Intellectual functioning in adolescents with indicators of psychosis: evidence for decline in functioning related to number of psychotic features?

Substantial research has demonstrated that adults with schizophrenia display intellectual decline compared to their premorbid levels of functioning. Research of this type, however, is not as common in adolescents with psychotic disorders. Since many first-episode adolescents with psychotic disorders other than schizophrenia may eventually meet criteria for this diagnosis, we examined first admission adolescents with variable psychiatric diagnoses. In this study, current intellectual functioning was compared to estimated premorbid functioning (estimated with word recognition reading), and the difference between these scores was related to the number of indicators of psychosis that was present in each case. Subjects consisted of 513 inpatients, ranging in age from 13 to 17 years, who were admitted to the adolescent service of a private psychiatric hospital. Indicators of psychosis came from clinical diagnoses, self-report measures, and clinical rating scales. Across the entire sample of 513 subjects the greater the number of indicators of psychosis that was present, the greater the estimated premorbid/current intelligence quotient (IQ) discrepancy. Type of IQ test, differences in intellectual premorbid functioning, demographic variables, and type of treatment were all unassociated with risk for IQ discrepancy. Within the limitations of estimation of premorbid intellectual functioning, these data suggest that intellectual decline is present at the time of the first psychiatric admission in psychotic adolescent patients who do not necessarily meet diagnostic criteria for schizophrenia and that this discrepancy is greater in patients with more indicators of psychosis.     

Premorbid performance IQ deficit in schizophrenia

OBJECTIVE: Performance IQ (PIQ) is often lower than verbal IQ (VIQ) in schizophrenic patients. Whether PIQ < VIQ precedes psychotic symptoms in schizophrenia remains uncertain. METHOD: We investigated premorbid IQ scores in 63 subjects assessed at a child and adolescent psychiatric unit (mean age 13.1 years, SD 3.2), who at follow-up in adulthood (mean age 30.9 years, SD 3.9) received a lifetime RDC diagnosis of schizophrenia-related psychosis, affective disorder, or no psychiatric disorder. RESULTS: Premorbid PIQ < VIQ significantly differentiated the groups with schizophrenia-related psychosis and no psychiatric disorder. Subjects with schizophrenia-related psychosis had a significantly lower mean value for premorbid PIQ, but not VIQ, compared to subjects who developed affective disorder or subjects without psychiatric disorder. CONCLUSION: Our results emphasize premorbid intellectual deficits in schizophrenia. Those deficits might largely be in consequence of an impairment on the PIQ scale.     

Neurological signs and cognitive performance distinguish between adolescents with and without psychosis

Neurological and cognitive aspects of adolescent psychotic disorders are understudied. The authors assessed 19 adolescents with psychosis and 16 healthy comparison subjects using the Neurological Evaluation Scale (NES) and age-appropriate Wechsler intelligence quotient (IQ) scales. NES scores were highest and IQ scores were lowest among subjects with psychosis. Subjects with psychosis did not demonstrate age-related decreases in NES score. The combination of NES and IQ scores predicted both the presence of psychosis and psychiatric diagnosis. There were no relationships between medication status and either NES or IQ scores. These results support a broadly conceived neurodevelopmental formulation of adolescent psychotic disorders.     

Six-year outcomes in first admission adolescent inpatients: clinical and cognitive characteristics at admission as predictors

Persistent functional disability is common after even a single psychiatric admission in people with schizophrenia or bipolar disorder, but less is known about other conditions and about adolescent onset patients. This study examined clinical symptoms and cognitive performance at the time of the first admission for the prediction of 6-year outcomes. First admission adolescent patients with a variety of psychiatric diagnoses were assessed with comprehensive clinical ratings of psychopathology, a neuropsychological assessment, and received clinical diagnoses while experiencing their first psychiatric admission. They were contacted 6 years after discharge and examined with a structured assessment of psychiatric symptoms and functioning. Despite the low levels of overall impairment at follow-up, at least 20% of the variance in depression, psychosis, poor peer relationships and poor school attendance 6 years after the hospital admission were predicted by information collected during the hospitalization. Attentional deficits during admission predicted the presence of psychosis at follow-up more substantially than psychotic symptoms during admission, as well as predicting risk for relapse. Attentional deficits during a first psychiatric admission predicted risk for manifesting psychosis at 6-year follow-up to a more substantial degree than either a psychosis diagnosis or psychotic symptoms at admission. In contrast to psychosis, depression at follow-up was predicted by admission symptomatology, but not by cognitive deficits.     

IQ stabilization in childhood-onset schizophrenia

OBJECTIVE: To examine the long term IQ trajectory for childhood-onset schizophrenia (COS) in an expanded, prospective longitudinal study. METHODS: Seventy children meeting DSM criteria for schizophrenia were tested at 2 year intervals with age appropriate Wechsler intelligence tests and repeated administration of information and comprehension WISC subtests even after age 18. For a subgroup with 31 patients, pre-NIH IQ test administrations were available including 18 pre-psychotic and 13 post-psychotic subjects. The pattern of IQ performance over time was determined using mixed model regression analysis. RESULTS: No progressive cognitive decline was seen up to 13+ years post psychosis onset. For the subgroup of subjects with pre-illness scores, there had been an initial steep decline in IQ, from about 2 years prior to 1.7 years after onset of psychotic symptoms, as reported for adult patients. CONCLUSIONS: The level long-term trajectory of IQ measures in COS appears stable, similar to that reported for adult onset patients. For COS, level cognitive functioning extends up to 13+ years post psychosis onset, in spite of chronic illness and concomitant, progressive loss of cortical gray matter.     

Risk factors for the emergence of psychotic disorders in adolescents with 22q11.2 deletion syndrome

OBJECTIVE: The 22q11.2 deletion syndrome is the most common known genetic risk factor for the development of schizophrenia. The authors conducted a longitudinal evaluation of adolescents with 22q11.2 deletion syndrome to identify early risk factors for the development of psychotic disorders. METHOD: Sixty children, 31 with 22q11.2 deletion syndrome and 29 comparison subjects with idiopathic developmental disability matched for age and IQ, underwent a baseline evaluation between 1998 and 2000; of these, 51 children (28 and 23 in the two groups, respectively) underwent follow-up evaluation between 2003 and 2005. A standardized comprehensive psychiatric, psychological, and adaptive functioning evaluation was conducted in both waves. Participants with 22q11.2 deletion syndrome were also genotyped for the catechol O-methyltransferase (COMT) Met/Val polymorphism and underwent magnetic resonance imaging scans. RESULTS: The two groups had similar baseline neuropsychiatric profiles. At follow-up, 32.1% of subjects with 22q11.2 deletion syndrome had developed psychotic disorders as compared with 4.3% of comparison subjects. In the 22q11.2 deletion syndrome group, baseline subthreshold psychotic symptoms interacted both with the COMT genotype and with baseline symptoms of anxiety or depression to predict 61% of the variance in severity of psychosis at follow-up evaluation. Lower baseline verbal IQ was also associated with more severe psychotic symptoms at follow-up evaluation. CONCLUSIONS: Genetic, cognitive, and psychiatric risk factors for the evolution of psychotic disorders in 22q11.2 deletion syndrome during adolescence were identified. Early intervention in the subgroup of children with subthreshold signs of psychosis and internalizing symptoms (especially anxiety symptoms) may reduce the risk of developing psychotic disorders during adolescence.     

Duration of untreated psychosis and neuropsychological function in first episode psychosis

PURPOSE: We investigated whether duration of untreated psychosis (DUP) prior to first presentation was associated with cognitive function in first episode psychosis (FEP) subjects. We predicted that longer DUP would be associated with greater neurocognitive impairment. METHOD: 180 subjects with schizophrenia (and 93 subjects with Other Psychoses) performed a neurocognitive battery assessing IQ, verbal learning, working memory, visual learning and speed of processing. DUP was defined as the number of days between first onset of psychotic symptoms and first contact with psychiatric services. RESULTS: Longer DUP was associated with impaired performance in verbal IQ (p=0.04), verbal learning (p=0.02), and verbal working memory (p=0.04) in FEP subjects with schizophrenia. These associations remained significant for verbal IQ when scores were corrected for age, gender, educational level and ethnicity. CONCLUSIONS: Longer DUP is associated with poorer neurocognitive ability in schizophrenia subjects at time of first presentation. Since this was a cross-sectional study we can not tell whether longer DUP was a cause or a consequence of the poorer performance.     

A comparative profile analysis of neuropsychological functioning in patients with schizophrenia and bipolar psychoses.

Evidence for neuropsychological deficits in schizophrenia is substantial whereas evidence for the specificity of dysfunction is relatively sparse. To assess specificity, we compared neuropsychological function in patients with chronic schizophrenia, patients with chronic psychotic bipolar disorder and normal controls. Groups were comparable on age, ethnicity and expected intellectual ability (based on single word reading). Patients with schizophrenia and bipolar psychoses were also relatively similar on age at onset and number of hospitalizations. Using multivariate analyses of variance with sex and parental SES as covariates (our primary analyses), patients with schizophrenia were significantly more impaired than controls on seven of eight neuropsychological functions (all but verbal ability), and were significantly more impaired than bipolar patients on abstraction, perceptual-motor speed and vigilance. Bipolar patients were significantly impaired compared to controls on declarative verbal memory, and showed moderate-to-large effect size decrements on abstraction, perceptual-motor speed and vigilance. Results were not attenuated when IQ was controlled, which was significantly lower in patients with schizophrenia. Analyses indicated that the two psychiatric groups had similar profile patterns, but that patients with schizophrenia had a more severe impairment than patients with bipolar psychoses. Further research is required to determine whether similar mechanisms underly the neurocognitive deficits in these disorders.     

Patients with methamphetamine psychosis admitted to a psychiatric hospital in Japan

To examine the clinical characteristics of methamphetamine (MAP) psychosis in Japan, we evaluated 104 patients with MAP psychosis (80 men and 24 women) admitted to the closed psychiatric units of Tokyo Metropolitan Matsuzawa Hospital between 1988 and 1991. There has recently been a steep increase in the number of admissions for MAP psychosis, reflecting the growth of the epidemic of MAP abuse in Japan. Although more than half of the patients were discharged within one month, 16 patients were hospitalized for more than 3 months. Most of the patients showed paranoid psychotic state similar to schizophrenia, consistent with previous reports. Despite the abstinence from MAP and antipsychotic medication, psychotic symptoms tended to persist in some of the patients. The etiological role of MAP psychosis in the development of long-lasting psychotic state was discussed.     

A follow-up study of a child psychiatric clientele with special regard to the diagnosis of psychosis

A 20-year follow-up of a child psychiatric clientele of 322 patients demonstrates that nearly one third have been admitted to psychiatric departments or mental hospitals in adulthood. One tenth belonged to the group with psychoses either as a child or grown-up. While the incidence of manic-depressive psychosis did not differ from a normal population of the same sex and age, the child psychiatric clientele is overrepresented by psychotic patients later on diagnosed as schizophrenia. The outcome of infantile psychosis was in half of the cases chronic psychosis; five of 10 psychosis proto-infantilis patients were diagnosed schizophrenia in adulthood. This result is not in accordance with the modern view that psychosis proto-infantilis is a special disease with no clinical connection to schizophrenia. The clinical entity of infantile psychosis and borderline psychosis seems to be affirmed by a common clinical and diagnostic course into borderline psychosis or schizoid character disorders. Nine patients with psychosis in adulthood did not belong to the group of psychosis in childhood.     

Executive function in schizophrenia: is it linked to psychosis and poor life functioning?

The authors examined the relationship of major aspects of executive function to acute psychosis and long-term outcome in patients enrolled in a 15-year study of the natural history of psychosis. They evaluated 157 patients, including 42 schizophrenic, 42 other psychotic, and 73 nonpsychotic psychiatric patients 15 years after index hospitalization. Patients were administered the Wisconsin Card Sorting Test (WCST) and measures of psychosis and posthospital adjustment. Schizophrenia patients performed significantly worse than both nonschizophrenic psychiatric control groups on WCST indices, regardless of psychosis. Aspects of executive function were impaired in schizophrenia patients with severe deficits in their level of overall functioning and outcome and also in many with only moderate impairment in overall functioning; however, these deficits were seen to a greater degree in schizophrenia patients with very poor overall functioning. Executive function deficits appear to be a core component of schizophrenia rather than an effect of acute psychotic disorganization, and are associated with long-term outcome.     

Neuropsychological functioning in first-break, never-medicated adolescents with psychosis

The purpose of the current study was to examine neuropsychological functioning in a group of never-medicated first-break adolescents with psychosis. It is the first report of cognition in a sample of adolescents with psychosis in which all patients were drug-naive. Twenty-nine adolescent patients (mean age = 16.07; SD = 2.00; 15 male and 14 female patients) experiencing their first psychotic episode and 17 age-matched and sex-matched normal volunteers (mean age = 16.88; SD = 2.39; 9 male and 8 female subjects) were recruited and assessed with a neuropsychological battery. Measures of attention, memory, language, executive functioning, perceptual motor processing, and motor speed were obtained. Psychiatric symptomatology, estimated verbal IQ, and parental socioeconomic status were also determined. Patients with psychosis were significantly more impaired than normal volunteers; effect sizes were greatest in the areas of executive functioning, attention, and memory, and significantly smaller in areas of language, perceptual motor processing, and motor speed. The pattern was not altered when differences in verbal IQ and parental socioeconomic status were controlled. Sex and age interactions indicated that younger male patients were particularly impaired. The findings demonstrate neuropsychological deficits in adolescents with psychosis and suggest that cognitive deficits are core symptoms in psychotic disorders.     

Olfactory deficits, cognition and negative symptoms in early onset psychosis

BACKGROUND: Smell identification deficits (SID) are common in adult schizophrenia, where they are associated with negative symptoms and lower intelligence. However, smell identification has not been examined in adolescents with early onset psychosis, wherein diagnosis is often obscure, and there are few prognostic predictors. METHOD: We examined smell identification, diagnosis, neuropsychological performance and symptoms in 26 well characterized adolescents with early onset psychosis, age 11-17 years. RESULTS: SID existed in the sample and were more common in patients with schizophrenia and psychotic depression than in patients with psychosis NOS and bipolar disorder. As in adults, SID were significantly associated with greater negative symptoms and lower verbal IQ. However, the associations of verbal IQ (and other verbal tasks) to smell identification in this pediatric sample were explained by the relation of both of these types of variables to negative symptoms. CONCLUSIONS: SID existed across this sample of youths with psychotic disorder, and were specifically related to typical characteristics of schizophrenia, such as negative symptoms and lower intelligence, but not to features of bipolar disorder, such as grandiosity. SID is a characteristic of early onset psychosis that may be useful for prognostic purposes.     

Nonschizophrenic psychotic disorders: the case of cycloid psychoses

BACKGROUND: Cycloid psychosis is a psychiatric disorder known for about 100 years. This disorder is at present partly and simplified represented in the ICD-10. SAMPLING AND METHODS: Over a period of 15 months, 139 consecutively acutely admitted psychotic patients were assessed, by means of different diagnostic instruments, in order to investigate the prevalence and the symptom profile of cycloid psychoses. In addition, the concordance between the diagnoses cycloid psychosis, brief psychotic disorder, and acute polymorphic psychotic disorder with or without symptoms of schizophrenia was calculated. RESULTS: Cycloid psychoses were present in 13% of the patients. There was a significant but small overlap with the DSM brief psychotic disorder and the ICD acute polymorphic psychotic disorder. CONCLUSIONS: This study demonstrates that cycloid psychoses can be identified with the proper diagnostic instruments in a proportion that is also found in other studies. Since this type of psychosis entails a distinct prognosis and may require a specific treatment, its identification is of clinical importance. Limitations are the nature of the psychiatric facility with an inherent bias in the selection of patients and the lack of a long-term evaluation.     

Narcolepsy presenting as schizophrenia: a literature review and two case reports

Schizophrenia is a psychiatric disorder that causes significant disability and morbidity. Narcolepsy is a disorder, less prevalent than schizophrenia, but a disorder in which symptoms overlap with schizophrenia. This overlap in symptoms can cause narcolepsy to be confused with schizophrenia. The differences and similarities between narcolepsy and schizophrenia are discussed in the context of two cases. The first case describes an adolescent and the second case describes a refractory case of narcolepsy that did not respond to stimulants. Both cases were previously diagnosed as schizophrenia and did not respond to trials of antipsychotics and other psychotropics. The patients were reevaluated and referred to sleep testing at our facility for clinical suspicion of narcolepsy. Both patients underwent polysomnography with subsequent multiple sleep latency testing. The sleep testing results and multiple sleep latency testing criteria for narcolepsy are also discussed. The patients were treated for narcolepsy resulting in remission of the psychotic symptoms with significant behavioral improvement. We recommend that psychiatrists consider narcolepsy in the differential diagnosis when faced with refractory psychosis.     

What is schizophrenia?

Summary The psychotic syndrome at the core of schizophrenia appears to be invariable across cultures. The risk of morbidity also seems to vary very little from country to country and over medium periods of time. Moreover, apart from gender differences in first onset, the cumulative lifetime risk is the same in females and males. A similar epidemiological pattern is only found in pathological conditions that are characterized by a precisely defined section of a psychopathological dimension with a continuous distribution in the population, e.g. severe mental retardation being the extreme section of normally distributed IQ values. The interpretation of schizophrenic psychosis as the extreme section of a psychopathological dimension or disposition that is almost evenly distributed in all populations is supported by the fact that milder psychiatric disorders occur more frequently before the onset of the psychosis and in close relatives of schizophrenic patients. The psychopathological heterogeneity of these disorders argues against the assumption of a manifest psychopathological dimension with a continuous transition from the schizophrenic psychosis to the normal schizothymic personality. More probable is a continuously distributed latent vulnerability to schizophrenia — with or without a threshold effect — which in severe degrees disposes to the uniform reaction pattern of the schizophrenia syndrome. Smaller degrees of vulnerability are associated with an increased risk for milder patterns of disturbances, which are also more strongly determined by environment and personality and therefore are rather heterogeneous. These assumptions lead to other epidemiological and genetic models than Kraepelin's early concept of a disease entity does.     

Sibling Characteristics and Early Onset Psychoses Among the Young Adolescent Patient Population

We investigated the relationship between sibling characteristics (birth order, number of siblings and birth interval) and early onset psychosis among adolescent psychiatric inpatients and their mentally healthy controls. A short birth interval of 1–2 years to the nearest sibling was more common among adolescents with schizophrenia and schizophrenia spectrum psychoses and differed significantly from healthy controls (p = 0.037). A large family (at least 6 children in family) was more common among adolescents with psychosis NOS than among healthy controls (p = 0.035). The birth order among young adolescents with any subtype of psychosis did not differ from healthy controls. Sibling characteristics may be contributing factors in the multifactorial aetiology of schizophrenia and other psychotic disorders. Further studies are required to determine whether sibling characteristics reflect other unknown environmental factors.     

Basic symptoms, temperament and character in adolescent psychiatric disorders

Objective: Basic symptoms are early subtle changes in thinking, feeling and perception that are subjectively experienced and precede the onset of a psychotic illness. In adult samples, high basic symptom scores are regarded as specific risk factors for the development of schizophrenia. The aim of this study was to explore the relevance of basic symptoms of psychiatric disorders in adolescent patients with special focus on early detection of psychosis. Furthermore, the association between basic symptoms and personality traits has been investigated. METHOD: From 89 adolescents, who were consecutive inpatients with different psychiatric disorders in 1995 and 1997, 54 were followed up 4.7 years later. Patients were examined with the Bonn Scale for the Assessment of Basic Symptoms at the time of the first presentation and follow-up. Additionally, personality traits were assessed at follow-up using the Junior Temperament and Character Inventory. RESULTS: None of the subjects made the transition to schizophrenia, despite high baseline scores of basic symptoms at the initial assessment. Indirect minus symptoms were found to be the most valid predictor of a persisting psychiatric diagnosis. In addition, this specific category was strongly associated with the personality traits harm avoidance and self-directedness. CONCLUSION: In adolescents, basic symptoms in association with personality traits present as a nonspecific indicator of psychopathology rather than as an indicator of vulnerability to schizophrenia.