Premorbid adjustment and remission of positive symptoms in first-episode psychosis

The impact of premorbid social and intellectual functioning in childhood and early adolescence on the developmental course of schizophrenia is not sufficiently understood. In a retrospective case study (93 consecutive in-patients, 43 males and 50 females) of first-episode psychosis occurring in adolescence, the relationship between premorbid adjustment and short-term therapeutic outcome under treatment conditions was examined. All of the patients had a DSM-111-R diagnosis of schizophrenia (n=56) or schizoaffective disorder (n=37). The mean age of the patients at the time of the study was 15.8 (SD=1.0). Premorbid functioning during childhood and early adolescence was assessed by using the Cannon-Spoor et al. Premorbid Adjustment Scale (PAS) and studied with respect to its prognostic relevance for short-term therapeutic outcome (eight weeks) under neuroleptic treatment (350–700 mg Chlorpromazin dose equivalent). Criteria for clinical outcome were obtained from the study by Pearlson et al. (1989) which defines three grades (complete remission, partial remission and no response), according to the degree of positive symptomatology. Statistical analysis was based on nonparametric variance analysis. Patients with complete remission of positive symptoms after eight weeks of therapy had experienced far better premorbid adjustment in early adolescence and in childhood. Diagnosis and gender did not bias this result. Our data suggest that premorbid social functioning is a crucial variable with regard to therapeutic outcome in first-episode psychosis. Previous studies have reported a relation between poor premorbid functioning and negative symptoms. We found premorbid adjustment related to the course of positive symptoms.     

A 12-month outcome study of insight and symptom change in first-episode psychosis

Aim: We first aimed to evaluate the progression of insight and psychopathology over the first year of treatment for a psychosis. We hypothesized that improvement in insight would associate with improvement in positive and negative symptoms, and depressive and anxious symptom exacerbation. Secondly, in an exploratory analysis, we aimed to identify quantitatively distinct insight trajectory groups, and to describe the impact of psychopathology over time on the different trajectory groups. Methods: One-hundred and sixty-five patients were administered a comprehensive clinical evaluation, and insight was rated on the Scale for Assessment for Unawareness of Mental Disorder, item 1 (awareness of mental disorder), at admission and after 1, 2, 3, 6, 9 and 12 months. Results: In a generalized estimating equation (GEE) model of change, insight improved concurrently with positive, negative and anxious symptoms between baseline and month 1 in the entire cohort. Latent group-based trajectory analysis revealed five insight groups: good, increasing, decreasing, moderate poor and very poor. GEE modelling revealed that the very poor and moderate poor insight groups displayed greater overall negative symptoms than patients with good and increasing insight trajectories. The good insight group showed significantly greater overall depressive symptoms than the diminished and very poor insight groups. Conclusions: The results suggest that specific longitudinal insight trajectories were driving the observed associations between insight and negative and depressive symptoms in the entire first-episode psychosis cohort. Persistently poor insight may be an important factor in negative symptom maintenance. Good or increasing course of insight may be early clinical indicators of a liability to depression.     

首发精神病患者快感缺失水平与认知功能的关系

目的 探讨首发精神病患者快感缺失水平及其与认知功能的关系,分析其认知功能的影响因素.方法 选取2016年12月-2019年3月在广州医科大学附属脑科医院就诊的符合《精神障碍诊断与统计手册(第5版)》(DSM-5)诊断标准的首发精神病患者143例.采用阳性和阴性症状量表(PANSS)评定患者的精神症状,以其中N2情绪退缩...     

Proportion and predictors of remission and recovery in first-episode psychosis: Systematic review and meta-analysis

BackgroundTo determine the proportion of patients in symptomatic remission and recovery following a first-episode of psychosis (FEP).MethodsA multistep literature search using the Web of Science database, Cochrane Central Register of Reviews, Ovid/PsychINFO, and trial registries from database inception to November 5, 2020, was performed. Cohort studies and randomized control trials (RCT) investigating the proportion of remission and recovery following a FEP were included. Two independent researchers searched, following PRISMA and MOOSE guidelines and using a PROSPERO protocol. We performed meta-analyses regarding the proportion of remission/recovery (symptomatic plus functional outcomes). Heterogeneity was measured employing Q statistics and I² test. To identify potential predictors, meta-regression analyses were conducted, as well as qualitative reporting of studies included in a systematic review. Sensitivity analyses were performed regarding different times of follow-up and type of studies.ResultsOne hundred articles (82 cohorts and 18 RCTs) were included in the meta-analysis. The pooled proportion of symptomatic remission was 54% (95%CI [30, 49–58]) over a mean follow-up period of 43.57 months (SD = 51.82) in 76 studies. After excluding RCT from the sample, the proportion of remission remained similar (55%). The pooled proportion of recovery was 32% (95%CI [27–36]) over a mean follow-up period of 71.85 months (SD = 73.54) in 40 studies. After excluding RCT from the sample, the recovery proportion remained the same. No significant effect of any sociodemographic or clinical predictor was found.ConclusionsHalf of the patients are in symptomatic remission around 4 years after the FEP, while about a third show recovery after 5.5 years.     

Exposure to trauma and the clinical presentation of first-episode psychosis in South Africa

Objective

To evaluate the relationship between a history of traumatic experiences and the clinical features of first-episode psychosis (FEP).

Method

We tested associations between trauma variables and duration of untreated psychosis (DUP), age of onset (AO), PANSS-rated positive and negative symptoms and depressive symptoms (Calgary Depression Scale) in a sample of 54 FEP patients.

Results

Mean DUP was 34.4 weeks, while mean AO was 24.7 years. Witnessing a seriously violent assault (49%) was associated with high positive symptoms (p = 0.002), while a significant personal experience of racism and discrimination (39%) was associated with high depressive (p = 0.042) symptoms. Previous sexual assault (44% of females) was associated with high positive (p = 0.028) and negative (p = 0.035) symptoms with a trend association with depressive symptoms (p = 0.092).

Conclusion

Our findings suggest that previous traumatic experience is associated with positive and affective symptoms in FEP.     

Differential associations of cognitive insight components with pretreatment characteristics in first-episode psychosis

An increasing number of studies have focused on cognitive insight (i.e. awareness of one's own thinking) in psychotic disorders. However, little is known about the premorbid and pretreatment correlates of cognitive insight in the early course of psychosis. One hundred and three patients experiencing first-episode psychosis (FEP) were assessed shortly after treatment initiation for cognitive insight. Pretreatment and baseline clinical, functional and neurocognitive characteristics were examined. The self-reflectiveness dimension of cognitive insight was independently associated with clinical insight and executive functioning, whereas self-certainty was associated with premorbid IQ, premorbid academic adjustment and clinical insight. The amount of variance explained by the independent variables was small to moderate. Self-reflectiveness and self-certainty have differential pretreatment correlates in FEP and may reflect separate cognitive processes which require targeted interventions.     

The relationship between family resiliency factors and caregiver-perceived duration of untreated psychosis in persons with first-episode psychosis

Although the family has an important role in the early detection and intervention of first-episode psychosis (FEP), there are few findings reporting associations between family strengths and early treatment-seeking experiences. This study aimed to investigate, within the framework of the resiliency model of family stress, adjustment, and adaptation, the association between family coping strategies, resource management factors and duration of untreated psychosis (DUP) in Iranian families with one adult child with FEP. Hundred and seven individuals referred to three medical centers in Tehran and diagnosed with FEP participated in this study. Caregiver-perceived DUP was measured via semi-structured interviews administered to primary caregivers. They also completed two questionnaires regarding family resources of stress management and family coping strategies. Data analysis indicated that the Family Inventory of Resources of Management (FIRM) total scale score did not significantly explain the variance of caregiver-perceived DUP, but one of the FIRM subscales, the Extended Family Social Support, and the Family Crisis-Oriented Personal Evaluation scale (F-COPES) total score and one its subscales, the Acquiring Social Support, explained a significant amount of the variance of caregiver-perceived DUP. The results suggest that higher family resiliency, especially social support, facilitates the family?s appropriate adaptive reaction (i.e., treatment-seeking), with the consequent decrease of DUP.     

Assessment of empathy in first-episode psychosis and meta-analytic comparison with previous studies in schizophrenia

Empathy is a multidimensional construct that relies on affective and cognitive component processes. A few studies have reported impairments of both cognitive and affective empathy components in patients with schizophrenia. It is, however, not known whether these difficulties are already present at psychosis onset. The affective and cognitive components of empathy were thus assessed in 31 patients with first-episode psychosis (FEP) and 31 matched healthy controls using the Interpersonal Reactivity Index (IRI). Our results were then compared to previous studies of empathy in patients with more chronic schizophrenia via a meta-analysis. In addition, we also assessed the relationship between empathy ratings, Mentalizing performance and clinical symptoms. Contrary to what has been reported in people with more chronic schizophrenia, the IRI ratings did not significantly differ between FEP and controls in our study, though a trend was observed for the Personal distress scale. For the Perspective taking scale, our meta-analysis revealed a significantly lower effect size in this study with FEP patients relative to previous schizophrenia studies. In the FEP group, the IRI ratings were not related to positive, negative or general psychopathology symptoms, but a significant relationship emerged between the Liebowitz Social Anxiety Scale and Perspective taking (negative correlation). In addition, a significant positive correlation was observed between the Empathic concern subscale and our theory of mind task. This study supports the idea that the cognitive component of empathy is less affected in patients with first-episode psychosis relative to patients with more chronic schizophrenia, and the impairments reported in previous reports with more chronic populations should be interpreted in light of a possible deterioration of this cognitive skill. The findings also provide some insight into the relationship between empathy and clinical symptoms such as social anxiety.     

Cortical thickness is associated with poor insight in first-episode psychosis

Through conceptualizing poor insight in psychotic disorders as a form of anosognosia (neurological deficit), frontal lobe dysfunction is often ascribed a vital role in its pathogenesis. Whether non-frontal brain regions are important for insight remains to be investigated. We used a multi-method approach to examine the neural morphometry of all cortical regions for insight in first-episode psychosis. Insight was rated in 79 people with a first-episode psychosis with the awareness of illness and awareness of treatment need and efficacy items of the Scale for assessment of Unawareness of Mental Disorder. Participants were assessed with magnetic resonance imaging. Cortical thickness analysis and voxel-based morphometry were utilized to identify the possible neuroanatomical basis of insight. Cortical thickness technique revealed that poorer awareness of illness was associated with regional thinning in left middle frontal and inferior temporal gyri. Poorer awareness of treatment need and efficacy was associated with cortical thinning in left medial frontal gyrus, precuneus and temporal gyri. No significant associations emerged between any insight measure and gray matter density using voxel-based morphometry. The results confirm predictions derived from the anosognosia/neuropsychology account and assert that regional thickness in frontal cortex is associated with awareness of illness in the early phase of psychosis. The fact that prominent thickness reductions emerged in non-frontal regions of the brain in parietal and temporal cortices for both awareness of illness and awareness of treatment need and efficacy suggests that the neural signature of insight involves a network of brain structures, and not only the frontal lobes as previously suggested.     

Life and treatment goals of individuals hospitalized for first-episode nonaffective psychosis

First-episode psychosis typically emerges during late adolescence or young adulthood, interrupting achievement of crucial educational, occupational, and social milestones. Recovery-oriented approaches to treatment may be particularly applicable to this critical phase of the illness, but more research is needed on the life and treatment goals of individuals at this stage. Open-ended questions were used to elicit life and treatment goals from a sample of 100 people hospitalized for first-episode psychosis in an urban, public-sector setting in the southeastern United States. Employment, education, relationships, housing, health, and transportation were the most frequently stated life goals. When asked about treatment goals, participants' responses included wanting medication management, reducing troubling symptoms, a desire to simply be well, engaging in counseling, and attending to their physical health. In response to queries about specific services, most indicated a desire for both vocational and educational services, as well as assistance with symptoms and drug abuse. These findings are interpreted and discussed in light of emerging or recently advanced treatment paradigms—recovery and empowerment, shared decision-making, community and social reintegration, and phase-specific psychosocial treatment. Integration of these paradigms would likely promote recovery-oriented tailoring of early psychosocial interventions, such as supported employment and supported education, for first-episode psychosis.     

分裂样精神病与精神分裂症阴性、阳性症状比较

目的：探讨分裂样精神病与精神分裂症阴性和阳性症状的特点。方法：对49例分裂样精神病与70例精神分裂症患者的阴性和阳性症状作对照研究。结果：两组患者阳性和阴性症状的发生率差异无显著性（P〉0.05）;分裂样精神病组中有妄想症状者明显多于精神分裂症组;而精神分裂症组中情感平淡、思维贫乏等阴性症状者明显多于分裂样精神病（P〈0.01）。结论：分裂样精神病与精神分裂症在阴性、阳性症状方面存在差异。     

Comparison of generic and disease-specific measures of quality of life in first-episode psychosis

Background

Quality of life (QOL) is now recognised as an important measure of outcome that could potentially influence clinical decision-making for those with a first-episode psychosis (FEP). A number of QOL instruments are available however; many differ in their conceptual orientation which may have serious implications for the outcome of QOL studies, interpretation of findings and clinical utility. We aimed to compare two commonly used tools representing both generic and disease-specific constructs to examine whether both tools appraise the same underlying QOL traits and also whether disease-specific tools retain their psychometric properties when used in FEP groups.

Methods

We assessed 159 consecutive individuals presenting with FEP in a defined catchment area with two commonly used QOL tools and examined the findings using the multi-trait multi-method matrix.

Results

Similarly named domains of QOL between both tools (Psychological Wellbeing, Physical Health, Social Relations) showed good convergent validity using confirmatory factor analysis. However, discriminant validity was not established given that domains loading onto their indicated latent factors were more strongly correlated with their non-corresponding latent factors.

Conclusions

A major consideration in undertaking the present study was to assess the extent to which the outcome of QOL studies in FEP were valid and that systematic error did not provide another plausible explanation for findings. Establishing convergent validity demonstrates that either tool could be used satisfactorily to measure the QOL construct identified however; we did not establish discriminant validity. Doing so would have demonstrated that QOL domains are substantively different in that they contain some unique piece of information determining clinical utility. These findings are important for our understanding of multi-dimensional models of QOL.     

Clinical correlates of maltreatment and traumatic experiences in childhood and adolescence among predominantly African American, socially disadvantaged, hospitalized, first-episode psychosis patients

Associations among maltreatment and traumatic experiences in childhood and adolescence, later substance use, and subsequent mental health outcomes for individuals with schizophrenia-spectrum disorders have been initially explored in previous studies; however, research on these factors in socially disadvantaged patients with first-episode psychosis is unavailable. This exploratory, correlational analysis examined associations between maltreatment and trauma-related variables (e.g., traumatic experiences, parental harsh discipline, violence exposure) and: social variables (years of education attained and extent of Axis IV psychosocial problems at initial hospitalization), substance abuse (age at initiation of alcohol and cannabis use, as well as estimates of lifetime intake of both), and positive and negative symptom severity. Rates of childhood abuse and traumatic events were remarkably high in the sample. Years of educational attainment and number of Axis IV psychosocial problems were substantially correlated with several domains of childhood abuse/traumatic events. Age at initiation of alcohol and cannabis use, and lifetime alcohol and cannabis intake, were correlated with a number of trauma domains. Whereas positive symptom severity was correlated with four of the trauma variables, negative symptom severity was correlated only with prior emotional neglect. These results provide insights into the relations among childhood traumatic events, substance use, and clinical features of first-episode psychosis, creating hypotheses for future research.     

Duration of untreated psychosis may predict acute treatment response in first-episode schizophrenia

There is growing evidence for a relationship between the duration of untreated psychosis (DUP) and the prognosis in schizophrenia. The objective of this study is to evaluate whether DUP and premorbid level of social functioning are related to treatment response in acute treatment of first-episode schizophrenia. Seventy-nine first-episode schizophrenia patients were assessed with BPRS, SAPS, and SANS on admission and discharge during their first hospitalisation. Percentage of the difference between admission and discharge in total scores of all scales were taken as measures of absolute symptom reduction. The median DUP was 6 months (mean=8.6). DUP was correlated with reduction in BPRS and SAPS scores but not SANS scores. Patients with a short DUP (n=41) also showed a higher reduction in BPRS, and SAPS scores than those with a long DUP. Premorbid Adjustment Scale (PAS) scores were inversely correlated with age at onset and positively correlated with BPRS scores at admission. We did not find any relationship between PAS scores and response to treatment. Our findings suggest that DUP may be an important predictor of response in acute treatment of first-episode schizophrenia and thus, attempts for early diagnosis may also have a positive effect on acute treatment response.     

Diagnostic stability of first-episode psychosis and predictors of diagnostic shift from non-affective psychosis to bipolar disorder: a retrospective evaluation after recurrence

Diagnostic changes during follow-up are not uncommon with a first-episode psychosis (FEP). This study aimed to evaluate the diagnostic stability of the FEP and to identify factors associated with a diagnostic shift from non-affective psychosis to bipolar disorder. Considering that the diagnosis of FEP is frequently more definite after recurrence in many clinical settings, a retrospective evaluation after recurrence was preformed. Subjects were 150 patients with psychotic disorders who had been admitted to a psychiatric ward both for first episode and recurrence of their psychosis. Consensus diagnosis was made for each episode through a review of hospital records. Patients diagnosed with non-affective psychoses at the first episode were included in the analysis of predictive factors of a diagnostic shift to bipolar disorder. First-episode diagnoses were revised upon recurrence in 20.7% of patients. The most common change was to bipolar disorder accounting for more than half of all diagnostic changes. Schizophrenia exhibited the highest prospective and retrospective diagnostic consistencies. Female gender, short duration of untreated psychosis, high level of premorbid functioning, and several symptoms including lability, mood elation, hyperactivity, and delusions with religious or grandiose nature were identified as predictive factors for a diagnostic shift from non-affective psychosis to bipolar disorder. Clinical features of psychoses seem to evolve during the disease course resulting in diagnostic changes upon recurrence in a significant portion of FEP. Special consideration on a diagnostic shift to bipolar disorder is required in patients exhibiting the predictive factors identified in the current study.     

Neurocognition and occupational functioning in patients with first-episode psychosis: a 2-year follow-up study

Neurocognitive deficits are a core feature of schizophrenia that is associated with poor occupational functioning. Few studies have investigated this relationship in patients with first-episode psychosis. The current study examined the characteristics of employed and unemployed patients with first-episode psychosis at baseline and 2-year follow-up, and the predictive value of neurocognition on employment status. One-hundred and twenty-two first-episode psychosis patients were assessed with clinical and neurocognitive measures at baseline. Occupational status was assessed at baseline and 2-year follow-up. Those unemployed at baseline were rated lower on global functioning and were more likely to have a schizophrenia spectrum disorder. Total employment rates were 41% at baseline and 38% at 2-year follow-up. Four employment paths emerged at follow-up, defined as persistently employed, becoming unemployed, entering employment and persistently unemployed. The persistently employed group had the highest global functioning score. For the total sample, baseline employment status and sustained attention predicted employment status at follow-up. For those employed at baseline, better sustained attention, higher global functioning, more positive symptoms and less alcohol use predicted persistent employment at follow-up. For those unemployed at baseline, none of the variables predicted change in employment status. Implications of these results are discussed.     

Factors associated with functional psychosocial status in first-episode psychosis

Aim: This study aimed to determine which of demographic/premorbid, psychiatric or neuropsychological variables are most closely associated with functional status around the time of diagnosis of first‐episode psychosis. This was with a view to determining factors that should be the focus of intervention in these early stages of illness. Methods: The Western Sydney First Episode Psychosis Project collected data on young persons (aged 13–25) with newly diagnosed psychosis (n = 92). Psychosocial functional status was measured using the Role Functioning Scale (RFS). Multiple regression analyses were carried out to identify predictors of RFS score from a wide range of predictor variables. Results: Psychiatric variables accounted for the most variance in RFS score. Positive and Negative Syndrome Scale (PANSS) Negative subscale and Young Mania Rating Scale score were found to be significant individual predictors, with variables from the other domains failing to contribute to the overall model. In separate models, demographic/premorbid and neuropsychological factors weakly related to functional status. Conclusions: Psychiatric factors were the main influence on psychosocial functioning in first‐episode psychosis at baseline. Evidence suggests the relationships between symptoms, cognition and demographics with function might change over time, depending on the stage of illness being examined.     

Negative symptoms in first episode non-affective psychosis

OBJECTIVE: To determine the prevalence of negative symptoms and to examine secondary sources of influence on negative symptoms and the role of specific negative symptoms in delay associated with seeking treatment in first episode non-affective psychosis. METHOD: One hundred and ten patients who met Diagnostic Statistical Manual-IV (DSM-IV) criteria for a first episode of schizophrenia spectrum psychoses were rated for assessment of negative, positive, depressive and extrapyramidal symptoms, the premorbid adjustment scale and assessment of demographic and clinical characteristics including duration of untreated psychosis (DUP). RESULTS: Alogia/flat affect and avolition/anhedonia were strongly influenced by parkinsonian and depressive symptoms, respectively. A substantial proportion (26.8%) of patients showed at a least moderate level of negative symptoms not confounded by depression and Parkinsonism. DUP was related only to avolition/anhedonia while flat affect/alogia was related to male gender, diagnosis of schizophrenia, age of onset and the length of the prodrome. CONCLUSION: Negative symptoms that are independent of the influence of positive symptoms, depression and extra pyramidal symptoms (EPS) are present in a substantial proportion of first episode psychosis patients and delay in seeking treatment is associated mainly with avolition and anhedonia.     

Cortisol awakening response in patients with psychosis: Systematic review and meta-analysis

The cortisol awakening response (CAR), defined as the increase in cortisol release in response to waking up, shows associations with social and environmental risk factors of schizophrenia and has been studied as a potential biomarker in schizophrenia. We report a systematic review and meta-analysis of 11 studies and 879 participants focusing on the CAR of patients with schizophrenia, first-episode psychosis, and at-risk mental states. Random-effects meta-analysis showed that CAR is attenuated in patients with psychosis compared to healthy controls (g = ⿿0.426, 95% CI ⿿0.585 to ⿿0.267, p < 0.001, 11 between-group comparisons, n = 879). Subgroup analysis showed flattened CAR in patients with schizophrenia (g = ⿿0.556, 95% CI ⿿1.069 to ⿿0.044, p < 0.05, 2 between-group comparisons, n = 114) and first-episode psychosis (g = ⿿0.544, 95% CI ⿿0.731 to ⿿0.358, p < 0.001, 6 between-group comparisons, n = 505), but not in individuals with at-risk mental states. These distinctive alterations of hypothalamic-pituitary-adrenal axis function may have important implications for CAR as a marker for transition risk. However, the lack of objective verification of sampling adherence in these studies may limit the interpretation of the results.