As such, it may be a good candidate for inclusion in prediction algorithms and could represent an advantageous target for early intervention.

Neuropsychological Deficits in the Prodromal Phase and Course of an Early-Onset Schizophrenia

Objectives: Although clear advances have been achieved in the study of early-onset schizophrenia (EOS), little is known to date about premorbid and prodromal neuropsychological functioning in EOS. Method: Here, we report on a case of an adolescent male with EOS who underwent neuropsychological testing before and after illness onset. Results: Marked cognitive deficits in the domains of attention, set-shifting, and verbal memory were present both pre-onset and during the course of schizophrenia, though only deficits in verbal memory persisted after illness-onset and antipsychotic treatment. Conclusion: The findings of this case study suggest that impairments in the verbal memory domain are particularly prominent symptoms of cognitive impairment in prodromal EOS and persist in the course of the disorder, which further demonstrates the difficult clinical situation of adequate schooling opportunities for adolescent patients with EOS.

Differential neurodevelopmental trajectories in patients with early-onset bipolar and schizophrenia disorders

Schizophrenia and bipolar disorders share not only clinical features but also some risk factors such as genetic markers and childhood adversity, while other risk factors such as urbanicity and obstetric complications seem to be specific to schizophrenia. An intriguing question is whether the well-established abnormal neurodevelopment present in many children and adolescents who eventually develop schizophrenia is also present in bipolar patients. The literature on adult bipolar patients is controversial. We report data on a subgroup of patients with pediatric-onset psychotic bipolar disorder who seem to share some developmental trajectories with patients with early-onset schizophrenia. These early-onset psychotic bipolar patients have low intelligence quotient, more neurological signs, reduced frontal gray matter at the time of their first psychotic episode, and greater brain changes than healthy controls in a pattern similar to early-onset schizophrenia cases. However, patients with early-onset schizophrenia seem to have more social impairment, developmental abnormalities (eg, language problems), and lower academic achievement in childhood than early-onset bipolar patients. We suggest that some of these abnormal developmental trajectories are more related to the phenotypic features (eg, early-onset psychotic symptoms) of these 2 syndromes than to categorically defined Diagnostic and Statistical Manual of Mental Disorders disorders.

Subtyping first-episode non-affective psychosis using four early-course features: potentially useful prognostic information at initial presentation

AIM

Heterogeneity of symptoms, course and outcomes in primary psychotic disorders complicates prognosis, treatment and diverse aspects of research. This study aimed to identify interpretable subtypes of first-episode non-affective psychosis based on four early-course features (premorbid academic functioning, premorbid social functioning, duration of the prodrome and age at onset of psychosis).

METHODS

Data from 200 well-characterized patients hospitalized in public-sector inpatient units for first-episode non-affective psychosis were used in latent profile analyses. Derived subtypes were then compared along a number of clinical dimensions using analyses of variance.

RESULTS

Using four early-course features, three classes were derived. A good premorbid/short prodrome subtype was characterized by a lower severity of positive symptoms, better social/occupational/global functioning, and a shorter duration of untreated psychosis; a poor premorbid/early onset subtype demonstrated greater negative and preoccupation symptoms, as well as greater psychosocial problems; and a long prodrome/late onset subtype was characterized by greater dysphoric symptoms.

CONCLUSIONS

Findings indicate a need for further research with first-episode samples on the utility of subtyping based on early-course (premorbid, prodromal and onset-related) characteristics. Such efforts could enhance the parsing of heterogeneity, thereby advancing clinical practice and research.

Functional development in clinical high risk youth: prediction of schizophrenia versus other psychotic disorders

This study evaluates premorbid social and academic functioning in clinical high-risk individuals as predictors of transition to schizophrenia versus another psychotic disorder. Participants were 54 individuals enrolled in phase one of the North American Prodrome Longitudinal Study who over two and a half years of follow-up met criteria for schizophrenia/schizophreniform disorder (n=28) or another psychotic disorder (n=26). Social and academic functioning in childhood, early adolescence, and late adolescence was assessed at baseline using the Cannon-Spoor Premorbid Adjustment Scale. Social maladjustment in late adolescence predicted significantly higher odds of transition to schizophrenia versus another psychotic disorder independent of childhood and early adolescent adjustment (OR=4.02) and conveyed unique risk over academic maladjustment (OR=5.64). Premorbid academic maladjustment was not associated with psychotic disorder diagnosis. Results support diagnostic specificity of premorbid social dysfunction to schizophrenia in clinical high-risk youth and underscore an important role for social maladjustment in the developmental pathology of schizophrenia and its prediction.

An ecologically valid performance-based social functioning assessment battery for schizophrenia

Psychiatrists pay more attention to the social functioning outcome of schizophrenia nowadays. How to evaluate the real world function among schizophrenia is a challenging task due to culture difference, there is no such kind of instrument in terms of the Chinese setting. This study aimed to report the validation of an ecologically valid performance-based everyday functioning assessment for schizophrenia, namely the Beijing Performance-based Functional Ecological Test (BJ-PERFECT). Fifty community-dwelling adults with schizophrenia and 37 healthy controls were recruited. Fifteen of the healthy controls were re-tested one week later. All participants were administered the University of California, San Diego, Performance-based Skill Assessment-Brief version (UPSA-B) and the MATRICS Consensus Cognitive Battery (MCCB). The finalized assessment included three subdomains: transportation, financial management and work ability. The test-retest and inter-rater reliabilities were good. The total score significantly correlated with the UPSA-B. The performance of individuals with schizophrenia was significantly more impaired than healthy controls, especially in the domain of work ability. Among individuals with schizophrenia, functional outcome was influenced by premorbid functioning, negative symptoms and neurocognition such as processing speed, visual learning and attention/vigilance.

The relationship of early premorbid adjustment with negative symptoms and cognitive functions in first-episode schizophrenia: a prospective three-year follow-up study

Premorbid adjustment is an important prognostic factor of schizophrenia. The relationships between sub-components of premorbid adjustment and outcomes on symptoms and cognition in first-episode schizophrenia were under-studied. In the current study, we prospectively followed up 93 patients aged 18-55 years presenting with first-episode schizophrenia-spectrum disorder. Psychopathological and cognitive assessments were conducted at baseline, clinical stabilization, 12, 24 and 36 months. Premorbid adjustment was sub-divided into discrete functional domains, developmental stages and premorbid-course types based on ratings of the Premorbid Adjustment Scale (PAS). The study focused on early developmental stages to minimize contamination by prodromal symptoms. Results indicated that gender differences in premorbid functioning were primarily related to early-adolescence adjustment and academic domain. Social domain was more strongly related to negative symptoms, while academic domain was more consistently linked to cognitive outcome (Wisconsin Card Sorting test and verbal fluency). Patients with stable-poor premorbid course had more severe negative symptoms and cognitive impairment. In conclusion, in a Chinese cohort of first-episode schizophrenia-spectrum disorder, sub-components of early premorbid adjustment were shown to be differentially related to clinical and cognitive measures. The results highlighted the importance of applying a more refined delineation of premorbid functioning in studying illness outcome.

Occupational outcome in bipolar disorder is not predicted by premorbid functioning and intelligence

OBJECTIVES

Bipolar disorder (BD), over the long term, can manifest a variety of outcomes depending on a number of different conditions. There is a need for further knowledge regarding preventive factors as well as predictors of the disabling course of the disorder. Studies regarding the impact on functional outcome of premorbid and current general intellectual function [intelligence quotient (IQ)] and premorbid functioning in BD patients are sparse. The present study addressed the role of premorbid functioning [assessed with the Premorbid Adjustment Scale (PAS)], intelligence, course of illness, and sociodemographics on occupational outcome in BD.

METHODS

Bipolar disorder patients were recruited consecutively from psychiatric units (outpatient and inpatient) in four major hospitals in Oslo, Norway [(N = 226: 64.4% bipolar I disorder (BD-I); 30.1% bipolar II disorder (BD-II); 5.5% bipolar disorder not otherwise specified (BD-NOS); 38.6% males]. The associations between current IQ, premorbid IQ [assessed using the National Adult Reading Test (NART)], PAS, clinical and sociodemographic characteristics, and receipt of disability benefit were analysed using descriptive statistics and logistic regression analyses.

RESULTS

The number of hospitalizations for depressive episodes and illness duration was associated with a higher risk of receipt of disability benefit. PAS, premorbid and current IQ, as well as decline in IQ, did not explain the higher risk of receipt of disability benefits.

CONCLUSIONS

Severe clinical course of BD was associated with receipt of disability benefit. Occupational outcome was unrelated to PAS, premorbid and current IQ, as well as decline in IQ. This suggests that the persistence of severe clinical symptoms, rather than global cognitive functioning, determines occupational outcome in BD and emphasizes the protective potential of early and continuous clinical treatment.

Premorbid impairments in early-onset psychosis: differences between patients with schizophrenia and bipolar disorder

BACKGROUND

Despite the large body of research on premorbid impairments in schizophrenia, studies comparing different early-onset psychoses are scarce.

AIMS

To examine premorbid impairments in first episodes of early-onset bipolar and schizophrenia disorders.

METHOD

We compared premorbid adjustment and other premorbid variables such as IQ and developmental abnormalities in a cohort of children and adolescents (N=69) with bipolar disorder (BP) or schizophrenia (SZ) experiencing their first psychotic episode and in a healthy control group (N=91).

RESULTS

Schizophrenia patients showed more social impairment in childhood than bipolar patients (p<0.05) and healthy controls (p<0.001) and had higher rates of developmental abnormalities (p<0.05) than healthy controls. Between childhood and early adolescence, schizophrenia and bipolar patients showed a greater decline in academic adjustment than healthy controls, more specifically in adaptation to school (p<0.01).

CONCLUSIONS

Early-onset schizophrenia patients show more early social impairment than early-onset bipolar patients. Intellectual premorbid abnormalities are less specific and probably more linked to early-onset psychosis.

Spanish validation of the Premorbid Adjustment Scale (PAS-S)

BACKGROUND

The Premorbid Adjustment Scale (PAS) has been the most widely used scale to quantify premorbid status in schizophrenia, coming to be regarded as the gold standard of retrospective assessment instruments.

AIMS

To examine the psychometric properties of the Spanish version of the PAS (PAS-S).

METHOD

Retrospective study of 140 individuals experiencing a first episode of psychosis (n=77) and individuals who have schizophrenia (n=63), both adult and adolescent patients. Data were collected through a socio-demographic questionnaire and a battery of instruments which includes the following scales: PAS-S, PANSS, LSP, GAF and DAS-sv. The Cronbach's alpha was performed to assess the internal consistency of PAS-S. Pearson's correlations were performed to assess the convergent and discriminant validity.

RESULTS

The Cronbach's alpha of the PAS-S scale was 0.85. The correlation between social PAS-S and total PAS-S was 0.85 (p<0.001); while for academic PAS-S and total PAS-S it was 0.53 (p<0.001). Significant correlations were observed between all the scores of each age period evaluated across the PAS-S scale, with a significance value less than 0.001. There was a relationship between negative symptoms and social PAS-S (0.20, p<0.05) and total PAS-S (0.22, p<0.05), but not with academic PAS-S. However, there was a correlation between academic PAS-S and general subscale of the PANSS (0.19, p<0.05). Social PAS-S was related to disability measures (DAS-sv); and academic PAS-S showed discriminant validity with most of the variables of social functioning. PAS-S did not show association with the total LSP scale (discriminant validity).

CONCLUSION

The Spanish version of the Premorbid Adjustment Scale showed appropriate psychometric properties in patients experiencing a first episode of psychosis and who have a chronic evolution of the illness. Moreover, each domain of the PAS-S (social and academic premorbid functioning) showed a differential relationship to other characteristics such as psychotic symptoms, disability or social functioning after onset of illness.

Diagnostic specificity of poor premorbid adjustment: comparison of schizophrenia, schizoaffective disorder, and mood disorder with psychotic features

Individuals with schizophrenia have significant deficits in premorbid social and academic adjustment compared to individuals with non-psychotic diagnoses. However, it is unclear how severity and developmental trajectory of premorbid maladjustment compare across psychotic disorders. This study examined the association between premorbid functioning (in childhood, early adolescence, and late adolescence) and psychotic disorder diagnosis in a first-episode sample of 105 individuals: schizophrenia (n=68), schizoaffective disorder (n=22), and mood disorder with psychotic features (n=15). Social and academic maladjustment was assessed using the Cannon-Spoor Premorbid Adjustment Scale. Worse social functioning in late adolescence was associated with higher odds of schizophrenia compared to odds of either schizoaffective disorder or mood disorder with psychotic features, independently of child and early adolescent maladjustment. Greater social dysfunction in childhood was associated with higher odds of schizoaffective disorder compared to odds of schizophrenia. Premorbid decline in academic adjustment was observed for all groups, but did not predict diagnosis at any stage of development. Results suggest that social functioning is disrupted in the premorbid phase of both schizophrenia and schizoaffective disorder, but remains fairly stable in mood disorders with psychotic features. Disparities in the onset and time course of social dysfunction suggest important developmental differences between schizophrenia and schizoaffective disorder.

Using latent class growth analysis to form trajectories of premorbid adjustment in schizophrenia

Premorbid adjustment varies widely among individuals with schizophrenia and has been shown to bear significantly on prodrome and onset characteristics, and on cognition, symptoms, and functioning after onset. The current analysis focused on the Premorbid Adjustment Scale, a retrospective measure assessing social and academic function at several time points from early childhood to illness onset. In an effort to explore discrete developmental subtypes, we applied latent class growth analysis to data from the Premorbid Adjustment Scale in our sample of individuals with schizophrenia (N = 208), finding three latent trajectory classes. The first of these classes showed consistently adequate-to-good social and academic functioning before onset; the second showed initially good function and deterioration with time until onset; the third showed poor functioning in childhood that deteriorated further during the years up to diagnosis. The classes differed significantly in terms of age of onset, processing speed, and functioning after onset. There were no significant differences in symptomatology. Our findings illustrate a potentially powerful methodological approach to the problem of heterogeneity in schizophrenia research, and add weight to the notion that aspects of premorbid history may be useful for subtyping schizophrenia patients. The potential implications of this subtyping strategy, including those pertaining to potential genetics studies, are discussed.

Social disability at admission for a first psychosis does not predict clinical outcome at 5-year follow-up

Although it has often been reported that premorbid social deficits are associated with clinical outcome in schizophrenia, the association between clinical outcome and social disabilities during admission for a first psychosis is still unclear. We examined whether a detailed assessment of social disability (assessed using the Groninger Social Disabilities Schedule-II) in the month before admission for a first psychotic episode contributed to the prediction of disease outcome in terms of psychopathology in 82 patients with schizophrenia. After controlling for the Positive and Negative Syndrome Scale sum score at baseline, none of the social disability domains significantly predicted the number of relapses or the severity of clinical symptoms at a 5-year follow-up. Our results suggest that poor social functioning at admission does not necessarily predict poor disease outcome. Following Di Michele and Bolino (Psychopathology 37:98-104, 2004), we hypothesize that, to reliably predict the course of schizophrenia, it may be necessary to assess social functioning during clinical stabilization.

Factors involved in the level of functioning of patients with schizophrenia according to latent variable modeling

PURPOSE

This study aimed at using latent variable modelling to explore the significantly contributing variables to functioning in schizophrenia patients.

METHODS

The study cohort comprised 296 schizophrenia patients evaluated once for demographic characteristics, functioning (FROGS, SWN-K, QLS) and symptomatology (Positive and Negative Syndrome Scale [PANSS]). First exploratory multivariate analyses were conducted and then a model with functioning as a latent variable was proposed and tested with the data.

RESULTS

Symptomatology as negative, cognitive and excitation factor are significant predictors of functioning assessed through FROGS (P<0.0001), SWN-K and QLS (P<0.001). The model was constructed with functioning defined as a latent variable, indicators are subscores on FROGS, SWN-K, QLS and exogenous variable included symptomatology, Duration of Untreated Psychosis (DUP) and educational level.

CONCLUSION

Using the five clinical dimensions of the PANSS, (Positive, Negative, Cognitive, Anxiety/Depression and Excitation) the negative and cognitive dimensions are highly correlated via the latent variable to the three dimensions of functioning evaluated by the FROGS: "daily life", "social functioning" and "treatment" and the QLS subscores (interpersonnal, common object, instrumental role). Educationnal level is positively linked to functioning but not DUP. The model emphasizes the need for treatment strategies that have an effect on cognitive-factors, to improve functioning in schizophrenia.

Talking about Life after Early Psychosis: The Impact on Occupational Performance

Background. In early psychosis, the phase of illness and developmental stage pose unique challenges to recovery and provision of services. Insight into subjective experience is needed to achieve optimal outcomes.

Purpose. To understand the complex ways that early psychosis affects occupational performance.

Methods. Phenomenology and occupational life history were used to explore lived experience of occupational performance with five participants. Three interviews with each person focused on life before, during, and following illness onset.

Findings. Qualitative analysis identified eight themes describing how psychosis is experienced as a lifelong phenomenon, how changes in occupational performance occur as life unfolds around the acute episode, and how participants move ahead with their lives.

Implications. Integration of developmental frameworks, focus on productive roles, and thoughtful application of client-centred practice emerge as issues with important practice implications as individuals develop awareness of disability and strive to maintain control over occupational choices and, ultimately, their lives.

Predictors of recovery from psychosis Analyses of clinical and social factors associated with recovery among patients with first-episode psychosis after 5 years

INTRODUCTION

This paper aims to investigate the predictors of good outcome after first-episode non-affective psychosis and the clinical and social trajectories of those that recover.

METHODS

A cohort of 255 patients with first-episode non-affective psychosis was interviewed 5 years after first diagnosis and treatment. Recovery was defined as working or studying, having a GAF-function score of 60 or above, having remission of negative and psychotic symptoms, and not living in a supported housing facility or being hospitalized during the last 2 years before the five-year follow-up interview.

RESULTS

A total of 40 (15.7%) were found to be recovered, and 76 (29.8%) had a job or were studying after 5 years. Of those working, as many as 20 still had psychotic symptoms. Also notable is that out of the 40 recovered, less than half were recovered after 2 years. Recovery after 5 years was predicted by female sex (OR 2.4, 95% CI 1.0-5.8), higher age (OR 0.91, 95% CI 0.83-0.99), pre-morbid social adaptation (OR 0.72, 95% CI 0.56-0.93), growing up with both parents (OR 2.6, 95% CI 1.0-6.8) and low level of negative symptoms (OR 0.51, 95% CI 0.33 to 0.77) at baseline.

DISCUSSION

Our findings suggest that a stable social life with normal social functioning has a predictive value for good outcome. These measures might be influenced by negative symptoms, but in the multivariate analysis with negative symptoms included they have an independent effect. Also our findings suggest that, after first-episode psychosis, some patients can still experience psychotic symptoms, but have a job and a fairly stable life.

Environmental factors and social adjustment as predictors of a first psychosis in subjects at ultra high risk

BACKGROUND

The onset of schizophrenia is associated with genetic, symptomatic, social and environmental risk factors. The aim of the present study was to determine which environmental factors may contribute to a prediction of a first psychotic episode in subjects at Ultra High Risk (UHR) for developing psychosis.

METHOD

We included 72 UHR subjects and followed them over a period of 36 months, of whom nineteen (26.4%) made a transition to psychosis. We applied survival analyses to determine associations between a transition to psychosis and environmental factors and social adjustment. To determine which items are the best predictors of transition to a first psychotic episode, Cox Regression analyses were applied.

RESULTS

Urbanicity, receiving state benefits and poor premorbid adjustment (PMA) significantly influenced the transition to psychosis. Urbanicity (Wald=10.096, p=.001, HR=30.97), social-sexual aspects (Wald=8.795, p=.003, HR=1.91) and social-personal adjustment (Wald=10.794, p=.001, HR=4.26) appeared to be predictors for developing psychosis in our UHR group.

CONCLUSIONS

Environmental characteristics and social adjustment are predictive of transition to a psychosis in subjects at UHR. These characteristics should be implemented in a model for prediction of psychosis. Such a model would be more specific than current models and may lead to patient-specific preventive interventions.

Outcome measurement in chronic mental illness

This review begins with an outline of outcome measurement in the country where it has been most thoroughly implemented, namely Australia. There follows a consideration of what constitutes an outcome in mental illness generally, and chronic mental illness in particular. Some instruments, such as the Health of the Nation Outcome Scales (HoNOS), focus primarily on illness severity, and examples of their use in the area of chronic mental illness are presented. Other instruments, such as the Life Skills Profile (LSP), assess personal functioning or disability, and that literature is reviewed. One major area of attention in the chronically mentally ill is quality of life. Another fruitful approach to assessing outcome is to look at needs, especially unmet needs, for which the leading instrument is the Camberwell Assessment of Need; relevant findings are reviewed. The most recent area of interest is recovery. While several scales have been developed, there are as yet relatively few reports of their application with patients with chronic mental illness. The concluding section considers the benefits and weaknesses of using the same standard instruments with all consumers within a service, and shows the utility of outcome results in groups and individuals with generally small overall changes.

Is poor premorbid functioning a risk factor for suicide attempts in first-admission psychosis?

BACKGROUND

While poor premorbid functioning is associated with poorer outcomes in psychotic illnesses, little is known about whether it is also a risk factor for suicide attempts.

OBJECTIVE

The current study examined the association of premorbid functioning and suicide attempts in a county-wide cohort of first-admission inpatients.

METHOD

Data were derived from participants of the Suffolk County Mental Health Project (n=444) over the course of 48-month follow-up. Premorbid functioning was estimated and categorized (good vs. poor/declining) using the Premorbid Adjustment Scale (PAS).

RESULTS

Poorer premorbid functioning was significantly associated with increased likelihood of a suicide attempt prior to first psychiatric hospital admission. Specifically, 33.0% of participants with poor/declining premorbid functioning had a history of suicide attempts compared to 23.5% with good premorbid functioning. Among participants with a prior attempt (n=126), poor premorbid functioning was significantly associated with an increased likelihood of additional attempts during the four years after first hospitalization.

CONCLUSION

Identifying those with poor premorbid functioning and prior histories of attempts could help clinicians target high-risk patients. Thus, greater attention to persons with both risk factors may form the basis for early interventions aimed towards reducing the risk for subsequent suicide attempts.

Pathways to functional outcomes in schizophrenia: the role of premorbid functioning, negative symptoms and intelligence

BACKGROUND

Social and intellectual premorbid functioning are generally estimated retrospectively, and related to clinical or hospitalization outcomes in schizophrenia. Yet the relationship between premorbid functioning assessed prior to psychiatric hospitalization and postmorbid functional outcomes has not been examined.

OBJECTIVES

To test competing models of the relationship between (a) functional outcomes with (b) premorbid functioning assessed on nationally administered tests prior to psychiatric hospitalization, postmorbid intellectual functioning and symptomatology using a historical prospective design.

METHODS

Ninety one inpatient and outpatient males with schizophrenia or schizoaffective disorder, aged 19 to 35, were examined using the Positive and Negative Syndrome Scale, the WAIS-III and Strauss and Carpenter social and occupational functional outcome scale. Premorbid intelligence and social functioning data were obtained from national standardized tests administered during high school prior to first hospitalization for schizophrenia.

RESULTS

Path modeling showed that premorbid intelligence and behavioral functioning directly predicted postmorbid IQ and negative symptoms, and indirectly predicted postmorbid social and occupational functioning via negative symptoms. Item level analysis indicated that better social and occupational outcomes occurred in a group with few negative symptoms.

CONCLUSIONS

Premorbid functioning, postmorbid IQ and negative symptoms are related, yet the relationship between premorbid functioning and postmorbid functional outcomes appears to be mediated by postmorbid negative symptoms.

Premorbid adjustment: a phenotype highlighting a distinction rather than an overlap between schizophrenia and bipolar disorder

BACKGROUND

Premorbid adjustment (PMA) in schizophrenia (SZ) has been widely studied and shown to be worse in individuals who develop SZ as compared to controls. It has been proposed as a predictor of clinical presentation and outcome, and may delineate a specific SZ phenotype for genetic and other biological studies. Research into PMA in BD has been scarce and inconclusive.

AIMS

The authors compared PMA in individuals suffering from BD with that of healthy controls and investigated whether levels of PMA in BD patients correlate with specific phenotypic features.

METHODS

The authors investigated 344 BD patients and 137 population-based controls. Retrospective PMA assessment was performed using the Premorbid Adjustment Scale (PAS). An overall score as well as sub-scores for age ranges and functional domains were obtained.

RESULTS

Patients had a better overall PAS score than controls and outperformed controls during early and late adolescence. They scored significantly better than controls in the functional domains "sociability and withdrawal" and "adaptation to school". No differences were observed for the other subscales and there were no differences between groups during childhood. No association was observed between PMA and any of the phenotype characteristics investigated.

CONCLUSIONS

In the largest study to date on PMA in BD, PMA was shown to be better in bipolar patients than in healthy controls. PMA in BD is not a simple proxy for commonly studied phenotypic markers of severity. PMA emerges as a phenotype in its own right, and highlights an aspect of disparity rather than overlap between SZ and BD.

Premorbid functioning of patients with first-episode nonaffective psychosis: a comparison of deterioration in academic and social performance, and clinical correlates of Premorbid Adjustment Scale scores

BACKGROUND

Motivated by a previous study among male veterans [Allen, D.N., Frantom, L.V., Strauss, G.P., van Kammen, D.P., 2005. Differential patterns of premorbid academic and social deterioration in patients with schizophrenia. Schizophr. Res. 75, 389-397], the present analysis examined: (1) patterns of premorbid academic and social functioning during childhood, early adolescence, and late adolescence, and (2) associations between these premorbid functioning dimensions and a number of clinical variables.

METHODS

Data on premorbid functioning were collected using the Premorbid Adjustment Scale (PAS) in 95 hospitalized first-episode patients. Analyses were similar to those conducted by Allen and colleagues (2005).

RESULTS

Deterioration was evident in both academic and social functioning from childhood to early adolescence, along with a pronounced/accelerated deterioration in academic functioning from early adolescence to late adolescence, occurring in both male and female patients. Age at onset of prodromal symptoms was predicted by childhood/early adolescent/late adolescent academic functioning scores, and age at onset of psychotic symptoms was significantly associated only with childhood academic functioning. Severity of negative symptoms was predicted by childhood and late adolescent social functioning scores, and severity of general psychopathology symptoms was predicted by late adolescent academic functioning, as well as childhood and late adolescent social functioning scores.

CONCLUSIONS

Consistent with prior findings, deterioration in premorbid functioning appears to be more pronounced in the academic than social dimension of the PAS. Some PAS scores are predictive of ages at onset of prodrome/psychosis and severity of psychotic symptoms. Ongoing research on premorbid adjustment in schizophrenia may have implications for future prevention goals.

Validity of the premorbid adjustment scale

BACKGROUND

The aim of the current study was to test the predictive and concurrent validity of the Premorbid Adjustment Scale (PAS) by comparing it with another similar but more elaborate retrospective measure and with data collected during late adolescence.

METHODS

We compared PAS late adolescence scores (age 16-18 years) of 91 males with schizophrenia or schizoaffective disorder with data on behavior collected in adolescence, before the first psychotic episode as part of standardized Draft Board screening, and with the same measure readministered during adulthood and modified to collect the same data again retrospectively.

RESULTS

The correlation of the PAS social withdrawal and social relations items with the social behavior scale of the Draft Board were .76 and .80, respectively, for the concurrent ratings and .52 and .53, respectively, for the data collected at age 17 years. The correlation of the PAS school achievements and school adjustment items with the functioning in structured environments scale of the Draft Board were .71 and .72, respectively, for the concurrent ratings and .43 and .47, respectively, for the data collected at age 17 years.

CONCLUSIONS

Our results support the predictive and concurrent validity of the PAS and the validity of self-reported data on premorbid functioning in persons with schizophrenia.

Evaluating Psychosocial Interventions in First-Episode Psychosis

Little is known about what influences the success of psychosocial interventions for first-episode psychosis. One possible explanation for the mixed results of clinical trials is the influence of confounders on outcome. Psychosocial functioning prior to the onset of psychosis (premorbid adjustment) is one possible confounder. In order to examine the importance of premorbid adjustment to occupational therapists providing and evaluating psychosocial interventions, this study compared the baseline characteristics and premorbid adjustment of the people with first-episode psychosis referred to psychosocial rehabilitation with those of the people not referred, and the outcomes of both groups.

All people with first-episode psychosis (n = 171) were assessed at baseline, including their premorbid adjustment. The participants were followed up 4 years later. A subgroup (n = 44) had been referred to psychosocial rehabilitation. The baseline presentation, premorbid adjustment and outcomes (symptoms and functioning) at 4 years of both groups were compared.

The results showed that the people referred to a psychosocial rehabilitation programme had a poorer premorbid adjustment and fewer years in education than those not referred. Unsurprisingly, those not referred had better outcomes 4 years after initial presentation. It was concluded that premorbid psychosocial functioning is influential in determining the likelihood of referral to psychosocial rehabilitation and can influence evaluations of psychosocial interventions.

Premorbid adjustment, symptom development and quality of life in first episode psychosis: a systematic review and critical reappraisal

OBJECTIVE

To systematically review the relationship of premorbid adjustment to symptomatology in first episode psychosis (FEP), taking into account the influence of duration of untreated psychosis (DUP).

METHOD

Electronic databases were searched to identify relevant studies.

RESULTS

A variety of approaches to the reporting of premorbid adjustment were identified. There was no significant association between premorbid adjustment and DUP, supporting the proposition that they are independent constructs. The effect of premorbid adjustment upon positive symptomatology was negligible. Premorbid adjustment had a modest effect upon negative symptoms and quality of life, increasing over duration of follow-up.

CONCLUSION

Premorbid adjustment remains a valid construct in the study of FEP. Both premorbid adjustment and DUP confer independent effects on aspects of symptomatology in FEP. Results for premorbid adjustment are similar to previous findings in more chronic samples. The potential for conceptualizing premorbid functioning by developmental, academic/social and typological approaches is currently underexploited.

The promise of early intervention

The focus of this review is the research and clinical work in early psychosis and early intervention which over the past 10-15 years has had a tremendous impact on the field of schizophrenia. Unparalleled progress has been made in programme and service development with a wide range of reported research results, outcome studies, treatment approaches and new initiatives. Traditional areas are being explored in the first episode that can add to our knowledge of schizophrenia. New areas that have a specific relevance for early intervention such as the duration of untreated psychosis and pathways to care are being widely studied. Despite the criticism of the lack of randomized controlled trials, there is a wealth of positive outcome from both effectiveness studies and limited controlled trials. However, there are still many unanswered issues which are in developing stages or which require further investigation.

Premorbid adjustment in schizophrenia--an important aspect of phenotype definition

Schizophrenia is a heterogeneous disorder, and early signs of disorder such as poor premorbid adjustment (PMA) are often present before the onset of diagnosable illness. Differences in PMA between patients may be suggestive of differing aetiological pathways. Poor PMA in schizophrenia has repeatedly been reported to be associated with male sex, earlier age at onset, illness severity, negative symptoms, and poor outcome. Studies of schizophrenia patients systematically assessed for PMA have used small patient samples and have rarely used controls.

OBJECTIVE

To investigate possible correlations of PMA, as measured with the Cannon-Spoor Premorbid Adjustment Scale (PAS), with such meaningful clinical characteristics as sex, age at onset, negative symptoms etc. using one of the largest samples of schizophrenia inpatients as well as controls characterised for PMA to date.

METHOD

PMA, diagnosis and lifetime symptoms were assessed in 316 inpatients with schizophrenia and 137 population based controls using the PAS and the Structured Clinical Interview for DSM.

RESULTS

Controls demonstrated better PAS scores than inpatients with schizophrenia. Earlier age at onset and negative symptoms were found to be associated with poorer PAS scores. There was no difference in PAS ratings between males and females in patients with schizophrenia. Among the control probands, females showed significantly better PAS scores than males.

CONCLUSION

PAS scores are worse in individuals who eventually develop schizophrenia, and the distribution of these scores among schizophrenia inpatients is correlated with specific clinical features. Earlier findings, which had reported an association with age at onset and negative symptoms in small patient samples, were substantiated. The widely reported association of poor PMA with male sex, if genuinely present, does not appear to be disease specific. Our findings suggest that PMA is in itself a valuable phenotype characteristic and that it may represent a specific biological phenotype which may be of value in sub-sample selection.

The child and adolescent first-episode psychosis study (CAFEPS): design and baseline results

OBJECTIVE

The child and adolescent first-episode psychosis study (CAFEPS) is a multicenter, two-year, longitudinal project aiming to evaluate different clinical, neuropsychological, neuroimaging, biochemical, immunological, and genetic variables and treatment and prognostic factors in these patients. This paper describes the methods and rationale behind the study and the general characteristics of the sample.

METHOD

At six different centers, from March 2003 through November 2005, we consecutively recruited 110 patients, ages 9-17 years, who presented with a first psychotic episode. Controls were recruited from the same geographic areas and were matched for gender and age.

RESULTS

Patients had lower socioeconomic status (SES) (p=0.018) and parental years of education (p<0.001) than controls. The percentage of patients recruited increased with age (p<0.001) and there was a higher percentage of males (p<0.001). The total mean PANSS score was 89.03+/-20.1, the positive score 23.8+/-6.5 and the negative score 20.02+/-8.8. There were no significant differences between the genders with respect to age, parental years of education, SES, or scores in premorbid adjustment or general functioning. There were statistically significant positive correlations between age and positive symptoms and between all PANSS subscales and the Disability Assessment Schedule, and negative correlations between positive symptoms and global functioning. Diagnoses after the baseline evaluation were: psychotic disorder not otherwise specified (NOS) 35.5%, schizophreniform disorder 24.5%, mood disorder with psychotic symptoms 22.7%, schizophrenia 10%, schizoaffective disorder 2.7%, and other psychotic disorders 4.5%. Patients had worse premorbid adjustment (p<0.001) and global functioning (p<0.001) than controls after controlling for SES.

CONCLUSIONS

Infancy and adolescence adjustment and global functioning are lower in children and adolescents with psychotic disorders than in controls, severity of symptoms are related to general disability, and the most frequent diagnoses are psychotic disorders NOS.