Abstract
Increasing evidence shows that personality pathology is common among patients at clinical high risk (CHR) for psychosis. Despite the important impact that this comorbidity might have on presenting high-risk psychopathology, psychological functioning, and transition to full psychotic disorders, the relationship between personality syndromes and CHR state has received relatively little empirical attention. The present meta-analytic review aimed at 1) estimating the prevalence rates of personality disorders (PDs) in CHR individuals and 2) examining the potential role of PDs in predicting transition from CHR state to a full-blown psychotic disorder. The systematic search of the empirical literature identified 17 relevant studies, including a total of 1,868 CHR individuals. Three distinct meta-analyses were performed to provide prevalence estimates of PDs in the CHR population. The first and more comprehensive meta-analysis focused on any comorbid PD (at least one diagnosis), the second one focused on schizotypal personality disorder (SPD), and the last one focused on borderline personality disorder (BPD). Moreover, a narrative review was presented to define the predictive role of personality disorders in promoting more severe outcomes in CHR patients. The findings showed that the prevalence rate of personality disorders in CHR patients was 39.4% (95% CI [26.5%–52.3%]). More specifically, 13.4% (95% CI [8.2%–18.5%]) and 11.9% (95% CI [0.73%–16.6%]) of this clinical population presented with SPD and BPD, respectively. Finally, the studies examining the effects of baseline personality diagnoses on conversion to psychotic disorders showed contradictory and insufficient results concerning the potential significant impact of SPD. Conversely, no effect of BPD was found. This meta-analytic review indicated that the CHR population includes a large subgroup with serious personality pathology, that may present with attenuated psychotic symptoms conjointly with distinct and very heterogeneous personality features. These findings support the need for improved understanding of both core psychological characteristics of CHR patients and differentiating aspects of personality that could have relevant clinical implications in promoting individualized preventive interventions and enhancing treatment effectiveness.
Highlights
Very early detection and intervention in the course of illness are considered the crucial goals for realizing meaningful improvements in the outcome of schizophrenia spectrum disorders
This study sought to answer some specific questions: a) Is comorbid personality pathology prevalent among CHR individuals? b) Are some specific personality disorders (PDs) more common than others? c) Is the risk of conversion to psychosis greater in CHR populations with comorbid PDs? Adopting strict inclusion criteria, a total of 17 studies with 1,828 patients were included in this meta-analytic review
Previous reviews and meta-analyses pointed out the huge variability of mental disorders in CHR individuals and high prevalence rates for many psychopathological syndromes or conditions [e.g., Ref. [57]]
Summary
Very early detection and intervention in the course of illness are considered the crucial goals for realizing meaningful improvements in the outcome of schizophrenia spectrum disorders. Much research and many clinical works over the last 20 years have explored the possibility of intervention before the onset of the full psychotic disorder, in order to preempt negative clinical outcomes These efforts focused on the pre-psychotic or “prodromal” stages of illness, which have been defined as the period of time characterized by increasing changes in thinking, feeling, and behaving from a person’s premorbid mental state and level of functioning up to the appearance of psychotic features [1, 2]. BSs have been conceptualized as the most immediate symptomatic expression of neurobiological aberrations, underlying the development of schizophrenia spectrum disorders [4] These symptoms could be described in terms of subjective subclinical disturbances in different domains (i.e., perception, thought processing, language, and attention) that are phenomenologically distinct from classical psychotic symptoms, by reason of their self-experienced nature and fully preserved insight and reality testing [5, 6]
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