Course Of Psychotic Disorders Research Articles

Psychosis Polyrisk Score (PPS) for the Detection of Individuals At-Risk and the Prediction of Their Outcomes.

Primary prevention in individuals at Clinical High Risk for psychosis (CHR-P) can ameliorate the course of psychotic disorders. Further advancements of knowledge have been slowed by the standstill of the field, which is mostly attributed to its epidemiological weakness. The latter, in turn, underlies the limited identification power of at-risk individuals and the relatively modest ability of CHR-P interviews to rule-in a state of risk for psychosis. In the first part, this perspective review discusses these limitations and traces a new approach to overcome them. Theoretical concepts to support a Psychosis Polyrisk Score (PPS) integrating genetic and non-genetic risk and protective factors for psychosis are presented. The PPS hinges on recent findings indicating that risk enrichment in CHR-P samples is accounted for by the accumulation of non-genetic factors such as: parental and sociodemographic risk factors, perinatal risk factors, later risk factors, and antecedents. In the second part of this perspective review we present a prototype of a PPS encompassing core predictors beyond genetics. The PPS prototype may be piloted in the next generation of CHR-P research and combined with genetic information to refine the detection of individuals at-risk of psychosis and the prediction of their outcomes, and ultimately advance clinical research in this field.

Socially differentiated life trajectories of individuals with experience of psychosis: A biographical study

The role of social factors in the development and course of psychotic disorders has been increasingly acknowledged in recent decades. The present study examines the role of social, family and environmental factors in shaping biographical trajectories of people experiencing psychosis. Biographical interviews were conducted with 27 individuals with experience and diagnosis of psychotic disorders, in several locations in Greece. The narratives were subjected to biographical analysis, culminating in the formation of five biographical types, characterized by stigma, chronicity, marginalization, suffering and defiance. Early recognition and community management of distress were found to distinguish participants with more favorable therapeutic itineraries. Availability of community mental health services, access to empowering popular and professional discourses and participation in interpersonal relationships and social networks seem to exercise positive influence, while internalized social stigma, possibly related to primary socialization in restrictive familial environments, and lack of access to resources can be detrimental.

Identification of patients with recent-onset psychosis in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic instruments

PurposeThere is considerable variation in epidemiology and clinical course of psychotic disorders across social and geographical contexts. To date, very little data are available from low- and middle-income countries. In sub-Saharan Africa, most people with psychoses remain undetected and untreated, partly due to lack of formal health care services. This study in rural South Africa aimed to investigate if it is possible to identify individuals with recent-onset psychosis in collaboration with traditional health practitioners (THPs).MethodsWe developed a strategy to engage with THPs. Fifty THPs agreed to collaborate and were asked to refer help-seeking clients with recent-onset psychosis to the study. At referral, the THPs rated probability of psychosis (“maybe disturbed” or “disturbed”). A two-step diagnostic procedure was conducted, including the self-report Community Assessment of Psychic Experiences (CAPE) as screening instrument, and a semi-structured interview using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Accuracy of THP referrals, and test characteristics of the THP rating and the CAPE were calculated.Results149 help-seeking clients were referred by THPs, of which 44 (29.5%) received a SCAN DSM-IV diagnosis of psychotic disorder. The positive predictive value of a THP “disturbed” rating was 53.8%. Test characteristics of the CAPE were poor.ConclusionTHPs were open to identifying and referring individuals with possible psychosis. They recognized “being disturbed” as a condition for which collaboration with formal psychiatric services might be beneficial. By contrast, the CAPE performed poorly as a screening instrument. Collaboration with THPs is a promising approach to improve detection of individuals with recent-onset psychosis in rural South Africa.

5.2 RETHINKING THE COURSE OF PSYCHOTIC DISORDERS: IDENTIFYING LATENT TRAJECTORIES

BackgroundThe clinical course of psychotic disorders is highly variable. Typically, researchers have captured course types using broad categories, e.g. the WHO instruments to assess course and outcome distinguish three categories: episodic (i.e., no episode > 6 months), continuous (i.e., no remission > 6 months), and neither (i.e., an episode and a remission > 6 months). However, whether these adequately capture symptom trajectories of psychotic disorders has not been assessed. Using AESOP-10 data, we sought to identify classes of individuals with specific symptom trajectories over a 10 year follow up and to, then, compare trajectories with WHO categories and examine associations between trajectories and baseline demographic characteristics and diagnoses.MethodsAESOP-10 is a follow-up, at 10 years, of a cohort of 552 patients with a first episode psychosis identified in south-east London and Nottingham, UK. At follow-up, we collated detailed information on clinical and social course and outcome. This included collating extensive information on month by month fluctuations in presence of psychotic symptoms. Using this data, we fitted growth mixture models to identify latent trajectory classes that accounted for heterogeneity in patterns of change in psychotic symptoms over time.ResultsWe had sufficient data on occurrence of psychotic symptoms throughout the follow up on 326 (~ 60%) patients.A four-class quadratic growth mixture model best fit the data, with four trajectories defined by variations in the mean number of months psychotic per year during the follow-up period: (1) low and reducing [intermittent] (58.5%); (2) persistently high [persistent] (30.6%); (3) high, followed by gradual reduction [late improvement] (5.6%); and (4) intermediate, followed by gradual increase [late decline] (5.4%). When compared with the usual classification of course types (episodic, continuous, neither), the intermittent class included all those in the episodic category (n 94 of 94; 100%) and the persistent class included almost all those in the continuous category (n 72 of 78 persistent; 92%). A majority of those in the neither category had an intermittent trajectory (i.e., n 90 of 145; 62%), with the remainder spread across the other three classes (i.e., n 25, 17% persistent; n 14, 10% late decline; n 16, 11% late improvement).Compared with those with an intermittent trajectory, patients with a persistent trajectory were less often women (OR 0.6, 95% CI 0.4–0.9), more often of black Caribbean ethnicity (OR 2.3, 95% CI 1.2–4.1), and less often had a diagnosis of affective psychosis (OR 0.2, 95% CI 0.1–0.4). There were no differences by age. Numbers were small, but there were indications that those with a late decline trajectory more closely resembled those with a persistent trajectory (i.e., less often women, more often of black Caribbean ethnicity, less often diagnosis of affective psychosis) than did those with a late improvement trajectory.DiscussionOur current approach to classifying course of psychotic disorders may be flawed, particularly in specifying a group as neither episodic nor continuous. Our findings suggest this group is heterogeneous and includes patients whose outcomes more closely resemble one of the two main trajectories, intermittent or persistent. Only a small proportion of patients fit neither. These patients constitute clinically important sub-groups whose trajectories appear to change, either from an initially positive or initially negative course, some years after first contact with mental health services. Our failure to fully characterise trajectories of psychosis may confound efforts to elucidate predictors of long-term outcome.

F132. IDENTIFICATION OF PATIENTS WITH RECENT ONSET PSYCHOSIS IN KWAZULU NATAL, SOUTH AFRICA: A PILOT STUDY WITH TRADITIONAL HEALTH PRACTITIONERS AND DIAGNOSTIC INSTRUMENTS

BackgroundThere is considerable variation in epidemiology and clinical course of psychotic disorders across social and geographical contexts. To date, very little data is available of low- and middle-income countries (LMICs). Obtaining valuable evidence from under-represented regions such as Sub-Saharan Africa holds the promise of advancing our knowledge and understanding of psychosis and will provide a strong basis for redressing inequities in service provision for people with psychotic disorders living in LMICs. Many patients in these countries remain undetected and untreated, partly due to lack of formal health care facilities. This study in rural South Africa aimed to investigate if it is possible to identify patients with recent onset psychosis in collaboration with traditional health practitioners (THPs).MethodsWe developed a strategy to engage with THPs. Key to the collaboration between psychiatry, THPs and the local community, was the building of trust by recognizing and acknowledging local authorities, mutual respect for health constructs, taking time to find common ground, and adaptation of the procedures to sociocultural norms. Fifty THPs agreed to collaborate and were asked to refer help-seeking clients with recent onset psychosis to the study. At referral, the THPs rated probability of psychosis (“maybe disturbed” or “disturbed”). A two-step diagnostic procedure was conducted, including the self-report Community Assessment of Psychic Experiences (CAPE) as screening instrument, and a semi-structured interview using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Accuracy of THP referrals, and test characteristics of the THP rating and the CAPE were calculated.ResultsIn six months, 149 help-seeking clients were referred by THPs, of which 44 (29.5%) received a SCAN DSM-IV diagnosis of psychotic disorder. The positive predictive value of a THP “disturbed” rating was 53.8%. Test characteristics of the CAPE were poor.DiscussionThis pilot study in rural South Africa found that it is possible to identify patients with recent onset psychosis in collaboration with THPs. THPs not only grasped the concept of psychosis, they recognized “being disturbed” as a condition that is often difficult to treat and for which collaboration with psychiatric mental health care might be beneficial. By contrast, the CAPE performed poorly as a screening instrument. Collaboration with THPs is a promising approach to improve detection of patients with psychosis in LMIC.

19.4 CAT IN FIRST-EPISODE PSYCHOSIS: FEASIBILITY, ACCEPTABILITY AND POTENTIAL TO ENHANCE VOCATIONAL RECOVERY

BackgroundCognitive and functioning impairments are present early in the course of psychotic disorder and remain one of the greatest treatment challenges in this population. While Cognitive Adaptation Training (CAT) is found to improve a range of outcomes in chronic schizophrenia, it has received limited investigation in first-episode psychosis (FEP). CAT may be particularly useful for addressing vocational recovery in FEP because the cognitive impairments experienced by individuals with FEP predict poorer vocational outcomes and impede the effectiveness of vocational interventions such as supported employment. The aim of this presentation is to present the findings of a pilot study investigating the feasibility and acceptability of CAT in young people with FEP and to describe the clinical considerations and adaptations required when delivering CAT with this population. Preliminary findings on the potential value of CAT in improving vocational outcomes in FEP will also be presented.MethodsThis was a single-arm feasibility study of CAT conducted at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. Five FEP participants received 9 months of manually-guided CAT. A range of feasibility and acceptability measures were recorded, including participant and case manager satisfaction ratings. Participants’ goals, functional needs and clinical observations and adaptations were also recorded. Formal measures of functioning, quality of life and motivation were independently administered pre- and post-intervention.ResultsAll participants completed the CAT intervention and session attendance rates were very high (95.3%). Participants and their case managers indicated strong satisfaction with CAT as indicated by overall positive mean ratings on the satisfaction items. CAT did not negatively affect existing case management, with case managers reporting that it enhanced their treatment. Vocational recovery (education, employment) was found to be a primary functional goal of most participants. Accordingly, the CAT intervention had a strong focus on vocational functioning, including functional domains that are requisite for successful work or educational outcomes, including organisation and planning, transportation and activities of daily living. Being mindful of factors that may be common in young FEP patients included cognitive heterogeneity, family involvement, flexibility in compensatory and environmental supports used, and the experience of stigma. There were mean improvements from baseline to post-intervention on most formal outcome measures, with the largest effects in global functioning, planning and organisation, and quality of life.DiscussionThis study provides encouraging preliminary evidence that CAT is a highly feasible and acceptable intervention in FEP, which may be easily integrated within existing early intervention services. Vocational recovery is important to young people with FEP. CAT is an intervention that appears well suited to addressing this need. The effectiveness of CAT in improving functional outcomes, particularly vocational recovery in FEP warrants further investigation in a larger trial.

Declining Clinical Course of Psychotic Disorders Over the Two Decades Following First Hospitalization: Evidence From the Suffolk County Mental Health Project.

Kraepelin considered declining course a hallmark of schizophrenia, but others have suggested that outcomes usually stabilize or improve after treatment initiation. The authors investigated this question in an epidemiologically defined cohort with psychotic disorders followed for 20 years after first hospitalization. The Suffolk County Mental Health Project recruited first-admission patients with psychosis from all inpatient units of Suffolk County, New York (response rate, 72%). Participants were assessed in person six times over two decades; 373 completed the 20-year follow-up (68% of survivors); 175 had schizophrenia/schizoaffective disorder. Global Assessment of Functioning (GAF), psychotic symptoms, and mood symptoms were rated at each assessment. Month 6, when nearly all participants were discharged from the index hospitalization, was used as a reference. In the schizophrenia group, mean GAF scores declined from 49 at month 6 to 36 at year 20. Negative and positive symptoms also worsened (Cohen's d values, 0.45-0.73). Among participants without schizophrenia, GAF scores were higher initially (a mean of approximately 64) but declined by 9 points over the follow-up period. Worsening began between years 5 and 8. Neither aging nor changes in antipsychotic treatment accounted for the declines. In all disorders, depression improved and manic symptoms remained low across the 20 years. The authors found substantial symptom burden across disorders that increased with time and ultimately may undo initial treatment gains. Previous studies have suggested that better health care delivery models may preempt this decline. In the United States, these care needs are often not met, and addressing them is an urgent priority.

Patterns of illness and care over the 5\xa0years following onset of psychosis in different ethnic groups; the GAP-5 study

PurposePrevious research has not provided us with a comprehensive picture of the longitudinal course of psychotic disorders in Black people living in Europe. We sought to investigate clinical outcomes and pattern of care in Black African and Black Caribbean groups compared with White British patients during the first 5 years after first contact with mental health services for psychosis.Methods245 FEP cases aged 18–65 who presented to psychiatric services in 2005–2010 in South London (UK). Using the electronic psychiatric clinical notes in the South London and Maudsley NHS Foundation Trust (SLaM), extensive information was collected on three domains—clinical, social, and service use.ResultsDuring the 5-year follow-up (mean = 5.1 years, s.d. = 2.4; 1251 person years) after first contact with mental health services, a higher proportion of Black African and Black Caribbean ethnicity had compulsory re-admissions (χ2 = 17.34, p = 0.002) and instances of police involvement during an admission to a psychiatric unit (χ2 = 22.82, p < 0.001) compared with White British ethnic group. Patients of Black African and Black Caribbean ethnicity did not differ from the ethnic group in overall functional disability and illness severity, or frequency of remission or recovery during the follow-up period. However, patients of Black ethnicity become increasing socially excluded as their illness progress.ConclusionsThe longitudinal trajectory of psychosis in patients of Black ethnicity did not show greater clinical or functional deterioration than white patients. However, their course remains characterised by more compulsion, and longer periods of admission.

Second stage development of an early screening tool for detection of vulnerability to schizophrenia, as an example of empathic action

Statement of the Problem: The concept of empathy in psychiatry infers an understanding, concern or interest in a person’s emotional state or experience. The experience of psychosis that usually precedes schizophrenia is often frightening; destabilizing a person’s sense of self and confidence in reality. Empathic action calls for ways to diminish the likelihood of a person experiencing psychosis. Methodology & Theoretical Basis: The current research tests the theory that vulnerability to developing this type of psychosis can be identified by an early-screening-tool (Schizophrenia-Traits-Questionnaire, STQ) in teenage, in a second stage of development by Flourish Australia. Originally developed in a PhD by the author, it is based on the neurodynamic/ psychobiological theory of Robert Miller. Originally, 600 adults participated in the STQ to test both the theory and its power to predict whether someone would fit into the schizophrenia category or not. The current research trial is on teenagers. Findings: The factor analysis supported the underlying theory and thirteen (13) of the items in combination, in the original sample, accurately predicted schizophrenia to 85% accuracy with no mention of psychotic symptoms. With early-detection and the appropriate education and resources, not only can the STQ potentially stop a psychotic episode from occurring, it also identifies the types of occupations to avoid, to prevent being overwhelmed by stimuli/environments that challenge.

Sleep Disturbances and Suicide Risk in an 8-Year Longitudinal Study of Schizophrenia-Spectrum Disorders.

Disrupted sleep is one of the prominent but often overlooked presenting symptoms in the clinical course of psychotic disorders. The aims of this study were to examine the prevalence of sleep disturbances, particularly insomnia and nightmares, and their prospective associations with the risk of suicide attempts in patients with schizophrenia-spectrum disorders. A naturalistic longitudinal study was conducted in outpatients diagnosed with schizophrenia-spectrum disorders recruited from the psychiatric outpatient clinic of a regional university-affiliated public hospital in Hong Kong. A detailed sleep questionnaire was completed by 388 patients at baseline in May-June 2006. Relevant clinical information was extracted from clinical case notes from June 2007-October 2014. Prevalence of frequent insomnia and frequent nightmares was 19% and 9%, respectively. Baseline frequent insomnia was significantly associated with an increased incidence of suicide attempts during the follow-up period (adjusted hazard ratio = 4.63, 95% confidence interval 1.40-15.36, P < 0.05). Nightmare complaint alone did not predict the occurrence of suicide attempts, but the comorbidity of nightmares and insomnia was associated with the risk of suicide attempt over follow-up (adjusted HR = 11.10, 95% confidence interval: 1.68-73.43, P < 0.05). Sleep disturbances are common in patients with schizophrenia-spectrum disorders. The association between sleep disturbances and suicidal risk underscores the need for enhanced clinical attention and intervention on sleep disturbances in patients with schizophrenia.

Effectiveness of long-acting injectables and clozapine in a real-world setting during the early-stages of psychotic illness

IntroductionIntervention in the early-stages of psychosis may be able to shape the clinical course; critical period (CP) is best represented by the first 5 years from first admission (FA).ObjectivesTo investigate the effectiveness of pharmacological intervention within and beyond the CP.Aims(1) To compare hospitalization rates of patients stabilized on treatment with LAIs and CLZ. (2) To determine whether treatment with LAIs and CLZ within CP can influence hospitalization rates.MethodsData were retrospectively collected from patients diagnosed with non-affective psychoses with FA between 2000 and 2014; 200 patients were then divided into three groups, according to stabilized treatment regimen during the final year of observation: treatment as usual (TAU), CLZ, LAIs. hospitalization duration (HSPD) and frequency (HSP) were calculated for each group.ResultsDespite a major severity before assignment to either CLZ or LAIs treatment, HSPD and HSP in both groups shifted below those observed for the TAU arm. Patients who began treatment with LAIs within the CP showed a highly significant decrease of both HSPD and HSP (respectively 17.4 ± 18 vs. 2.6 ± 8.2; Z = −2.856; P &lt; 0.005 and 1.1 ± 0.8 vs. 0.2 ± 0.5; Z = −3.115; P &lt; 0.005). No significant changes in hospitalization rates were observed for subjects who began treatment with LAIs after the CP.ConclusionsOur study confirms that treatment with either CLZ or LAIs significantly impacts the course of psychotic disorders. The data seem to suggest that LAIs and CLZ should be considered more effective than conventional oral antipsychotics in the early-stages of psychotic illness. The difference among treatments tends to wane beyond the CP, especially for LAIs.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Impact of vulnerability to stress in the development and course of first psychotic episode

IntroductionThe stress diathesis hypothesis is one of the leading models of etiology of psychotic disorders. Cortisol is one of the most researched stress hormone; yet its role in first psychotic episode is currently subject of many researches. Psychotic disorder occurs when “enough” stress attacks vulnerable personality. Stress response activates HPA axis that results in cascade effects on several body systems (immune, neuroendocrine and inflammatory). Dysregulation of the HPA axis and increased cortisol levels have been implicated in psychotic as well as in other psychiatric disorders.ObjectiveTo follow treatment response through changes in clinical status and stress biomarkers evaluation in longitudinal 18 months research in drug naive FEP.AimTo assess endocrine and autonomic responses to acute psychosocial stress, their associations with onset of the first psychotic episode and their subsequent remission.MethodsWe studied 17 subjects with FEP and age and gender matched controls who were exposed to the Trier Social Stress Test. Other materials have explored clinical status through standardized clinical psychiatric interview and validated psychiatry scales as well as measured laboratory biomarkers (cortisol, prolactin, insulin).ResultsOur preliminary findings on a sample of 40 participants indicate a differences between patients and controls in terms of response to stress measured by TSST.ConclusionIn our continued longitudinal research, we plan to further explore the role of hypothalamic-pituitary-adrenal activity in onset and course of psychotic disorder and its relation with other biomarkers.Disclosure of interestThe authors have not supplied their declaration of competing interest.

GROUP 6 year outcome data in relation to antipsychotic medication

ObjectiveGenetic risk and outcome of psychoses (GROUP) is a 6 year longitudinal cohort study that focus on gene–environment vulnerability and resilience in patients with psychotic disorders, their unaffected family members and non-related controls. Its main aim is to elucidate etiological and pathogenetic factors that influence the onset and course of psychotic disorders. In this substudy, we will examine medication use over time, its relation with (the change in) metabolic syndrome status and effects on the brain.MethodsA consortium of four university psychiatric centers and their affiliated mental health care institutions, conducted the GROUP study. At baseline, 1120 patients, 1057 siblings, 919 parents and 590 healthy controls were included. After inclusion, participants, except parents, were evaluated again after three and six years of follow-up. Extensive assessment of genetic factors, environmental factors, medication use, metabolic parameters and outcome were performed. Moreover, brain imaging was performed in a subset of participants, using a 1.5 Tesla MRI scanner.ResultsAt baseline 65% of patients used atypical antipsychotics, 16% used conventional antipsychotics and 19% used clozapine. Siblings and controls used no antipsychotics. Forty-three percent of patients, 21.3% of siblings and 9.1% of controls used antidepressants; 43.9% of patients, 2.1% of siblings and none of the controls used a mood stabilizer. We are currently analyzing the medication data over time in relation to (change in) metabolic syndrome status and the effects on the brain.ConclusionGROUP is a longitudinal cohort study in patients with psychotic disorders, their healthy siblings and controls without psychosis. This naturalistic substudy examines medication use, its association with (change of) metabolic status and effects on the brain in subjects with (high risk of) psychosis.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Decreases in perceived maternal criticism predict improvement in subthreshold psychotic symptoms in a randomized trial of family-focused therapy for individuals at clinical high risk for psychosis.

Perceived criticism (PC) is a measure of how much criticism from 1 family member "gets through" to another. PC ratings have been found to predict the course of psychotic disorders, but questions remain regarding whether psychosocial treatment can effectively decrease PC, and whether reductions in PC predict symptom improvement. In a sample of individuals at high risk for psychosis, we examined a) whether Family Focused Therapy for Clinical High-Risk (FFT-CHR), an 18-session intervention that consists of psychoeducation and training in communication and problem solving, brought about greater reductions in perceived maternal criticism, compared to a 3-session family psychoeducational intervention; and b) whether reductions in PC from baseline to 6-month reassessment predicted decreases in subthreshold positive symptoms of psychosis at 12-month follow-up. This study was conducted within a randomized controlled trial across 8 sites. The perceived criticism scale was completed by 90 families prior to treatment and by 41 families at 6-month reassessment. Evaluators, blind to treatment condition, rated subthreshold symptoms of psychosis at baseline, 6- and 12-month assessments. Perceived maternal criticism decreased from pre- to posttreatment for both treatment groups, and this change in criticism predicted decreases in subthreshold positive symptoms at 12-month follow-up. This study offers evidence that participation in structured family treatment is associated with improvement in perceptions of the family environment. Further, a brief measure of perceived criticism may be useful in predicting the future course of attenuated symptoms of psychosis for CHR youth.

Challenges to the uniqueness of psychotic experience in psychosis: insights on research methodology and intervention.

SummaryPaul Bebbington’s recent Special Article on the value of psychosocial epidemiology as a tool for understanding the symptomatology of psychosis provides a fresh perspective on understanding the etiology of schizophrenia and related psychotic conditions. Assessment of psychotic-like experiences in non-clinical populations may help to clarify the role of non-psychotic symptoms such as anxiety and depression in the onset and course of psychotic disorders. This approach may also make it possible to expand the repertoire of interventions for preventing the onset or ameliorating the course of psychotic conditions. There is, however, a long road to travel before the mapping of the relationships between brain pathology, psychological symptoms, environmental stressors, and clinical diagnoses are sufficiently detailed to merit the creation of a new psychiatric nosology.

Selective Attention to Threat is Specific to Delusions in First-Episode Psychosis

People diagnosed with a psychotic disorder show a selective attention to threat bias. However, it is unknown whether this attentional bias is specifically related to delusions or more generally to psychosis since the absence of the bias has not been established in people with psychosis (without delusions). It is also unknown when this bias develops in the course of psychotic disorder. These issues are investigated in people with first episode psychosis (FEP). The Stroop task was administered to three participant groups: a FEP group with current delusions (n = 31), a FEP group without current delusions (n = 11), and a non-psychiatric control group (n = 25). The FEP with delusions group showed a selective attention to threat words compared to the other groups (p = .02). Selective attention to threat is specifically related to delusions, is present early in the course of psychosis and may be candidate for new cognitive-behavioural therapies to treat medication-resistant delusions.

The epigenome and postnatal environmental influences in psychotic disorders

Schizophrenia spectrum disorders and bipolar spectrum disorders are the product of both heritable and non-heritable factors, the impact of which converges at different biological levels. Recent evidence from molecular approaches has provided new insights about how environmental exposures cause persistent alterations in the regulation of gene expression, particularly by so-called epigenetic mechanisms. The aim of this review is to provide an overview of findings of epigenetic studies in psychotic disorders, summarizing findings of human and animal studies on epigenetic alterations due to postnatal environmental exposures associated with psychotic disorders. Electronic and manual literature search of MEDLINE, EMBASE and PSYCHINFO, using a range of search terms around epigenetics, DNA methylation, histone modifications, psychoses, schizophrenia, bipolar disorder and environmental risks associated with psychotic disorders as observed in human and experimental animal studies, complemented by review articles and cross-references. Despite several promising findings of differential epigenetic profiles in individuals with psychotic disorders in the studies published to date, the knowledge of the role of epigenetic processes in psychotic disorder remains very limited, and should be interpreted cautiously given various challenges in this rapidly evolving field of research. Integration of epigenetic findings into biopsychosocial models of the etiology of psychotic disorders eventually may yield important insights into the biological underpinnings of the onset and course of psychotic disorders.

910 – Schizophrenia and violence at home

Introduction There is good evidence from epidemiological studies that the diagnosis of schizophrenia is associated with an increased risk of violence.Some studies have linked the presence of positive symptoms, first psychotic episode, duration of untreated psychosis and lack of insight with violent behavior. Objective The primary objective was to identify factors related to violent behavior in patients diagnosed with psychotic disorder attended by our group, a multidisciplinary mobile outreach team (EMSE). Methodology We evaluated a total of 249 patients diagnosed with psychotic disorder between 2007 and 2012. We administered the following scales: PANSS, GAF (Global Assessment of Functioning), CGI (Clinical Global Impression), GEP (Severity of psychiatric illness scale, AVAT (Instrument to assess violent behavior in mental illness) and SUMD (Scale unawareness of mental disorders). To study the correlation between the scales and the score of the AVAT instrument we used the Pearson correlation. Clinical variables were also compared between aggressive and non-aggressive patients using Chisquare and Student's. Results There is a positive correlation between AVAT and PANSS-P (r = 0.544), ICG (r = 0.472), GEP (r = 0.515) and a negative correlation between AVAT and GAF (r = -0357). The correlation between AVAT and SUMD is positive (r = 0.119) but not statistically significant. Conclusion The presence of positive symptoms and clinical severity has been linked to increased aggressiveness and to predict the occurrence of violent behavior in the course of psychotic disorder. Unlike other studies, no correlation was observed with the lack of insight.

Toxoplasma gondii and neuropsychiatric diseases: strain hypothesis

Keywords Toxoplasma gondii Neuropsychiatricdiseases Strain hypothesisDear sir,The recent review article on Toxoplasma gondii and neu-ropsychiatric diseases is very interesting [1]. Fabiani et al.[1] reviewed the relationship between T. gondii and neu-ropsychiatric diseases, and mentioned some possiblemechanisms of T. gondii that might contribute to the eti-ology of neuropsychiatric diseases. Moreover, Fabiani andhis colleagues briefly remarked ‘‘strain’s parasite, timingand source of infection, and genetic host factors representpotential links between infection with T. gondii and neu-ropsychiatric diseases’’. However, i would like to commenton the importance of parasite strains in the intensity ofalterations induced by T. gondii and its roles in the etiologyof neuropsychiatric diseases. T. gondii consists of threemain genotypes with some differences in virulence andepidemiological patterns. Strain I has higher virulence thanstrains II and III. Strains I and II have been observed inAIDS patients and congenital infections, whereas strain IIIis more prevalent in animals [2]. In vitro and in vivo studiesalso showed variations in these strains [3–5], for example,gene expression in cells infected with strain I was higherthan strains II and III [4, 5]. Remarkably, an in vitro study inneuroepithelial cells showed that not only gene expressionin cells infected with type I was higher than the two otherbut also infection with type I mostly affects those genesrelated to the central nervous system functions [3]. More-over, there are evidences that the type I of T. gondii is moreinvolved in the course of psychotic disorders. In this regard,Xiao et al. [5] observed that the risk of developing adultschizophrenia and psychotic disorders in children’s ofpregnant women infected with strain I T. gondii was sig-nificantly higher than unaffected controlled mothers(OR = 1.94; p = 0.03). Groe¨r et al. [6] also found that therisk of anxiety and depression was increased in pregnantwomen with higher titers of T. gondii IgG antibody. Inter-estingly, the depression and anxiety scores were highest inwomen with serotype I. Furthermore, the differencebetween two subtypes of strain II in induction of behavioralalterations was observed in a mouse model [7].In conclusion, among many factors connecting T. gondiiand neuropsychiatric diseases, parasite strains play a piv-otal role in the intensity of alterations induced by T. gondii.Hence, strain hypothesis offers a new insight about the roleof T. gondii in the etiology of neuropsychiatric diseases.

Social dysfunction in first-episode psychosis and relations to neurocognition, duration of untreated psychosis and clinical symptoms

Signs of social dysfunction are present early in the course of psychotic disorders. There is a lack of knowledge about how premorbid function, illness history, psychotic symptoms and neurocognitive characteristics are related to social function in patients with first episode psychosis (FEP). The relationship between these factors could provide important information about the psychopathology underlying social dysfunction and have implications for future prevention and treatment efforts. Our objective is to identify early predictors of social functioning in patients with FEP. We examined 166 patients and 166 age- and gender-matched healthy controls (HC). We used a validated and comprehensive measure of social functioning (the Social Functioning Scale), a comprehensive neurocognitive test battery, in addition to measures of psychotic symptoms, duration of untreated psychosis (DUP) and premorbid adjustment (the Premorbid Adjustment Scale). Lower childhood level of social adjustment and lower psychomotor speed had the strongest influence across measures of social functioning while symptoms and DUP had a weaker influence. The main result of the current study is that premorbid social adjustment and psychomotor speed had the strongest association with measures of social functioning in patients with FEP.