Themes of delusions and hallucinations in first-episode psychosis

Aim: The study aims to examine the themes of delusions and hallucinations in a cohort of adolescent and young adult patients (aged 15–26 years) presenting with a first episode of psychosis. Methods: Information was collected retrospectively from 143 randomly selected medical files, using a questionnaire. Results: Over 70% of patients were found to have either delusions or hallucinations at initial presentation. Delusions of persecution, reference and second person auditory hallucinations were the most commonly reported psychotic symptoms at initial presentation. Conclusions: Anxiety in the context of developmental life events may influence the presentation of patients in this age group. This patient group may also have a less well‐developed system of delusional beliefs compared with older patients with established illness. A better understanding of delusions and hallucinations in a first episode of psychosis may help early identification and engagement of these patients.     

Hopelessness and first-episode psychosis: a longitudinal study

Hopelessness has not been adequately studied in first-episode psychotic patients, although it is already present at the early stages, especially in schizophrenic patients. We have studied 96 neuroleptic-naive psychotic patients (49 schizophrenic patients and 47 other non-affective psychotic patients) over a period of 12 months after their first admission. The total score on the Hopelessness Scale (HS) at first admission was higher in the schizophrenic patients, and correlated with younger age and with negative symptoms. High HS scores at baseline predicted poor short-term outcome in schizophrenic patients, as evidenced by worse global functioning at the 12-month follow-up. These correlations were not observed in the other psychoses group. Our results suggest that young, severely affected schizophrenic patients who experience hopelessness might be at higher risk of poor outcome.     

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.     

Risperidone in first-episode psychosis: a longitudinal, exploratory voxel-based morphometric study

Previous studies have provided evidence supporting a neuroplastic effect of atypical antipsychotics. The present investigation explores the short-term effects of risperidone on brain parenchyma by performing voxel-based morphometry on baseline and 6-week follow-up MRI scans obtained from 15 neuroleptic-na?ve individuals with first-episode psychosis treated with risperidone and 15 healthy controls. The risperidone-treated subjects demonstrated changes in grey matter and white matter in several brain regions, including superior temporal gyrus. No areas of change were found in controls. The results of this exploratory investigation support the possibility that risperidone has short-term effects on brain parenchyma in individuals with first-episode psychosis.     

Executive functioning correctly classified diagnoses in patients with first-episode psychosis: evidence from a 2-year longitudinal study

Few studies have analysed factors that predict the ultimate clinical diagnosis in first-episode psychosis (FEP), and none has included cognitive factors. Eighty-six FEP patients and 34 healthy controls were recruited and followed up for two years. Positive and negative symptoms, depression, mania, duration of untreated psychosis (DUP), premorbid functioning, functional outcome and neurocognition were assessed over 2 years. Logistic regression models revealed that Wisconsin Card Sorting Test correctly distinguished the patients ultimately diagnosed with schizophrenia (87%) from those with bipolar disorder (80%) and those with other psychoses (85%), for an overall correct-diagnosis rate of 84.4%. The prediction was stable despite the inclusion of clinical and affective symptoms, DUP, clinical impression, and functional outcome scores. Results highlight the importance of reconsidering neurocognition as a diagnostic criterion for psychosis and schizophrenia.     

Cost-effectiveness of treating first-episode psychosis: five-year follow-up results from an Italian early intervention programme

Aim: Early intervention programmes are expected to result in the reduction of illness severity in patients with schizophrenia, and contain health‐care costs by reducing hospital admissions and improving the social functioning of patients. This study aimed to investigate the cost‐effectiveness of treatment in an early intervention programme in comparison to standard care. Methods: Retrospective analysis of data prospectively recorded in an urban area (Milan, Italy). Twenty‐three patients from an early intervention programme and 23 patients from standard care with first‐episode psychosis were evaluated on their use of services over a 5‐year period. The Health of the Nation Outcome Scale was used to measure clinical status. Results: Significant changes with respect to initial assessment were recorded on the Health of the Nation Outcome Scale, with larger effect sizes in the early intervention programme than in the standard care group. Consequently, the cost‐effectiveness ratio per reduced score of severity was lower in the early intervention programme than in standard care (€ 4802 vs. € 9871), with an incremental cost‐effectiveness ratio, or net saving of €−1204 for every incremental reduced score of severity. Over time, greater recourse to hospital and residential facilities to obtain comparable improvement in symptoms resulted in a steady cost increase for the patients in standard care. Conclusions: Allocation of funds to specialized early intervention programmes is the best alternative, as it can save costs by reducing the use of hospitals and residential facilities, and may produce net savings of costs in the long term.     

Neocortical gray matter volume in first-episode schizophrenia and first-episode affective psychosis: a cross-sectional and longitudinal MRI study.

BACKGROUND: Overall neocortical gray matter (NCGM) volume has not been studied in first-episode schizophrenia (FESZ) at first hospitalization or longitudinally to evaluate progression, nor has it been compared with first-episode affective psychosis (FEAFF). METHODS: Expectation-maximization/atlas-based magnetic resonance imaging (MRI) tissue segmentation into gray matter, white matter (WM), or cerebrospinal fluid (CSF) at first hospitalization of 29 FESZ and 34 FEAFF, plus 36 matched healthy control subjects (HC), and, longitudinally approximately 1.5 years later, of 17 FESZ, 21 FEAFF, and 26 HC was done. Manual editing separated NCGM and its lobar parcellation, cerebral WM (CWM), lateral ventricles (LV), and sulcal CSF (SCSF). RESULTS: At first hospitalization, FESZ and FEAFF showed smaller NCGM volumes and larger SCSF and LV than HC. Longitudinally, FESZ showed NCGM volume reduction (-1.7%), localized to frontal (-2.4%) and temporal (-2.6%) regions, and enlargement of SCSF (7.2%) and LV (10.4%). Poorer outcome was associated with these LV and NCGM changes. FEAFF showed longitudinal NCGM volume increases (3.6%) associated with lithium or valproate administration but without clinical correlations and regional localization. CONCLUSIONS: Longitudinal NCGM volume reduction and CSF component enlargement in FESZ are compatible with post-onset progression. Longitudinal NCGM volume increase in FEAFF may reflect neurotrophic effects of mood stabilizers.     

Predicting prognosis in patients with first-episode psychosis using auditory P300: A 1-year follow-up study

ObjectiveTo clarify the role of auditory P300 in predicting prognosis in patients with first-episode psychosis (FEP) during a 1-year follow-up.MethodsAuditory P300 of 24 patients with FEP and 24 matched healthy control (HC) participants were measured at baseline. The clinical status of the FEP patients was assessed at baseline and reassessed after 1 year. P300 amplitudes and latencies among the groups were analyzed using repeated measures analysis of variance. Multiple regression analysis was conducted to assess the predictive value of P300 in patients with FEP during the 1-year follow-up.ResultsAuditory P300 amplitudes were significantly smaller in FEP patients than HCs. Higher baseline P300 amplitudes at CPz significantly predicted better improvements in the Positive and Negative Syndrome Scale total, positive, and general scores, as well as in the Global Assessment of Functioning and Brief Psychiatric Rating Scale.ConclusionsP300 may predict improvements in symptoms, functional status, and overall psychiatric status in patients with FEP.SignificanceWe first show that P300 amplitude at baseline predicts symptomatic and functional improvements after 1 year of treatment in patients with FEP. This finding may aid in effective interventions from the beginning of a psychotic episode to improve subsequent outcomes in clinical practice.     

New-onset delusions and hallucinations in patients infected with HIV

OBJECTIVE: To assess the relationship between HIV-associated psychotic symptoms (i.e., delusions, hallucinations) and demographic, psychopathological and medical variables by comparing patients with and without cerebral opportunistic infections or metabolic encephalopathy. DESIGN: Cross-sectional study. PATIENTS: 26 patients admitted to hospital with HIV and new-onset psychotic symptoms, defined according to DSM-III-R criteria. OUTCOME MEASURES: A semistructured psychiatric interview using the Psychopathology Assessment Scale (AMDP-4) of the Association for Methodology and Documentation in Psychiatry system. Comprehensive medical assessments, including laboratory tests and computed tomographic scans, were also performed. RESULTS: Patients with cerebral opportunistic infections or metabolic encephalopathy (i.e., "secondary" psychosis, n = 13) were more likely to show disorders of consciousness, disorders of orientation and disturbances of attention and memory than those with no evidence of HIV-related cerebral disease (i.e., "primary" psychosis, n = 13); 10 patients (77%) with cerebral opportunistic infections or metabolic encephalopathy and only 1 (8%) patient without (p < 0.001) were diagnosed with delirium. These associations were stronger for the "secondary" patients with no focal brain lesions than for those with lesions. CONCLUSIONS: These findings suggest that "organic" symptoms of psychosis in those infected with HIV are related to the systemic and cerebral complications of HIV infection rather than to the psychotic process itself.     

Perceived and experienced stigma in first-episode psychosis: A 1-year follow-up study

ObjectivesPerceived/experienced stigma and its relationship with clinical outcome were investigated across the first year of treatment in a large sample with first-episode psychosis (FEP).MethodsFEP participants (n = 112) in the TOP study were investigated at baseline and 1-year follow-up. Perceived/experienced stigma was measured with items from the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), assessing problems because of barriers and hindrances, and living with dignity because of attitudes and actions of others. Clinical outcome included: symptoms, global functioning, self-rated disability and self-rated life satisfaction.ResultsIn the total sample, 46% perceived/experienced stigma at baseline, which decreased significantly to 32% at 1-year follow-up. Perceived/experienced stigma was present in 1/5 at both time-points (Sustained stigma), in 2/5 at only one time-point (Transient stigma), and in 2/5 it was not present at either time-point (No stigma). Compared to the No stigma group, the Sustained stigma group had significantly higher levels of positive, excited and depressive symptoms and self-rated disability, as well as lower levels of global functioning and life satisfaction at 1 year follow-up, while the Transient stigma group only had poorer functioning and higher self-rated disability. Yet the outcome variables improved across the first year of treatment in all three stigma groups.ConclusionPerceived/experienced stigma was common in FEP, yet the rate decreased across the first year of treatment. Although there was some clinical improvement across the first year of treatment irrespective of stigma, stigma was related to poorer clinical outcome in a bidirectional manner. This suggests that perceived/experienced stigma is an important target in the early stages of treatment.     

Misattribution of external speech in patients with hallucinations and delusions

BACKGROUND: One of the main cognitive models of positive symptoms in schizophrenia proposes that they arise through impaired self-monitoring. This is supported by evidence of behavioural deficits on tasks designed to engage self-monitoring, but these deficits could also result from an externalising response bias. We examined whether patients with hallucinations and delusions would demonstrate an externalising bias on a task that did not involve cognitive self-monitoring. METHOD: Participants passively listened (without speaking) to recordings of single adjectives spoken in their own and another person's voice, and made self/nonself judgements about their source. The acoustic quality of recorded speech was experimentally manipulated by altering the pitch. Fifteen patients with schizophrenia who were currently experiencing hallucinations and delusions, 13 patients with schizophrenia not experiencing current hallucinations and delusions and 15 healthy controls were compared. RESULTS: When listening to distorted words, patients with hallucinations and delusions were more likely than both the group with no hallucinations and delusions and the control group to misidentify their own speech as alien (i.e. spoken by someone else). Across the combined patient groups, the tendency to misidentify self-generated speech as alien was positively correlated with current severity of hallucinations but not with ratings of delusions or positive symptoms in general. CONCLUSIONS: These findings indicate that patients with hallucinations and delusions are prone to misidentifying their own verbal material as alien in a task which does not involve cognitive self-monitoring. This suggests that these symptoms are related to an externalising bias in the processing of sensory material, and not solely a function of defective self-monitoring.     

ORIGINAL ARTICLE: Argyrophilic grain disease with delusions and hallucinations: a pathological study

No clear clinical syndrome for argyrophilic grain disease (AGD) has yet been identified. Previous studies have documented its clinical features, namely, personality changes characterized by emotional disorder involving aggression or ill temper and relatively well‐preserved cognitive function, but the clinical manifestations of delusions and hallucinations as they appear in AGD have not been thoroughly described. Here, we report on a 72‐year‐old Japanese AGD patient who showed psychiatric symptoms, memory impairment and emotional change. He perceived and described a person who was not present and tried to grasp things on the floor though nothing was there. He also insisted that somebody was watching him and consequently always kept his curtains closed. These psychiatric symptoms were observed at an early stage in the patient's disease course. Serial neuroradiological examination showed progressive atrophy of the bilateral temporal lobes. The patient died at 79 years‐of‐age. Microscopic neuropathological examination showed transactivation responsive region (TAR)‐DNA‐binding protein of 43 kDa (TDP‐43) positive structures in addition to widespread argyrophilic grains and coiled bodies. According to recent recommendations for pathological diagnosis, this case corresponds to AGD with limbic TDP‐43 pathology. This case shows that patients with AGD that is eventually confirmed through autopsy can present with delusions and hallucinations early in the course of their disease. The clinical significance of TDP‐43 pathology in the brains of patients with AGD remains uncertain.     

Agreeableness and neuroticism as predictors of relapse after first-episode psychosis: a prospective follow-up study

Cross-sectional investigations, using the five-factor model of personality have evinced relationships among neuroticism, agreeableness, and psychotic symptoms. The current study examined these relationships via a prospective follow-up study with remitted first-episode psychosis patients. Baseline five-factor model personality profiles, diagnoses, symptom ratings, and premorbid adjustment ratings were followed by nine monthly ratings on Brief Psychiatric Rating Scale psychosis items in 60 first-episode patients. Valid baseline personality profiles were completed by 40 patients. Patients who had a return of symptoms scored higher on baseline neuroticism and agreeableness than those who remained in remission. Premorbid adjustment also predicted return of symptoms. After premorbid adjustment was controlled for, the agreeableness differences remained significant, but the neuroticism scores were no longer significantly different. It is concluded that lower agreeableness acts as a mediating variable in relapse. Further studies should clarify whether agreeableness is associated with specific biases in processing interpersonal information, and interpersonal behaviors.     

Encoding dysfunctions in a dynamic-static paradigm for visuospatial working memory in first-episode psychosis patients: a 2-year follow-up study

Aim: To investigate static and dynamic visuospatial working memory (VSWM) processes in first‐episode psychosis (FEP) patients and explore the validity of such measures as specific trait markers of schizophrenia. Methods: Twenty FEP patients and 20 age‐, sex‐, laterality‐ and education‐matched controls carried out a dynamic and static VSWM paradigm. At 2‐year follow up 13 patients met Diagnostic and Statistical Manual (of Mental Health Disorders) – Fourth Edition (DSM‐IV) criteria for schizophrenia, 1 for bipolar disorder, 1 for brief psychotic episode and 5 for schizotypal personality disorder. Results: Compared with controls, the 20 FEP patients showed severe impairment in the dynamic VSWM condition but much less impairment in the static condition. No specific bias in stimulus selection was detected in the two tasks. Two‐year follow‐up evaluations suggested poorer baseline scores on the dynamic task clearly differentiated the 13 FEP patients who developed schizophrenia from the seven who did not. Conclusions: Results suggest deficits in VSWM in FEP patients. Specific exploratory analyses further suggest that deficit in monitoring‐manipulation VSWM processes, especially involved in our dynamic VSWM task, can be a reliable marker of schizophrenia.     

The effect of atypical antipsychotics on pituitary gland volume in patients with first-episode psychosis: A longitudinal MRI study

BackgroundPituitary volume is currently measured as a marker of hypothalamic-pituitary-adrenal hyperactivity in patients with psychosis despite suggestions of susceptibility to antipsychotics. Qualifying and quantifying the effect of atypical antipsychotics on the volume of the pituitary gland will determine whether this measure is valid as a future estimate of HPA-axis activation in psychotic populations.AimsTo determine the qualitative and quantitative effect of atypical antipsychotic medications on pituitary gland volume in a first-episode psychosis population.MethodPituitary volume was measured from T1-weighted magnetic resonance images in a group of 43 first-episode psychosis patients, the majority of whom were neuroleptic-naïve, at baseline and after 3 months of treatment, to determine whether change in pituitary volume was correlated with cumulative dose of atypical antipsychotic medication.ResultsThere was no significant baseline difference in pituitary volume between subjects and controls, or between neuroleptic-naïve and neuroleptic-treated subjects. Over the follow-up period there was a negative correlation between percentage change in pituitary volume and cumulative 3-month dose of atypical antipsychotic (r = ? 0.37), i.e. volume increases were associated with lower doses and volume decreases with higher doses.ConclusionsAtypical antipsychotic medications may reduce pituitary gland volume in a dose-dependent manner suggesting that atypical antipsychotic medication may support affected individuals to cope with stress associated with emerging psychotic disorders.     

1-year follow-up study of cognitive function in first-episode non-affective psychosis

The longitudinal course of primary cognitive dysfunction seen in schizophrenia has yet to be fully clarified. Whereas some studies in chronic patients have revealed a progressive decline in cognitive abilities, those studies with first-episode patients have indicated that initial cognitive deficits might remain stable over time. The aim of this study was to examine the longitudinal course of cognitive functioning in patients with a first episode of schizophrenia. 112 patients with a first episode of schizophrenia-spectrum disorders and 22 healthy controls completed clinical and cognitive evaluations at baseline and again after 1 year. An extensive neuropsychological battery that comprised seven cognitive domains was used. Patients and controls improved their cognitive performance in virtually all the cognitive domains after one year. However, patients continued to show marked cognitive deficits after one year, unlike healthy volunteers. The longitudinal cognitive changes were similar in patients and controls in all domains except Verbal Memory (F = 11.67; df = 1; P = 0.001). The increase in cognitive scores found during early phases of the illness seems to be associated to practice-related changes and would not reflect a real cognitive enhancement but rather stability of deficit. Patients' deficits remained stable over time in all cognitive domains except Verbal Memory, in which less performance improvement was found. Further investigations are warranted to discern the variability in patterns of specific cognitive deficits over time.