Psychopathological dimensions in first-episode psychoses. From the trunk to the branches and leaves

BACKGROUND: Dimensional frameworks for structuring psychopathology have been formulated in recent years to overcome classification problems of categorical approaches. However, few studies have addressed the dilemma of hierarchy within symptoms or dimensions in psychosis. METHODS: This study was designed to examine the hierarchical structure of psychopathological dimensions in first episode psychosis. The sample consisted of 94 first-episode patients psychosis. An exhaustive psychopathological assessment was carried out using the AMDP-system. Consecutive principal component analyses of AMDP symptoms, determining 'a priori' the number of factors to be extracted, were carried out. RESULTS: Following the track of the resulting factor analyses, a 'vertical hierarchical' framework was achieved. Our schema organized dimensions in a series of echelons in which lower tiers are subsumed as subsets of those assigned to higher ranks. In addition, a final model comprising 10 dimensions provided an 'horizontal' and multidimensional structure comprising all relevant psychopathological dimensions in first-episode psychosis. CONCLUSIONS: This study confirmed to a great extent the existence of a hierarchical organization within psychopathological dimensions in 'first-episode' psychosis. The present 'hierarchical and multidimensional' model of psychopathological dimensions allows for selection of the level of complexity of 'candidate phenotypes' to use in neurobiological research of psychosis.     

Cognitive dimensions in first-episode schizophrenia spectrum disorders

BACKGROUND: The severity and pattern of cognitive deficits in epidemiological cohorts of patients with first-episode schizophrenia spectrum disorders still remains unclear. We aimed to characterize the basic cognitive functioning of a representative sample of patients with a first-episode schizophrenia spectrum disorders. METHOD: One hundred thirty-one patients experiencing first-episode psychosis and 28 healthy volunteers were administered a comprehensive neuropsychological evaluation. To reduce the number of cognitive test measures into meaningful cognitive dimensions, before analyzing differences between patient and healthy volunteer samples, exploratory factor analysis was carried out on data collected in patients group. The method of extraction was Principal Components Analysis with oblique rotation. RESULTS: An eight-factor model including verbal learning/memory, verbal comprehensive abilities, speed of processing/executive functioning, motor dexterity, motor speed, sustained attention, and impulsivity emerged. A significant below average performance in all cognitive dimensions, except impulsivity, was found. Patient's performance in speed of processing/executive functioning, motor dexterity and sustained attention dimensions exceeded one standard deviation below healthy comparison subjects. CONCLUSIONS: At early stages of the illness, patients display a marked impairment in several functionally relevant cognitive domains.     

Premorbid personality and psychopathological dimensions in first-episode psychosis

BACKGROUND: Broadening our knowledge of the relationship between personality and psychopathological dimensions in psychosis would provide insights into the nature of their underlying pathophysiology. Research, to date, has been carried out in chronic samples and the possibility that the personality assessment may have been contaminated by the psychotic episode cannot be ruled out. The aim of this study was to examine the relationships between personality and psychopathology in a 'first-episode psychosis' sample using a dimensional approach. METHOD: Premorbid personality dimensions of 94 consecutively admitted 'first-episode psychosis' patients were assessed through the information collected from parents or a close biological relative. A semi-structured interview (Premorbid Assessment Schedule; [Tyrer, P., 1988. Personality Disorders: Diagnosis, management and course. Wright, London]) was used by a rater, blind to the patients' psychopathological symptoms. Associations between dimensions of premorbid personality and psychopathology were examined through Pearson correlation coefficients. RESULTS: The negative dimension was strongly associated with higher scores on the schizoid dimension. Additionally, trends towards significant direct associations were found between the negative dimension and both the passive-dependent and the schizotypic dimensions, between the hostility/suspiciousness dimension and both sociopathic and passive-dependent dimensions, and between the manic dimension and the obsessional dimension. Canonical correlation analysis demonstrated that premorbid personality dimensions explained 17% of the variance of psychopathological dimensions. CONCLUSIONS: Our results suggest that premorbid personality dimensions may shape the expression of psychosis. Moreover, we hypothesize that certain personality dimensions, such as the schizoid dimension, should be considered nonspecific risk factors for expression of higher levels of negative symptomatology at the beginning of psychosis.     

Diagnostic specificity and neuroanatomical validity of neurological abnormalities in first-episode psychoses

OBJECTIVE: Neurological abnormalities are frequently seen in patients with first-episode psychotic disorders but are generally considered to be diagnostically nonspecific, neurologically nonlocalizing, and, hence, "soft." This study examined the neuroanatomical correlates and diagnostic specificity of abnormal findings on the neurological examination in first-episode schizophrenia and other psychotic disorders. METHOD: Neuroleptic-naive patients with schizophrenia (N=90) and with nonschizophrenia psychoses (N=39) and carefully matched healthy subjects (N=93) were compared on total and factor scores for a reliable subset of Neurological Evaluation Scale items. The relationship between neurological examination abnormalities and alterations in the relevant brain structures as assessed by magnetic resonance imaging was examined in a subset of subjects. RESULTS: Factor scores for repetitive motor task abnormalities were higher in both patient groups, relative to the healthy group, and did not distinguish between the patient groups. Factor scores for abnormalities in cognitively demanding and perceptual tasks were markedly higher in the schizophrenia group, relative to both comparison groups, and were not different between the nonschizophrenia psychoses group and the healthy comparison group. Higher scores for the cognitive/perceptual abnormalities factor were correlated with smaller volumes of the left heteromodal association cortex. CONCLUSIONS: Neurological signs may serve as expedient bedside measures that are potentially useful in the assessment of idiopathic psychoses, and cognitive/perceptual neurological signs may have a measure of diagnostic specificity. These findings provide neurobiological validation of abnormal findings on the neurological examination. These abnormalities may reflect discrete neuroanatomical alterations in schizophrenia and may have a localizing value.     

Personality profile in bipolar schizoaffective psychoses. A comparison with bipolar affective psychoses]

The aim of this study was to investigate personality profiles in patients with bipolar affective and schizoaffective disorder, classified according to ICD-9 criteria using objective psychological tests (Personal Research Form, Objective Analytical Test Battery, IPC-Query Form). The bipolar schizoaffective patients were further subtyped according to Research Diagnostic Criteria (RDC) into schizoaffective-affective and schizoaffective-schizophrenic patients. 81 patients took part in the study (29 bipolar affective and 52 bipolar schizoaffective patients; the latter were subtyped into 23 schizoaffective-schizophrenic and 29 schizoaffective-affective patients). We showed that the personality profiles are quite similar in schizoaffective-affective and schizoaffective-schizophrenic patients if compared to purely affective patients. But indeed there are pronounced differences between the schizoaffective-affective and the schizoaffective-schizophrenic subtypes, so that subtyping schizoaffective disorder like done in Research Diagnostic Criteria (RDC) seems to show that schizoaffective disorders are not a homogenous group.     

A prognostic study of clinical dimensions in adolescent-onset psychoses

Adolescent-onset psychoses often raise diagnostic difficulties because of the mixture of schizophrenic and affective features. This study examined prospectively which clinical dimensions contribute to difficulty in initial diagnosis and which clinical features have predictive value for outcomes of schizophrenia or affective disorders, and for eventual psychosocial functioning. Thirty-six adolescents consecutively admitted for a psychotic episode were followed up for 1 to 4 years. Symptoms were assessed at admission, at discharge, and once a year. DSM-III-R (APA 1989) diagnoses were assessed at admission and once a year. Comparisons were performed across initial and followup diagnostic groups. Positive symptoms did not differentiate the initial clinical pictures, while negative symptoms, manic symptoms, and disorganization differentiated the manic and depressive episodes in the acute phase. When initial positive symptoms (mainly delusions) were severe, they predicted a final diagnosis in the schizophrenia spectrum. Poor outcome was associated with more anhedonia-associality and lower functioning scores at admission. Results suggest (1) a higher vulnerability to positive symptoms in adolescents who will further develop schizophrenia and (2) the low specificity of affective symptoms at this age.     

Personality dimensions and criminal arrest

Previous studies have implicated antisocial personality disorder in criminal behavior, but little is known about the association between "normal" personality dimensions and arrest. We investigated the relationships between these personality dimensions and prior arrest in a sample of adults participating in a longitudinal epidemiological study. Between 1993 and 1999, psychiatrists re-examined subjects who were originally interviewed in Baltimore in 1981 as part of the Epidemiologic Catchment Area study; the psychiatrists diagnosed axis I and axis II disorders according to DSM-IV criteria. A total of 611 subjects also completed the Revised NEO Personality Inventory (NEO-PI-R), which assesses five broad factors and 30 facets of normal personality. History of criminal arrest in Maryland in the period 1981 to 1993 was determined from the state criminal justice database. Student's t test and logistic regression were used to evaluate relationships between NEO personality scores and prior arrest. Controlling for demographic characteristics, alcohol or drug use disorders, and DSM-IV personality disorder scores, the odds of prior arrest increased with scores on angry hostility, impulsiveness, and excitement-seeking dimensions. Prior arrest was inversely related to scores on trust, straightforwardness, compliance, modesty, dutifulness, and deliberation dimensions. The results suggest that specific dimensions of normal personality are related to criminal arrest in the community.     

Social and symptomatic outcomes of first-episode bipolar psychoses in an early intervention service

Aim: We aimed to establish the relative proportions of all diagnoses in people aged 14–35 years presenting to an early intervention in psychosis service, and to compare demographic variables, symptoms and outcomes between the bipolar psychoses and other psychoses at 3–6 months and 1 year post referral. Methods: Prospective 3‐ to 6‐month diagnostic and symptomatic assessments were carried out. Diagnoses were established using the Diagnostic Interview for Psychoses – Diagnostic Module. Symptoms and outcomes were assessed using standardized instruments at 3–6 months and 1 year. Bipolar diagnoses were grouped together in a bipolar group (n=16) and compared with all other diagnoses, in a non‐bipolar group (n=62). Parallel analysis was carried out using groups of lifetime elevated, expansive or irritable mood (n=32) and no lifetime elevated, expansive or irritable mood (n=46). Results: Bipolar disorders account for 20.5% of all new presentations to our service. Differences in outcomes over the range of psychotic diagnoses relate to early presence of negative symptoms. Psychoses with bipolar diagnoses or lifetime elevated, expansive or irritable mood showed lower rates of negative symptoms than other psychoses and had a higher quality of life and higher function at 3–6 months and 1 year. Conclusions: Planning for future early intervention services should take the high rate of affective psychoses and their need for diagnosis‐specific, evidence‐based treatments into account. Lifetime elevated, expansive or irritable mood may predict improved outcomes in early psychoses, possibly mediated by lower levels of negative symptoms.     

Personality and social interactions in patients with acute brief psychoses

Although a particularly vulnerable personality has been postulated by some authors as a pathogenetic factor in acute and transient psychotic disorders (ATPD) as introduced with ICD-10, little empirical work has been done on the subject. We therefore evaluated personality features and social interactions in a comparative study of patients with ATPD. We recruited all consecutive inpatients fulfilling the ICD-10 criteria of ATPD (F23) during a 5-year period, as well as control groups with "positive" schizophrenia (PS) and bipolar schizoaffective disorder (BSAD) matched for gender and age at index episode. For assessment of personality features and premorbid social contacts, we administered the NEO Five-Factor Inventory and a semi-structured interview. The assessment of the "Big Five" personality dimensions (neuroticism, extraversion, openness to experience, agreeableness, conscientiousness) with the NEO-FFI did not show any significant difference between ATPD patients and healthy controls. BSAD patients differed from mentally healthy controls on 2 of 5 subscales of the NEO-FFI (neuroticism, extraversion), but were otherwise indiscernible from ATPD patients and mentally healthy controls. In contrast, PS patients showed the most pronounced differences from the mentally healthy controls on the NEO-FFI, and had significantly less premorbid social interaction than the clinical controls. Within the limits of retrospective assessment, the present findings indicate that (1) patients with ATPD do not share the premorbid social impairment characteristic of schizophrenic patients and (2) the personality of patients with ATPD does not differ substantially from the general population.     

Integrating psychopathological dimensions in functional psychoses: a hierarchical approach.

Previous factor analysis studies of psychotic symptomatology have demonstrated three psychopathological dimensions: positive, negative and disorganization. However, few studies have analyzed non-schizophrenic samples and most use a syndrome-level of analysis or only schizophrenic symptom scales. This study examined how many dimensions underlie psychosis, and whether within psychosis there is a hierarchical organization of dimensions.A total of 660 inpatients with an acute psychotic episode were studied. Psychopathology was measured through a wide psychopathological assessment using the Manual for the Assessment and Documentation of Psychopathology (AMDP-system).Principal component factor analysis was carried out on 64 psychopathological symptoms scoring 1 or higher in at least 10% of the sample. A 15-factor solution was obtained which failed to depict a psychosis model on clinical and methodological grounds. Further predetermined factor analyses ranging from 1 to 15 factors were carried out to examine alternative factor solutions. A 10-dimensional model was the best model on clinical, statistical and conceptual grounds. Moreover, the examination of the 1 to 10 dimensional models allowed us to infer a hierarchical model of psychopathological dimensions, which can be represented in the frame of a tree-structure. The model permitted transitions between psychiatric categories and psychopathological dimensions, and it was able to integrate previous factor solutions with different numbers of resulting dimensions.The findings have implications for the design of future studies and for the hierarchical conceptualization of psychopathological dimensions.     

Prefrontal subregions and dimensions of insight in first-episode schizophrenia--a pilot study

While there are data supporting the use of light in clinical populations, there has been less investigation of relationships among light and psychological variables in non-clinical samples. Subjects were 459 ethnically diverse women (mean age 67.68) recruited as part of the Women's Health Initiative. Light exposure and sleep were measured with an Actillume wrist actigraph. Subjects completed questionnaires, investigating Social Support, Social Functioning, Social Strain, Quality of Life, Satisfaction with Life, Emotional Well-being, Optimism, Negative Emotional Expressiveness, and Role Limitation Due to Emotional Problems. Significant partial correlations (controlling for age, education and ethnicity) were found between mesor light exposure and Social Functioning, Quality of Life, Satisfaction with Life, and Emotional Well-Being. Quality of Life and Satisfaction with Life were also found to be significantly correlated with morning light. The most parsimonious model to account for the variance shared between mesor light and the predictors included only Quality of Life. The variance shared between mesor light exposure and social and emotional functioning could be subsumed under the variance shared between mesor light exposure and Quality of Life. Increased light exposure is related to improved quality of life and social and emotional functioning.     

Hippocampal volume in first-episode psychoses and chronic schizophrenia: a high-resolution magnetic resonance imaging study

BACKGROUND: It has been proposed that the hippocampus is a potential site for a neurodevelopmental lesion in schizophrenia. While smaller hippocampal volumes have been described in chronic schizophrenia, there have been few magnetic resonance imaging studies in first-episode psychosis. Furthermore, no studies have examined the specificity of this finding to first-episode schizophrenia, compared with first-episode affective psychosis. METHODS: Hippocampal and whole-brain volumes were estimated using high-resolution magnetic resonance imaging in 140 controls, 46 patients with chronic schizophrenia, and 32 patients with first-episode psychosis. RESULTS: Patients with chronic schizophrenia and first-episode psychosis had significantly smaller hippocampal volumes as compared with controls. Within the first-episode group, both patients with schizophrenia/schizophreniform psychosis and those with affective psychosis had smaller left hippocampal volumes as compared with controls. Smaller right hippocampal volumes were associated with age and illness duration in patients with chronic schizophrenia. Hippocampal volumes were not correlated with age of illness onset or medication dosage in either patient group. CONCLUSIONS: These data show that smaller hippocampal volumes are present from the onset of illness. While these findings would support the neurodevelopmental model of schizophrenia, the finding of smaller left hippocampal volume in patients with first-episode schizophrenia and affective psychosis does not support the prediction that smaller hippocampi are specific to schizophrenia. The association of smaller right hippocampal volumes with increased illness duration in chronic schizophrenia suggests either that there is further neurodegeneration after illness onset or that bilateral small hippocampi predict chronicity.     

Nightmares: Personality dimensions and psychopathological attributes

In this article, in an attempt to integrate recent findings with existing knowledge, we provide an overview of issues related to nightmares that could be useful as a guide to clinical work. After defining what should be considered as a nightmare, we look into the relationship of nightmares with issues such as normal development and maturation, as well as culture. Issues of stress and personality are then discussed in their relation to situational and chronic nightmares. State and trait factors are further elaborated on as we explore the relationship of nightmares and psychopathology. A brief review of organic and pharmacological causes of nightmares follows before we embark on a discussion of issues that relate nightmares to psychological trauma. Some final remarks on treatment conclude our review.     

Possible affective-state dependence of the Tridimensional Personality Questionnaire in first-episode psychosis.

The authors administered the Tridimensional Personality Questionnaire (TPQ) to 61 patients with first-episode psychosis. Subjects were classified into affective states according to DSM-III-R diagnoses. TPQ scores were compared among these states and correlated with two affective symptom subscales: "mania" and "depression." Manic subjects demonstrated little variation from normative TPQ scores. Compared with findings in manic subjects, the dimensional score for Harm Avoidance was elevated in all affective groups, "worry and pessimism" was elevated in mixed-state subjects, "shyness with strangers" was elevated in depressed and nonaffective subjects, and "attachment" was lower in depressed and nonaffective subjects. The Harm Avoidance dimensional score and two subdimensional scores were positively correlated with the "depression" subscale. The Harm Avoidance dimensional and subdimensional scores showed possible affective-state dependence that may limit the utility of this instrument as a personality measure in first-episode psychosis.     

Personality dimensions in social phobics with or without depression

OBJECTIVE: This study investigated the personality traits of social phobics using the Temperament and Character Inventory (TCI). METHOD: A sample of 178 social phobics was assessed with the TCI, and compared with controls. The patients were classified into two groups, according to the absence (SP group) or to the presence (SP+D group) of depression. RESULTS: We found significant elevated scores for harm avoidance (HA) in social phobics when compared with controls (16.2 +/- 2.7), in both the SP (26.2 +/- 3.5), and the SP+D (28.9 +/- 4.7), groups. Lower self-directedness scores were found in the SP and in the SP+D groups when compared with the controls. Patients with the generalized type of social phobia had higher HA scores as compared with other social phobics. CONCLUSION: The personality profile obtained in these social phobics, whatever their depressive symptomatology, reflects a dramatically anxious and avoidant temperament associated to an immature character.     

Personality dimensions in chronic fatigue syndrome and depression.

Chronic fatigue syndrome (CFS) is a poorly understood condition. Possible etiological factors include infectious agents, psychiatric disorders, and personality characteristics. We examined personality dimensions in 30 nondepressed patients with CFS, 20 patients with major depressive disorder (MDD), and 15 healthy controls. On the NEO-FFI, patients with CFS scored significantly lower than healthy controls on the extroversion subscale. On the neuroticism dimension of the Eysenck Personality Questionnaire (EPQ), patients with MDD scored higher than those with CFS, who in turn scored significantly higher than the healthy controls. CFS patients rated themselves as higher on neuroticism and less extroverted when ill than when they were well. Our results suggest that high scores on neuroticism and low scores on extroversion in CFS could be a reaction to chronic illness.     

Psychopathological dimensions in childhood and adolescent psychoses: a confirmatory factor analytical study

The present study explored psychopathological dimensions in psychoses of children and adolescents and the distribution of demographic and clinical variables across different psychopathological domains. This study included 101 consecutive patients aged 6-18 years who had a DSM-IV psychotic disorder (schizophrenia and related disorders or mood disorders). Exclusion criteria included presence of organicity, substance use disorders, and any other childhood disorder. Psychopathology was assessed with Scales for Assessment of Positive and Negative Symptoms. Analysis revealed a four-factor model comprising primary negative, secondary negative, manic and paranoid factors. Patients were regrouped into one of the four factors based on their symptomatology. Patients in these four groups differed in education and age of onset and duration of illness. This study confirmed the existence of a factor structure in psychoses of children and adolescents.     

Prefrontal subregions and dimensions of insight in first-episode schizophrenia — A pilot study

Deficits in insight are multidimensional, and include symptom unawareness and misattribution. We and others have observed that these deficits may be related to a prefrontal dysfunction. However, few studies have examined the relationship between specific prefrontal sub-regions and the awareness and attributional dimensions of insight in schizophrenia. This study examined the correlation between insight dimensions of awareness and attribution of symptoms and dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex (OFC) volume in 14 subjects with first-episode, antipsychotic-naïve (FEAN) schizophrenia. In addition, 21 healthy subjects provided control data for volumetric assessments. Insight was assessed with Scale to Assess Unawareness of Mental Disorders. Morphometric assessments were adjusted for intra-cranial volume and were conducted by trained raters blind to clinical information using BRAINS-2. Average scores on current awareness of symptoms (1 = aware; 5 = unaware) were negatively correlated with right DLPFC volume and average scores on current attribution of symptoms (1 = attribute; 5 = misattribute) with right medial OFC volume. Unawareness and misattribution of symptoms in FEAN schizophrenia may have distinct neuroanatomical bases. DLPFC deficits may have resulted in illness unawareness by interfering with self-monitoring, while OFC abnormalities may have mediated symptom misattribution by conferring aberrant salience to perceived symptomatology.