Understanding Identity Changes in Psychosis: A Systematic Review and Narrative Synthesis

Background and ObjectiveExperiencing psychosis can be associated with changes in how people see themselves as individuals and in relation to others (ie, changes in their identity). However, identity changes receive little attention in treatment, possibly due to a lack of clarity or consensus around what identity change means in people with psychosis. We aimed to create a conceptual framework synthesizing how identity changes are understood in the psychosis literature. MethodsElectronic databases were searched up to April 2020. Studies about identity changes among people with psychotic disorders were analyzed using narrative synthesis by a collaborative review team, including researchers from different disciplines, clinicians, and people who have experienced psychosis. ResultsOf 10 389 studies screened, 59 were eligible. Identity changes are understood in 5 ways as (1) characteristics of psychosis, (2) consequences of altered cognitive functioning, (3) consequences of internalized stigma, (4) consequences of lost roles and relationships, and (5) reflections of personal growth. These 5 understandings are not mutually exclusive. Across a heterogeneous literature, identity changes were mostly framed in terms of loss. ConclusionsOur conceptual framework, comprising 5 understandings, highlights the complexity of studying identity changes and suggests important implications for practice and research. For clinicians, this framework can inform new therapeutic approaches where the experience and impact of identity changes are acknowledged and addressed as part of treatment. For researchers, the conceptual framework offers a way of locating their understandings of identity changes when undertaking research in this area.     

From Real-World Events to Psychosis: The Emerging Neuropharmacology of Delusions

The earliest stages of delusion are characterized by an overabundance of meaningful coincidences impinging on the sufferer''s existing worldview. Successive events are seen by him as pointing to, and then confirming, a fundamentally new reality that takes him over and engulfs his everyday life. Research over the last 4 decades has revealed the importance of dopamine (DA), D2 receptors, and the basal ganglia in psychotic thinking. Recent work has implicated the aberrant reward learning initiated by the excess release of striatal DA in the attribution of excessive importance or “salience” to insignificant stimuli and events. But our knowledge of what is happening beyond D2 receptors has remained scant. The gap is especially apparent at the cellular and microcircuit levels, encompassing the plastic changes, which are believed to be essential for new learning, and whose processes may go awry in major mental illness. Now new pharmacological findings are advancing our understanding of information processing and learning within the striatum. DA has an important role in setting the strength of individual striatal connections, but it does not act in isolation. Two other modulator systems are critical, the endocannabinoids and adenosine. Thus, at medium spiny neurons belonging to the indirect pathway, D2 stimulation evokes endocannabinoid-mediated depression of cortical inputs. Adenosine acting at A2A receptors elicits the opposite effect. Remarkably, drugs that target the endocannabinoid and purinergic systems also have pro- or antipsychotic properties. Here, we discuss how the 3 modulators regulate learning within the striatum and how their dysfunction may lead to delusional thinking.     

Recovery in Psychosis from a Service User Perspective: A Systematic Review and Thematic Synthesis of Current Qualitative Evidence

There is a growing number of qualitative accounts regarding recovery from psychosis from a service user perspective. The aim of this study was to conduct a systematic review of these qualitative accounts. A thematic synthesis was utilised to synthesise and analyse seventeen studies included in the review. Studies were included if they used a qualitative methodology to explore service users’ experiences of recovery from psychosis as a primary research question. All included studies were subjected to a quality assessment. The analysis outlined three subordinate themes: the recovery journey, facilitators of recovery (e.g. faith and spirituality, personal agency and hope), and barriers to recovery (e.g. stigma and discrimination, negative effects of mental health services and medication). Recovery is an idiosyncratic process but includes key components which are important to people who experience psychosis. These should be explored within clinical practice.     

Understanding Language Abnormalities and Associated Clinical Markers in Psychosis: The Promise of Computational Methods

The language and speech of individuals with psychosis reflect their impairments in cognition and motor processes. These language disturbances can be used to identify individuals with and at high risk for psychosis, as well as help track and predict symptom progression, allowing for early intervention and improved outcomes. However, current methods of language assessment—manual annotations and/or clinical rating scales—are time intensive, expensive, subject to bias, and difficult to administer on a wide scale, limiting this area from reaching its full potential. Computational methods that can automatically perform linguistic analysis have started to be applied to this problem and could drastically improve our ability to use linguistic information clinically. In this article, we first review how these automated, computational methods work and how they have been applied to the field of psychosis. We show that across domains, these methods have captured differences between individuals with psychosis and healthy controls and can classify individuals with high accuracies, demonstrating the promise of these methods. We then consider the obstacles that need to be overcome before these methods can play a significant role in the clinical process and provide suggestions for how the field should address them. In particular, while much of the work thus far has focused on demonstrating the successes of these methods, we argue that a better understanding of when and why these models fail will be crucial toward ensuring these methods reach their potential in the field of psychosis.     

Schizophrenia and the Environment: Within-Person Analyses May be Required to Yield Evidence of Unconfounded and Causal Association—The Example of Cannabis and Psychosis

Hypotheses about the link between cannabis use and psychosis apply to the within-person level but have been tested mostly at the between-person level. We used a within-person design, in which a person serves as his own control, thus removing the need to consider confounding by any fixed (genetic and nongenetic) characteristic to study the prospective association between cannabis use and the incidence of attenuated psychotic experiences, and vice versa, adjusted for time-varying confounders. We combined 2 general population cohorts (at baseline: Early Developmental Stages of Psychopathology Study, n = 1395; Netherlands Mental Health Survey and Incidence Study-2, n = 6603), which applied a similar methodology to study cannabis use and attenuated psychotic experiences with repeated interviews (T0, T1, T2, and T3) over a period of approximately 10 years. The Hausman test was significant for the adjusted models, indicating the validity of the fixed-effects model. In the adjusted fixed-effects model, prior cannabis use was associated with psychotic experiences (aOR = 7.03, 95% CI: 2.39, 20.69), whereas prior psychotic experiences were not associated with cannabis use (aOR = 0.59, 95% CI: 0.21, 1.71). Longitudinal studies applying random-effects models to study associations between risk factors and mental health outcomes, as well as reverse causality, may not yield precise estimates. Cannabis likely impacts causally on psychosis but not the other way round.     

The Effects of Antipsychotic Treatment on Presynaptic Dopamine Synthesis Capacity in First-Episode Psychosis: A Positron Emission Tomography Study

Background

Elevated striatal dopamine synthesis capacity has been implicated in the etiology and antipsychotic response in psychotic illness. The effects of antipsychotic medication on dopamine synthesis capacity are poorly understood, and no prospective studies have examined this question in a solely first-episode psychosis sample. Furthermore, it is unknown whether antipsychotic efficacy is linked to reductions in dopamine synthesis capacity. We conducted a prospective [¹⁸F]-dihydroxyphenyl-L-alanine positron emission tomography study in antipsychotic naïve/free people with first-episode psychosis commencing antipsychotic treatment.

The Psychosis Project: outcome and cost-effectiveness of a psychoeducational treatment programme for schizophrenic adolescents

The outcome of a psychoeducational treatment programme for very early-onset schizophrenics was compared with a standard reference treatment. The study sample consisted of 12 patients in each group. Clinical outcome was assessed by relapses during the 2-year treatment period and changes in psychosocial functioning as measured by the Global Assessment Scale. A cost-effectiveness analysis was also carried out. The results indicated that the most effective programme measured by relapse was also the cheapest: the psychoeducational programme. Patients with poor premorbid psychosocial functioning benefit most from this treatment. Decisive with respect to how effective the programme can be is the cooperativeness of patients' parents and their ability to change their emotional attitudes toward the patient.     

Lack of Evidence for Regional Brain Volume or Cortical Thickness Abnormalities in Youths at Clinical High Risk for Psychosis: Findings From the Longitudinal Youth at Risk Study

There is cumulative evidence that young people in an “at-risk mental state” (ARMS) for psychosis show structural brain abnormalities in frontolimbic areas, comparable to, but less extensive than those reported in established schizophrenia. However, most available data come from ARMS samples from Australia, Europe, and North America while large studies from other populations are missing. We conducted a structural brain magnetic resonance imaging study from a relatively large sample of 69 ARMS individuals and 32 matched healthy controls (HC) recruited from Singapore as part of the Longitudinal Youth At-Risk Study (LYRIKS). We used 2 complementary approaches: a voxel-based morphometry and a surface-based morphometry analysis to extract regional gray and white matter volumes (GMV and WMV) and cortical thickness (CT). At the whole-brain level, we did not find any statistically significant difference between ARMS and HC groups concerning total GMV and WMV or regional GMV, WMV, and CT. The additional comparison of 2 regions of interest, hippocampal, and ventricular volumes, did not return any significant difference either. Several characteristics of the LYRIKS sample like Asian origins or the absence of current illicit drug use could explain, alone or in conjunction, the negative findings and suggest that there may be no dramatic volumetric or CT abnormalities in ARMS.Key words: magnetic resonance imaging, voxel-based morphometry, surface-based morphometry, early psychosis, schizophrenia     

The Ability to Rest at Home During COVID-19 Symptom Manifestation and Depressive Symptoms: Evidence From Korea

ObjectiveThis study investigated the association between ability to rest at home in times of coronavirus disease 2019 (COVID-19) symptom manifestation and depressive symptoms. MethodsThe 2020 Korea Community Health Survey data were used. The presence of depressive symptoms was determined using the Patient Health Questionnaire-9. The relationship between depressive symptoms and ability to rest at home was examined using logistic regression analysis. Additional analysis was performed on the reasons for the inability to stay at home. ResultsDepressive symptoms were more common in participants who could not rest at home if symptoms manifested (4.1%) than those who could rest at home (2.7%). Participants who could not rest at home (OR 1.53, 95% CI 1.34–1.74) were more likely to have depressive symptoms, particularly when they had to report to work (OR 1.50, 95% CI 1.30–1.74) or purchase daily necessities (OR 2.40, 95% CI 1.15–5.03). ConclusionInability to rest at home in the case of COVID-19 symptom manifestation was associated with depressive symptoms. The findings suggest the need to address the identified vulnerable groups to mitigate the mental health consequences of the pandemic.     

Psychosis and offending in British Columbia: characteristics of a secure hospital population

INTRODUCTION: There is an increased likelihood of violence in the mentally ill although the risk is small. AIMS: The study aimed to ascertain the features in a secure hospital population that linked offending and mental illness. METHOD: A survey of patients in the high security hospital serving the province of British Columbia in Canada was carried out. Information on 175 mentally disordered offenders was extracted and included demographic data and specific characteristics of their offences, diagnoses and psychotic symptoms. RESULTS: The most prevalent offences were crimes of violence, but 39% of patients were not primarily violent offenders. Almost two-thirds (61%) had two or more diagnoses. A large majority of the patients were psychotic, schizophrenia being the most common diagnosis. There was a highly significant association between psychosis and violence, but the strength of the association was not increased by the presence of imperative hallucinations or delusions. The sample comprised various ethnic groups, one of which, Native Americans, was over-represented. However, no association was found between violent offending and ethnicity, or age or years of illness. DISCUSSION: The study replicates previous findings of the link between violent offending and psychosis, but not a specific link between violent offending and psychotic drive. A surprising finding was a lack of association between violent offences and substance misuse.     

The Latent Structure of Negative Symptoms in Individuals With Attenuated Psychosis Syndrome and Early Psychosis: Support for the 5 Consensus Domains

Negative symptoms are prevalent in the prodromal and first-episode phases of psychosis and highly predictive of poor clinical outcomes (eg, liability for conversion and functioning). However, the latent structure of negative symptoms is unclear in the early phases of illness. Determining the latent structure of negative symptoms in early psychosis (EP) is of critical importance for early identification, prevention, and treatment efforts. In the current study, confirmatory factor analysis was used to evaluate latent structure in relation to 4 theoretically derived models: 1. a 1-factor model, 2. a 2-factor model with expression (EXP) and motivation and pleasure (MAP) factors, 3. a 5-factor model with separate factors for the 5 National Institute of Mental Health (NIMH) consensus development conference domains (blunted affect, alogia, anhedonia, avolition, and asociality), and 4. a hierarchical model with 2 second-order factors reflecting EXP and MAP, as well as 5 first-order factors reflecting the 5 consensus domains. Participants included 164 individuals at clinical high risk (CHR) who met the criteria for a prodromal syndrome and 377 EP patients who were rated on the Brief Negative Symptom Scale. Results indicated that the 1- and 2-factor models provided poor fit for the data. The 5-factor and hierarchical models provided excellent fit, with the 5-factor model outperforming the hierarchical model. These findings suggest that similar to the chronic phase of schizophrenia, the latent structure of negative symptom is best conceptualized in relation to the 5 consensus domains in the CHR and EP populations. Implications for early identification, prevention, and treatment are discussed.