Maternity in women with schizophrenia and schizoaffective disorder

PURPOSE

Maternity rates in women with schizophrenia have tripled in the past decades, with a current percentage similar to the general population (50-60%). However, mothers with schizophrenia present higher rates of single marital status, and social dysfunction than the general population. In addition, the incidence of unplanned pregnancy, abortions, miscarriages and obstetric complications is higher. This study aimed to describe variables related to maternity in this population.

METHODS

One-hundred and ninety-two outpatient women diagnosed with schizophrenia and schizoaffective disorders were included (DSM-IV-TR criteria) in a two-site study. Psychosocial risk factors, demographic variables and clinical features were recorded in the same visit. Non-parametric tests were used in order to describe variables for likelihood offspring in psychotic women.

RESULTS

One-hundred and forty-seven (76.6%) women suffered from schizophrenia and 45 (23.4%) schizoaffective disorder. Psychotic mothers used to be married/having a partner and presented a later onset of the illness (over 36 years old) compared to non-mothers. In addition, mothers generally presented pregnancy before the onset of illness. Regarding obstetric complications, around the 80% of the sample presented at least one obstetric complication. Although desire or wish of pregnancy was reported in 66.3% of the mothers, rates of planned pregnancy were 25% and only the 47.9% were currently taking care of their children with their husband/partner.

CONCLUSION

Maternity rate is high in this population. This study highlights the need to promote reproductive health care for women with mental disorders and to consider their reproductive life plan. Later onset of disease and being married are potential predictors of maternity in our sample of women with a schizophrenia and schizoaffective disorders while only the half were caring their children at the moment of the evaluation.

Association between free thyroxine levels and clinical phenotype in first-episode psychosis: a prospective observational study

Aim

To determine whether thyroid hormone levels are associated with a specific clinical phenotype in patients with first-episode psychosis (FEP).

Methods

Ninety-eight inpatients experiencing FEP and with less than 6 weeks of antipsychotic treatment were included in the study and were followed up for one year. Baseline psychiatric evaluation included assessment of prodromal symptoms, positive and negative symptoms, depressive symptoms, stressful life events and cycloid psychosis criteria. Thyroid function (thyroid-stimulating hormone (TSH) and free thyroxin (FT4)) was determined at admission. Partial correlation analysis was conducted to analyse the correlation between levels of TSH/FT4 and symptoms. Logistic regression was performed to explore the association between psychopathological symptoms, 12-month diagnoses and thyroid hormones while adjusting for covariates.

Results

Patients with prodromal symptomatology showed lower baseline FT4 levels (OR = 0.06; p = 0.018). The duration of untreated psychosis (DUP) was inversely associated with FT4 concentrations (r =  - 0.243; p = 0.039). FEP patients with sudden onset of psychotic symptoms (criteria B, cycloid psychosis) showed higher FT4 levels at admission (OR = 10.49; p = 0.040). Patients diagnosed with affective psychotic disorders (BD or MDD) at the 12-month follow-up showed higher FT4 levels at admission than patients diagnosed with nonaffective psychosis (schizophrenia, schizoaffective) (OR = 8.57; p = 0.042).

Conclusions

Our study suggests that higher free-thyroxine levels are associated with a specific clinical phenotype of FEP patients (fewer prodromal symptoms, shorter DUP duration and sudden onset of psychosis) and with affective psychosis diagnoses at the 12-month follow-up.

Schizoaffective disorder in homeless patients: A systematic review

BACKGROUND

Schizoaffective psychosis is a severe and chronic psychiatric disorder defined by the presence of mood symptoms, like mania and/or depression and schizophrenia, such as hallucinations and/or delusions.

AIMS

We aim to find out whether there is a correlation between schizoaffective psychosis and being homeless.

METHOD

To do so, a literature search was carried out in the PubMed platform in April 2022, using the keywords 'schizoaffective' and 'homeless'.

RESULTS

In this review, 28 articles from this search were included. Intrinsic characteristics, rates of psychiatric readmission, prediction of homelessness, medication noncompliance, and substance use were explored, as they were the main themes of the results.

CONCLUSIONS

The homeless population suffers from great diagnostic variability and the diagnosis schizoaffective psychosis is still evolving contributing to such diagnostic and treatment difficulties. Their frequent visits to the healthcare services, especially emergency room leads to consequent interaction with multiple healthcare professionals, resulting in a myriad of diagnoses, with clinical remission and therapeutic goals not being attained. More studies are necessary for a better evaluation of this super difficult population.

Impairments in goal-directed action and reversal learning in a proportion of individuals with psychosis

Cognitive impairment in psychosis is one of the strongest predictors of functional decline. Problems with decision-making processes, such as goal-directed action and reversal learning, can reflect cortico-striatal dysfunction. The heterogenous symptoms and neurobiology observed in those with psychosis suggests that specific cognitive phenotypes may reflect differing causative mechanisms. As such, decision-making performance could identify subgroups of individuals with more severe cortico-striatal dysfunction and help to predict their functional decline. The present work evaluated the relationship between goal-directed action, reversal learning, and symptom profiles in those with psychosis. We assessed decision-making processes in healthy controls (N = 34) and those with persistent psychosis (N = 45), subclassifying subjects based on intact/impaired goal-directed action. Compared with healthy controls (<20%), a large proportion (58%) of those with persistent psychosis displayed impaired goal-directed action, predicting poor serial reversal learning performance. Computational approaches indicated that those with impaired goal-directed action had a decreased capacity to rapidly update their prior beliefs in the face of changing contingencies. Impaired decision-making also was associated with reduced levels of grandiosity and increased problems with abstract thinking. These findings suggest that prominent decision-making deficits, indicative of cortico-striatal dysfunction, are present in a large proportion of people with persistent psychosis. Moreover, these impairments would have significant functional implications in terms of planning and abstract thinking.

Clozapine in patients with schizoaffective disorder: A systematic review

Schizoaffective disorder is defined by the appearance of positive psychotic symptomatology as well as affective features, even when it is considered a controversial nosologic entity, proving difficult to accord on its definition or diagnostic criteria. Due to these conceptual differences, it has been a challenge to study effective therapeutic measures and, consequently, the availability of data in the current literature, resulting in the extrapolation of clinical guidelines and recommendations initially established for patients with schizophrenia or bipolar disorder. The current study aimed to systematically search and summarize the published evidence to date about the use of clozapine in patients with schizoaffective disorder. Seven studies were identified, that are heterogeneous on their designs and methodology, including samples of patients mixed with bipolar or schizophrenic disorders. The evidence was summarized both in a table and a narrative fashion, suggesting that clozapine may be an effective treatment for both psychotic and affective symptoms, indistinctively of an acute or maintenance phase.

Clozapine in patients with schizoaffective disorder: A systematic review

Schizoaffective disorder is defined by the appearance of positive psychotic symptomatology as well as affective features, even when it is considered a controversial nosologic entity, proving difficult to accord on its definition or diagnostic criteria. Due to these conceptual differences, it has been a challenge to study effective therapeutic measures and, consequently, the availability of data in the current literature, resulting in the extrapolation of clinical guidelines and recommendations initially established for patients with schizophrenia or bipolar disorder. The current study aimed to systematically search and summarize the published evidence to date about the use of clozapine in patients with schizoaffective disorder. Seven studies were identified, that are heterogeneous on their designs and methodology, including samples of patients mixed with bipolar or schizophrenic disorders. The evidence was summarized both in a table and a narrative fashion, suggesting that clozapine may be an effective treatment for both psychotic and affective symptoms, indistinctively of an acute or maintenance phase.

A case report of acute hypothermia during initial inpatient clozapine titration with review of current literature on clozapine-induced temperature dysregulations

BACKGROUND

Here we describe a unique case of clozapine-associated hypothermia during initial titration of this medication in an acute inpatient psychiatry setting. Only a handful of cases on this topic have been published. We discuss possible pharmacologic mechanisms supporting or refuting the propensity of clozapine to induce hypothermia, as well as risk factors for clozapine-induced hypothermia, and a comparison to clozapine-induced hyperthermia.

CASE PRESENTATION

A 70 year-old African American female with treatment-refractory schizoaffective disorder developed hypothermia with a nadir temperature of 89 °F (31.7 °C) after 7 days on clozapine, on a total dose of 50 mg twice daily. Accompanying symptoms included bradycardia, hypotension, QTc prolongation, tachypnea, hypoxemia, and an absence of shivering. The patient was transferred to the ICU, and rewarmed within 10 h with the discontinuation of her clozapine, ziprasidone, and carvedilol. Broad spectrum antibiotics were initiated, but discontinued shortly after, as the patient had no leukocytosis, and blood cultures were negative.

DISCUSSION

While hypoglycemia, hypothyroidism, sepsis, and stroke were effectively ruled out, alternative drug-disease (including chronic kidney disease), and drug-drug interactions were considered possible contributing features. Benzodiazepines, valproic acid, ziprasidone, and the numerous antihypertensive agents the patient was taking were considered as either primary or compounding factors for hypothermia. After exclusion or inclusion of these alternative causes, we calculated a score of 4 (possible) for clozapine-induced hypothermia on the Naranjo Scale.

CONCLUSIONS

Clozapine-induced hypothermia may occur more commonly than clinicians believe. Practitioners should be cognizant of this potentially fatal phenomenon, and monitor for temperature dysregulations while on clozapine, especially during initial titration, in those with multiple comorbid factors, and on additional medications that may contribute to hypothermia.

The use of long-acting Aripiprazole in a multi-center, prospective, uncontrolled, open-label, cohort study in Germany: a report on global assessment of functioning and the WHO wellbeing index

BACKGROUND

In this non-interventional study, the functionality and well-being of patients with schizophrenia with aripiprazole once-monthly (AOM) was evaluated under real-life conditions in a naturalistic population.

METHODS

This non-interventional, prospective, multicenter 6-month study included 242 predominantly symptomatically stable patients (mean age 43.1 ± 15.1 years, 55% male) who switched their treatment to AOM after 9.7 (± 22.3) months of oral treatment. Outcome parameters included functionality (Global Assessment of Functioning, GAF), patient's wellbeing (WHO-5 Well-Being Index, WHO-5), and both patient's and clinician's assessment of efficacy and tolerability of AOM. Treatment emergent adverse events (TRAE) were also recorded.

RESULTS

At baseline, the mean GAF score was 47.0 (±13.9), indicating that patients experienced serious impairment in functioning. A continuous increase to 60.2 (±17.0) during treatment was found, with a robust and significant increase already after 4 weeks. At study start, patients reported diminished wellbeing, with a mean score of 10.6 (±5.6) on the WHO-5 scale. During treatment, patient wellbeing increased continuously with strong and significant improvements even after 4 weeks and an overall improvement of 4.8 (±6.9) over the course of 6 months with an endpoint of 15.4 (±5.5). Stratification of these results showed that more pronounced effects were achieved in younger patients ≤35 years (p<0.05 for GAF). The effectiveness and tolerability of AOM was rated good/very good by most patients (89.2 and 93.7%) and physicians (91.4 and 96.8%). Only few TRAEs occurred.

CONCLUSIONS

Our results show a significant positive effect after initiation of AOM treatment in predominantly stable patients with schizophrenia on their functioning and wellbeing, which was even more pronounced in patients aged ≤35 years, thereby supporting previous randomized controlled findings under routine conditions in clinical practice.

Autistic symptoms predict social cognitive performance in patients with schizophrenia

Schizophrenia spectrum disorders and Autism Spectrum Disorders (ASD) share many similarities. Among those features, social cognitive impairment is recognized as a key characteristic of both ASD and schizophrenia. In this study, the role of ASD symptoms, measured with the PANSS Autism Severity Score (PAUSS), was investigated as a predictor of social cognitive performance in patients with Schizophrenia spectrum disorders. Existent databases from 2 studies (SCOPE Phase 3 and SCOPE Phase 5), in which a total of 361 patients (mean age 41.7 years; 117 females) were assessed with tests of mental state attribution and emotion recognition, were analyzed. Less severe ASD symptoms, as well as younger age, better premorbid IQ, and neurocognition were identified as individual predictors of better social cognitive performance. These results suggest a role of ASD symptoms in affecting social cognitive performance in schizophrenia.

Visual hallucinations associated with multimodal hallucinations, suicide attempts and morbidity of illness in psychotic disorders

BACKGROUND

Visual hallucinations (VH) are a common, but understudied symptom of psychosis, experienced by individuals across diagnostic categories of psychotic and neuropsychiatric conditions. There are limited data on VH and associated clinical phenotypes in adult idiopathic psychotic disorders, which are needed to elucidate their relevance to psychotic illness paradigms.

METHOD

In this cross-sectional study, we examined clinical risk factors for VH in a well-characterized sample of 766 patients with adult psychotic disorders across diagnostic categories of schizophrenia (n = 227), schizoaffective disorder (n = 210), and bipolar I disorder (n = 329). The Structured Clinical Interview for DSM-IV-TR was used for diagnosis and symptom measurements.

RESULTS

The prevalence of VH was 26.1% (200/766). Multivariate logistic regression showed that VH were independently associated with the presence of hallucinations in other modalities, including auditory, tactile, olfactory, and gustatory hallucinations. History of a suicide attempt and catatonic behavior were also associated with VH. In addition, specific delusions were associated with VH, in particular, delusions of control, and religious, erotomanic and jealousy delusions. Diagnosis, negative symptoms, and family history of psychosis were not independent predictors of VH.

CONCLUSIONS

Results showed the clinical and disease relevance of VH as they were associated with severe morbidity of illness, including suicide attempts and catatonic behavior. Findings also suggest a phenotype associated with hallucinations in other modalities and specific types of delusions. Based on our findings, VH may be a significant factor in assessing for suicidality and illness severity, warranting clinical attention and further study of underlying mechanisms.

Role of tissue plasminogen activator and plasminogen activator inhibitor as potential biomarkers in psychosis

The identification of biological markers for psychosis has an impact on its diagnosis, prognosis, and likelihood of treatment response. Tissue plasminogen activator (tPA) is involved in important functions such as synaptic plasticity, long-term potentiation and neurogenesis. Plasminogen activator inhibitor (PAI-1) is the most important inhibitor of tPA. Preliminary studies have shown that schizophrenia patients have lower tPA and higher PAI-1 levels than the general population. The association of tPA and PAI-1 abnormalities with psychotic spectrum disorders, however, remains elusive. Our primary objective was to assess the plasma levels of tPA and PAI-1 in patients experiencing acute psychotic episodes as compared to those in healthy controls. In this prospective case-control study, we collected peripheral blood samples from psychiatric inpatients and healthy age, gender and race-matched subjects and determined plasma levels of tPA and PAI-1 by enzyme-linked immune-absorbent assays. Plasma levels of PAI-1 in patients with schizoaffective disorder were significantly lower as compared to those in control subjects (P = 0.03). tPA was lower in cases as compared to controls although it did not reach statistical significance. Asian patients and controls had lower PAI-1 levels. Further, Asian patients with schizoaffective disorder had significantly lower PAI-1 level compared to Asian patients with schizophrenia. Our results indicate that patients with schizoaffective disorder have lower PAI-1 levels than those with schizophrenia, affective psychosis, and healthy controls. Further studies are warranted to explore the potential of PAI-1 as a biomarker for diagnosing schizoaffective disorder.

Investigating the effect of climatic parameters on mental disorder admissions

The main objective of this study was to evaluate the role of climatic parameters and phenomena including the monthly number of dusty/rainy/snowy/foggy days, cloudiness (Okta), horizontal visibility, and barometric pressure (millibar) on major depressive disorder, bipolar, schizophrenia, and schizoaffective admissions. The monthly data related to the number of admissions in Farshchian hospital and climatic parameters from March 2005 to March 2017 were extracted. Random forest regression and dynamic negative binomial regression were used to examine the relationship between variables; the statistical significance was considered as 0.05. The number of dusty/rainy/snowy/foggy days, cloudiness, and the number of days with vision less than 2 km had a significant positive relationship with admissions due to schizophrenia (p < 0.05). Barometric pressure had a negative effect on schizophrenia admissions (p < 0.001). The number of dusty/rainy/snowy/foggy days and cloudiness had a significant effect on schizoaffective admissions (p < 0.05). Bipolar admissions were negatively associated with rainy days and positively associated with dusty days and cloudiness (p < 0.05). The number of rainy/dusty/snowy days and cloudiness had a positive significant effect on major depressive disorder admissions. The results of the present study confirmed the importance of climatic parameter variability for major depressive disorder, bipolar, schizophrenia, and schizoaffective admissions.

Effectiveness of aripiprazole once-monthly in schizophrenia patients pretreated with oral aripiprazole: a 6-month, real-life non-interventional study

BACKGROUND

In this study, the treatment of schizophrenia patients with aripiprazole once-monthly (AOM) was evaluated under real-life conditions in a naturalistic setting.

METHODS

This multicenter, prospective, non-interventional study included 242 patients (age = 43.1 ± 15.1 years, 55.0% male) who were monitored during 6 months of AOM treatment. Endpoints included measurements of psychopathology (Brief Psychiatric Rating Scale, BPRS) and severity of illness scales (Clinical Global Impressions-Severity, CGI-S, and -Improvement, CGI-I). Furthermore, treatment-related adverse events (TRAEs) were recorded.

RESULTS

At baseline, the mean BPRS total score was 54.1 ± 15.6, the mean CGI-S was 4.8 ± 0.8 and the most frequent illness category was 'markedly ill' (41.7%). Patients had been pretreated with oral aripiprazole for a mean duration of 9.7 months (SD: 22.3) and 87.9% were deemed by their clinician as "clinically stable" and for a mean of 5.9 months. The difference in global BPRS after 6 months was - 13.8 (SD: 16.0; 95% CI: [- 15.9; - 11.7]; p < 0.001). The proportion of patients with high CGI-S scores decreased and the proportion of patients with low scores increased significantly (p < 0.001, respectively). BPRS scores improved numerically especially well in younger patients ≤35 years, CGI-S scores decreased significantly more in this population. TRAEs were rare, with low incidences of extrapyramidal symptoms (2.9%) or weight increase (0.4%).

CONCLUSIONS

Treatment with AOM showed satisfying effectiveness in outpatients with further improvement of psychopathology after oral aripiprazole treatment for a considerable duration and even after having achieved clinically judged "stability". Our findings indicate a robust therapeutic effect of AOM and substantiate previous results from randomized controlled trials under real-world routine conditions.

Paliperidone palmitate once-monthly maintains improvement in functioning domains of the Personal and Social Performance scale compared with placebo in subjects with schizoaffective disorder

OBJECTIVE

Evaluate the effect of paliperidone palmitate once-monthly (PP1M) injectable on the specific functioning domains of the Personal and Social Performance (PSP) scale in patients with schizoaffective disorder (SCA) participating in a long-term study.

METHODS

This study (NCT01193153) included both in- and outpatient subjects with SCA experiencing an acute exacerbation of psychotic and mood symptoms. Subjects were treated with PP1M either as monotherapy or in combination with antidepressants or mood stabilizers during a 25-week open-label (OL) phase. Stabilized subjects were randomly assigned 1:1 (PP1M or placebo) into a 15-month double-blind (DB) relapse-prevention period. Functioning of the randomized subjects during OL and DB phases was evaluated using the PSP scale (four domains: socially useful activities, personal/social relationships, self-care, and disturbing/aggressive behaviors). Three statistical approaches were utilized to analyze PSP scores to assess robustness and consistency of findings. No adjustments were made for multiplicity.

RESULTS

334 of 667 enrolled subjects were stabilized with PP1M, randomly assigned to PP1M (n=164) or placebo (n=170) in the DB phase, and included in this analysis. Improvements in all PSP domain scores were observed during the OL phase and were maintained during the DB phase with PP1M, but decreased with placebo. Differences compared to placebo were significant in all four PSP domains during the DB phase (P≤0.008).

CONCLUSION

The analysis in this study showed that PP1M improves functioning, as measured by the four PSP domain scores, in symptomatic subjects with SCA. Functioning was maintained compared with placebo.

Dopamine serotonin stabilizer RP5063: A randomized, double-blind, placebo-controlled multicenter trial of safety and efficacy in exacerbation of schizophrenia or schizoaffective disorder

The study objectives were to evaluate the efficacy, safety, tolerability, and pharmacokinetics of RP5063 versus placebo. The study was conducted in adults with acute exacerbation of schizophrenia or schizoaffective disorder. This 28-day, multicenter, placebo-controlled, double-blind study randomized 234 subjects to RP5063 15, 30, or 50mg; aripiprazole; or placebo (3:3:3:1:2) once daily. The aripiprazole arm was included solely to show assay sensitivity and was not powered to show efficacy. The primary endpoint was change from baseline to Day 28/EOT (End-of-Treatment) in Positive and Negative Syndrome Scale (PANSS) total score; secondary endpoints included PANSS subscales, improvement ≥1 point on the Clinical Global Impressions-Severity (CGI-S), depression and cognition scales. The primary analysis of PANSS Total showed improvement by a mean (SE) of -20.23 (2.65), -15.42 (2.04), and -19.21 (2.39) in the RP5063 15, 30, and 50mg arms, versus -11.41 (3.45) in the placebo arm. The difference between treatment and placebo reached statistical significance for the 15mg (p=0.021) and 50mg (p=0.016) arms. Improvement with RP5063 was also seen for multiple secondary efficacy outcomes. Discontinuation for any reason was much lower for RP5063 (14%, 25%, 12%) versus placebo (26%) and aripiprazole (35%). The most common treatment-emergent adverse events (TEAE) in the RP5063 groups were insomnia and agitation. There were no significant changes in body weight, electrocardiogram, or incidence of orthostatic hypotension; there was a decrease in blood glucose, lipid profiles, and prolactin levels. In conclusion, the novel dopamine serotonin stabilizer, RP5063 is an efficacious and well-tolerated treatment for acute exacerbation of schizophrenia or schizoaffective disorder.

Examining Functional Resting-State Connectivity in Psychosis and Its Subgroups in the Bipolar-Schizophrenia Network on Intermediate Phenotypes Cohort

BACKGROUND

We sought to examine resting-state functional magnetic resonance imaging connectivity measures in psychotic patients to both identify cumulative differences across psychosis and subsequently probe deficits across conventional DSM-IV diagnoses and a newly identified classification using cognitive/neurophysiological data (Biotypes).

METHODS

We assessed 1125 subjects, including healthy control subjects, probands (schizophrenia, schizoaffective disorder, psychotic bipolar disorder), and relatives of probands. Probands and relatives were also segregated into Biotype groups (B1-B3, B1R-B3R using a method reported previously). Empirical resting-state functional magnetic resonance imaging networks were derived using independent component analysis. Global psychosis-related abnormalities were first identified. Subsequent post hoc t tests were performed across various diagnostic categories. Follow-up linear mixed model compared significance of within-proband differences across categories. Secondary analyses assessed correlations with biological profile scores.

RESULTS

Voxelwise tests between proband and control subjects revealed nine abnormal networks. Post hoc analysis revealed lower connectivity in most networks for all proband subgroups (DSM and Biotypes). Within-proband effect sizes of discrimination were marginally better for Biotypes over DSM. Reduced connectivity was noted in relatives of patients with schizophrenia in two networks and relatives of patients with psychotic bipolar disorder in one network. Biotype relatives showed similar deficits in one network. Connectivity deficits across four networks were significantly associated with cognitive control profile scores.

CONCLUSIONS

Overall, we found psychosis-related connectivity deficits in nine large-scale networks. Deficits in these networks tracked more closely with cognitive control factors, suggesting potential implications for disease profiling and therapeutic intervention. Biotypes performed marginally better in terms of separating out psychosis subgroups compared with conventional DSM or psychiatric diagnoses.

Callosal Abnormalities Across the Psychosis Dimension: Bipolar Schizophrenia Network on Intermediate Phenotypes

BACKGROUND

The corpus callosum has been implicated in the pathogenesis of schizophrenia and bipolar disorder. However, it is unclear whether corpus callosum alterations are related to the underlying familial diathesis for psychotic disorders. We examined the corpus callosum and its subregion volumes and their relationship to cognition, psychotic symptoms, and age in probands with schizophrenia (SZ), psychotic bipolar disorder (PBD), and schizoaffective disorder; their first-degree relatives; and healthy control subjects.

METHODS

We present findings from morphometric and neurocognitive analyses of 1381 subjects (SZ probands, n = 224; PBD probands, n = 190; schizoaffective disorder probands, n = 142; unaffected relatives, n = 483 [SZ relatives, n = 195; PBD relatives, n = 175; schizoaffective disorder relatives, n = 113]; control subjects, n = 342). Magnetization prepared rapid acquisition gradient-echo T1 scans across five sites were obtained using 3-tesla magnets. Image processing was done using FreeSurfer Version 5.1. Neurocognitive function was measured using the Brief Assessment of Cognition in Schizophrenia scale.

RESULTS

Anterior and posterior splenial volumes were significantly reduced across the groups. The SZ and PBD probands showed robust and significant reductions, whereas relatives showed significant reductions of intermediate severity. The splenial volumes were positively but differentially correlated with aspects of cognition in the probands and their relatives. Proband groups showed a significant age-related decrease in the volume of the anterior splenium compared with control subjects. Among the psychosis groups, the anterior splenium in probands with PBD showed a stronger correlation with psychotic symptoms, as shown by the Positive and Negative Syndrome Scale. All five subregions showed significantly high familiality.

CONCLUSIONS

The splenial volumes were significantly reduced across the psychosis dimension. However, this volume reduction impacts cognition and clinical manifestation of the illnesses differentially.

Does Biology Transcend the Symptom-based Boundaries of Psychosis?

Psychotic disorders, as defined by clinical features alone, overlap considerably in terms of symptoms, familial patterns, risk genes, outcome, and treatment response. As a result, numerous neurobiological measurements fail to distinguish patients with the most prevalent classic psychotic syndromes. Statistical methods applied to such biological measurements in large numbers of patients with psychosis yield novel categories that cut across traditional diagnostic boundaries. Such new classification approaches within psychosis hopefully represent an opportunity to transcend clinical phenomenologically defined syndromes in psychiatry with neurobiologically defined diseases that can advance drug discovery and support precision medicine approaches in psychiatry.

The relationship between cognitive insight and quality of life in schizophrenia spectrum disorders: Symptom severity as potential moderator

Cognitive insight is implicated in the formation and maintenance of hallucinations and delusions. However, it is not yet known whether cognitive insight relates to broader outcome measures like quality of life. In the current study, we investigated whether the component elements of cognitive insight-self-certainty and self-reflectiveness-were related to quality of life for 43 outpatients with schizophrenia or schizoaffective disorder. Cognitive insight was assessed using the Beck Cognitive Insight Scale (BCIS) while quality of life was assessed with Quality of Life Scale (QLS). We tested whether this relationship was moderated by clinical insight and symptom severity using the Scale to Assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). We found that self- reflectiveness had an unmoderated positive relationship with quality of life. Self-certainty was associated with better quality of life for people with more severe symptoms. Theoretical and clinical implications of these findings are discussed and areas of future research are proposed.

Visual and associated affective processing of face information in schizophrenia: A selective review

Perception of facial features is crucial in social life. In past decades, extensive research showed that the ability to perceive facial emotion expression was compromised in schizophrenia patients. Given that face perception involves visual/cognitive and affective processing, the roles of these two processing domains in the compromised face perception in schizophrenia were studied and discussed, but not clearly defined. One particular issue was whether face-specific processing is implicated in this psychiatric disorder. Recent investigations have probed into the components of face perception processes such as visual detection, identity recognition, emotion expression discrimination and working memory conveyed from faces. Recent investigations have further assessed the associations between face processing and basic visual processing and between face processing and social cognitive processing such as Theory of Mind. In this selective review, we discuss the investigative findings relevant to the issues of cognitive and affective association and face-specific processing. We highlight the implications of multiple processing domains and face-specific processes as potential mechanisms underlying compromised face perception in schizophrenia. These findings suggest a need for a domain-specific therapeutic approach to the improvement of face perception in schizophrenia.

A dimensional comparison between delusional disorder, schizophrenia and schizoaffective disorder

INTRODUCTION

Since the early description of paranoia, the nosology of delusional disorder has always been controversial. The old idea of unitary psychosis has now gained some renewed value from the dimensional continuum model of psychotic symptoms.

AIMS

1. To study the psychopathological dimensions of the psychosis spectrum; 2. to explore the association between psychotic dimensions and categorical diagnoses; 3. to compare the different psychotic disorders from a psychopathological and functional point of view.

MATERIAL AND METHODS

This is an observational study utilizing a sample of some 550 patients with a psychotic disorder. 373 participants had a diagnosis of schizophrenia, 137 had delusional disorder and 40 with a diagnosis of schizoaffective disorder. The PANSS was used to elicit psychopathology and global functioning was ascertained using the GAF measure. Both exploratory and confirmatory factor analyses of the PANSS items were performed to extract psychopathological dimensions. Associations between diagnostic categories and dimensions were subsequently studied using ANOVA tests.

RESULTS

5 dimensions - manic, negative symptoms, depression, positive symptoms and cognitive - emerged. The model explained 57.27% of the total variance. The dimensional model was useful to explained differences and similarities between all three psychosis spectrum categories. The potential clinical usefulness of this dimensional model within and between clinical psychosis spectrum categories is discussed.

A common risk variant in CACNA1C supports a sex-dependent effect on longitudinal functioning and functional recovery from episodes of schizophrenia-spectrum but not bipolar disorder

Sex is a powerful modulator of disease susceptibility, course and outcome. The gene CACNA1C is among the best replicated vulnerability genes of bipolar disorder and schizophrenia. The aim of the present study was to investigate whether sex and a variant in CACNA1C (rs10774035 as a proxy for the well-acknowledged risk variant rs1006737) influence psychosocial adaptation in a large German patient sample with schizophrenia-spectrum (n=297) and bipolar (n=516) disorders. We analyzed Global Assessment of Functioning (GAF) scores, retrospectively collected for different time points during disease course. We investigated whether CACNA1C sex-dependently modulates longitudinal GAF scores and recovery from episodes of psychiatric disturbance in the above mentioned disorders. Psychosocial recovery was measured as difference score between the current GAF score (assessing the last remission) and the worst GAF score ever during an illness episode. Covariate- adjusted association analyses revealed a sex × rs10774035 genotype interaction on longitudinal GAF and recovery from illness episodes only in schizophrenia-spectrum but not in bipolar disorders. In schizophrenia-spectrum affected males, rs10774035 minor allele (T) carriers had higher GAF scores at three time points (premorbid, worst ever, current). In contrast, females carrying rs10774035 minor alleles had impaired recovery from schizophrenia-spectrum episodes. These results encourage further investigations of gene × sex interactions and longitudinal quantitative phenotypes to unravel the rich variety of behavioral consequences of genetic individuality.

Assessing the contribution of borderline personality disorder and features to suicide risk in psychiatric inpatients with bipolar disorder, major depression and schizoaffective disorder

Suicidal behavior often accompanies both borderline personality disorder (BPD) and severe mood disorders, and comorbidity between the two appears to further increase suicide risk. The current study aims to quantify the risk of suicidality conferred by comorbid BPD diagnosis or features in three affective disorders: major depressive disorder (MDD), bipolar disorder (BP) and schizoaffective disorder. One hundred forty-nine (149) psychiatric inpatients were assessed by SCID I and II, and the Columbia Suicide Severity Rating Scale. Logistic regression analyses investigated the associations between previous suicide attempt and BPD diagnosis or features in patients with MDD, BP, and schizoaffective disorder, as well as a history of manic or major depressive episodes, and psychotic symptoms. Comorbid BPD diagnosis significantly increased suicide risk in the whole sample, and in those with MDD, BP, and history of depressive episode or psychotic symptoms. Each additional borderline feature also increased risk of past suicide attempt in these same groups (excepting BP) and in those with a previous manic episode. Of the BPD criteria, only unstable relationships and impulsivity independently predicted past suicide attempt. Overall, among patients with severe mood disorders, the presence of comorbid BPD features or disorder appears to substantially increase the risk of suicide attempts.

Pre-morbid fertility in psychosis: findings from the AESOP first episode study

Individuals with psychotic illnesses are known to have a reduced fertility. It is unclear whether this is due to biological or social factors. Most fertility studies have been conducted in chronic schizophrenia, where confounders like medication and hospitalisation make this difficult to elicit. A less severe reduction of fertility has been observed in some ethnic minorities, but results are inconsistent. We sought to investigate pre-morbid fertility in an ethnically diverse sample of individuals with first-onset psychosis. Data were derived from 515 people with a first psychotic episode (FEP) and 383 controls. We made case-control comparisons of differences in the proportion of those with children (fertility rates) and mean number of children (MNC). Analyses were then stratified by diagnosis, gender and ethnicity, and adjusted for potential confounders. We found that FEP showed a reduced fertility rate (age-adjusted OR of having children 0.47 [95% CI=0.39, 0.56]), irrespective of diagnosis, and there was little evidence of confounding by gender, ethnicity, religious background, education level, or history of past relationships (fully adjusted OR=0.55, 95% CI=0.37, 0.80). Women had a somewhat greater reduction in fertility rates than men (Men: age-adjusted OR 0.61 [95% CI 0.42, 0.89]; Women: age-adjusted OR 0.46 [95% CI 0.31, 0.69]) and we could not find any evidence of ethnic differences in the degree of fertility reduction. FEP who had previously experienced a stable relationship had an MNC that was comparable to that of the general population and had a later onset of illness. This is the largest case-control study to date to investigate fertility in first-onset psychosis. Our data suggests that fertility is affected, even prior to the onset of a psychotic illness, and there are likely to be biological and environmental factors involved, but the former seem to have a stronger influence.

Logic and justification for dimensional assessment of symptoms and related clinical phenomena in psychosis: relevance to DSM-5

Work on the causes and treatment of schizophrenia and other psychotic disorders has long recognized the heterogeneity of the symptoms that can be displayed by individuals with these illnesses. Further, researchers have increasingly emphasized the ways in which the severity of different symptoms of this illness can vary across individuals, and have provided evidence that the severity of such symptoms can predict other important aspects of the illness, such as the degree of cognitive and/or neurobiological deficits. Additionally, research has increasingly emphasized that the boundaries between nosological entities may not be categorical and that the comorbidity of disorders may reflect impairments in common dimensions of genetic variation, human behavior and neurobiological function. As such, it is critical to focus on a dimensional approach to the assessment of symptoms and clinically relevant phenomena in psychosis, so as to increase attention to and understanding of the causes and consequences of such variation. In the current article, we review the logic and justification for including dimensional assessment of clinical symptoms in the evaluation of psychosis in the Fifth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5).

Neuropsychological functioning predicts community outcomes in affective and non-affective psychoses: a 6-month follow-up

INTRODUCTION

Neurocognitive dysfunction is a major symptom feature of schizophrenia and bipolar disorder. A prognostic relationship between cognition and community outcomes is well-documented in schizophrenia and increasingly recognized in bipolar disorder. However, specific associations among neurocognition, diagnosis, state symptomatology, and community functioning are unclear, and few studies have compared these relationships among patients with affective and non-affective psychoses in the same study. We examined neurocognitive, clinical, and community functioning in a cross-diagnostic sample of patients with psychotic disorders over a 6-month follow-up interval.

METHOD

Neurocognitive, clinical and community functioning were assessed in participants with schizophrenia (n=13), schizoaffective disorder (n=17), or bipolar disorder with psychosis (n=18), and healthy controls (n=18) at baseline and 6months later.

RESULTS

Neurocognitive functioning was impaired in all diagnostic groups and, despite reductions in primary symptoms, did not recover on most measures over the follow-up period. Neurocognitive impairment was not associated with diagnosis or clinical improvement. Several neurocognitive scores at baseline (but not diagnosis or clinical baseline or follow-up scores) predicted community functioning at follow-up.

DISCUSSION

In one of the few studies to longitudinally examine neurocognition in association with clinical and outcomes variables in a cross diagnostic sample of psychotic disorders patients, neurocognitive deficits were pronounced across diagnoses and did not recover on most measures despite significant reductions in clinical symptoms. Baseline neurocognitive functioning was the only significant predictor of patients' community functioning six months later. Efforts to recognize and address cognitive deficits, an approach that has shown promise in schizophrenia, should be extended to all patients with psychosis.