The effectiveness and tolerability of trauma-focused psychotherapies for psychotic symptoms: A systematic review of trauma-focused psychotherapies.

INTRODUCTION: Psychological trauma is an established risk factor for psychosis. Trauma-focused psychotherapies (TFPT) have been suggested as a potential treatment for reducing psychotic symptoms in those who have experienced trauma. We therefore sought to investigate the effectiveness, tolerability, and acceptability of TFPT for psychotic symptoms. METHODS: We conducted a systematic review of studies of any form of TFPT that measured psychotic symptoms across a broad range of diagnoses. RESULTS: From 2584 papers initially identified, 17 studies (857 participants) met eligibility criteria. TFPT were found to be well tolerated, with very few adverse events. Acceptability was also high, with a mean dropout rate of 20%. CONCLUSIONS: Whilst the evidence of effectiveness for TFPT in reducing psychotic symptoms is weak, we found tentative evidence in favour of exposure-based interventions. Methodologically rigorous trials investigating the efficacy of TFPT for the treatment of psychotic symptoms are needed to assess this promising intervention.

Pediatric traumatic brain injury as a risk factor for psychosis and psychotic symptoms: a systematic review and meta-analysis.

BACKGROUND: Psychosis is one of the most disabling psychiatric disorders. Pediatric traumatic brain injury (pTBI) has been cited as a developmental risk factor for psychosis, however this association has never been assessed meta-analytically. METHODS: A systematic review and meta-analysis of the association between pTBI and subsequent psychotic disorders/symptoms was performed. The study was pre-registered (CRD42022360772) adopting a random-effects model to estimate meta-analytic odds ratio (OR) and 95% confidence interval (CI) using the Paule-Mandel estimator. Subgroup (study location, study design, psychotic disorder v. subthreshold symptoms, assessment type, and adult v. adolescent onset) and meta-regression (quality of evidence) analyses were also performed. The robustness of findings was assessed through sensitivity analyses. The meta-analysis is available online as a computational notebook with an open dataset. RESULTS: We identified 10 relevant studies and eight were included in the meta-analysis. Based on a pooled sample size of 479686, the pooled OR for the association between pTBI and psychosis outcomes was 1.80 (95% CI 1.11-2.95). There were no subgroup effects and no outliers. Both psychotic disorder and subthreshold symptoms were associated with pTBI. The overall association remained robust after removal of low-quality studies, however the OR reduced to 1.43 (95% CI 1.04-1.98). A leave-one-out sensitivity analysis showed the association was robust to removal of all but one study which changed the estimate to marginally non-significant. CONCLUSIONS: We report cautious meta-analytic evidence for a positive association between pTBI and future psychosis. New evidence will be key in determining long-term reliability of this finding.

Meaning and role of functional-organic distinction: a study of clinicians in psychiatry and neurology services.

The functional-organic distinction attempts to differentiate disorders with diagnosable biological causes from those without and is a central axis on which diagnoses, medical specialities and services are organised. Previous studies report poor agreement between clinicians regarding the meanings of the terms and the conditions to which they apply, as well as noting value-laden implications of relevant diagnoses. Consequently, we aimed to understand how clinicians working in psychiatry and neurology services navigate the functional-organic distinction in their work. Twenty clinicians (10 physicians, 10 psychologists) working in psychiatry and neurology services participated in semistructured interviews that were analysed applying a constructivist grounded theory approach. The distinction was described as often incongruent with how clinicians conceptualise patients' problems. Organic factors were considered to be objective, unambiguously identifiable and clearly causative, whereas functional causes were invisible and to be hypothesised through thinking and conversation. Contextual factors-including cultural assumptions, service demands, patient needs and colleagues' views-were key in how the distinction was deployed in practice. The distinction was considered theoretically unsatisfactory, eventually to be superseded, but clinical decision making required it to be used strategically. These uses included helping communicate medical problems, navigating services, hiding meaning by making psychological explanations more palatable, tackling stigma, giving hope, and giving access to illness identity. Clinicians cited moral issues at both individual and societal levels as integral to the conceptual basis and deployment of the functional-organic distinction and described actively navigating these as part of their work. There was a considerable distance between the status of the functional-organic distinction as a sound theoretical concept generalisable across conditions and its role as a gatekeeping tool within the structures of healthcare. Ambiguity and contradictions were considered as both obstacles and benefits when deployed in practice and strategic considerations were important in deciding which to lean on.

Prevalence of Neuroradiological Abnormalities in First-Episode Psychosis: A Systematic Review and Meta-analysis.

Importance: Individuals presenting with first-episode psychosis (FEP) may have a secondary ("organic") etiology to their symptoms that can be identified using neuroimaging. Because failure to detect such cases at an early stage can have serious clinical consequences, it has been suggested that brain magnetic resonance imaging (MRI) should be mandatory for all patients presenting with FEP. However, this remains a controversial issue, partly because the prevalence of clinically relevant MRI abnormalities in this group is unclear. Objective: To derive a meta-analytic estimate of the prevalence of clinically relevant neuroradiological abnormalities in FEP. Data Sources: Electronic databases Ovid, MEDLINE, PubMed, Embase, PsychINFO, and Global Health were searched up to July 2021. References and citations of included articles and review articles were also searched. Study Selection: Magnetic resonance imaging studies of patients with FEP were included if they reported the frequency of intracranial radiological abnormalities. Data Extraction and Synthesis: Independent extraction was undertaken by 3 researchers and a random-effects meta-analysis of pooled proportions was calculated. Moderators were tested using subgroup and meta-regression analyses. Heterogeneity was evaluated using the I2 index. The robustness of results was evaluated using sensitivity analyses. Publication bias was assessed using funnel plots and Egger tests. Main Outcomes and Measures: Proportion of patients with a clinically relevant radiological abnormality (defined as a change in clinical management or diagnosis); number of patients needed to scan to detect 1 such abnormality (number needed to assess [NNA]). Results: Twelve independent studies (13 samples) comprising 1613 patients with FEP were included. Of these patients, 26.4% (95% CI, 16.3%-37.9%; NNA of 4) had an intracranial radiological abnormality, and 5.9% (95% CI, 3.2%-9.0%) had a clinically relevant abnormality, yielding an NNA of 18. There were high degrees of heterogeneity among the studies for these outcomes, 95% to 73%, respectively. The most common type of clinically relevant finding was white matter abnormalities, with a prevalence of 0.9% (95% CI, 0%-2.8%), followed by cysts, with a prevalence of 0.5% (95% CI, 0%-1.4%). Conclusions and Relevance: This systematic review and meta-analysis found that 5.9% of patients presenting with a first episode of psychosis had a clinically relevant finding on MRI. Because the consequences of not detecting these abnormalities can be serious, these findings support the use of MRI as part of the initial clinical assessment of all patients with FEP.

Longitudinal associations between stroke and psychosis: a population-based study.

BACKGROUND: The co-occurrence of stroke and psychosis is a serious neuropsychiatric condition but little is known about the course of this comorbidity. We aimed to estimate longitudinal associations between stroke and psychosis over 10 years. METHODS: A 10-year population-based study using data from the English Longitudinal Study of Ageing. A structured health assessment recorded (i) first-occurrence stroke and (ii) psychosis, at each wave. Each were considered exposures and outcomes in separate analyses. Logistic and Cox proportional hazards regression and Kaplan-Meier methods were used. Models were adjusted for demographic and health behaviour covariates, with missing covariates imputed using random forest multiple imputation. RESULTS: Of 19 808 participants, 24 reported both stroke and psychosis (median Wave 1 age 63, 71% female, 50% lowest quintile of net financial wealth) at any point during follow-up. By 10 years, the probability of an incident first stroke in participants with psychosis was 21.4% [95% confidence interval (CI) 12.1-29.6] compared to 8.3% (95% CI 7.8-8.8) in those without psychosis (absolute difference: 13.1%; 95% CI 20.8-4.3, log rank p < 0.001; fully-adjusted hazard ratio (HR): 3.57; 95% CI 2.18-5.84). The probability of reporting incident psychosis in participants with stroke was 2.3% (95% CI 1.4-3.2) compared to 0.9% (95% CI 0.7-1.1) in those without (absolute difference: 1.4%; 95% CI 0.7-2.1, log rank p < 0.001; fully-adjusted HR: 4.98; 95% CI 2.55-9.72). CONCLUSIONS: Stroke is an independent predictor of psychosis (and vice versa), after adjustment for potential confounders.

Association between stroke and psychosis across four nationally representative psychiatric epidemiological studies.

BACKGROUND: Both stroke and psychosis are independently associated with high levels of disability. However, psychosis in the context of stroke has been under-researched. To date, there are no general population studies on their joint prevalence and association. AIMS: To estimate the joint prevalence of stroke and psychosis and their statistical association using nationally representative psychiatric epidemiology studies from two high-income countries (the UK and the USA) and two middle-income countries (Chile and Colombia) and, subsequently, in a combined-countries data-set. METHOD: Prevalences were calculated with 95% confidence intervals. Statistical associations between stroke and psychosis and between stroke and psychotic symptoms were tested using regression models. Overall estimates were calculated using an individual participant level meta-analysis on the combined-countries data-set. The analysis is available online as a computational notebook. RESULTS: The overall prevalence of probable psychosis in stroke was 3.81% (95% CI 2.34-5.82) and that of stroke in probable psychosis was 3.15% (95% CI 1.94-4.83). The odds ratio of the adjusted association between stroke and probable psychosis was 3.32 (95% CI 2.05-5.38). On the individual symptom level, paranoia, hallucinated voices and thought passivity delusion were associated with stroke in the unadjusted and adjusted analyses. CONCLUSIONS: Rates of association between psychosis and stroke suggest there is likely to be a high clinical need group who are under-researched and may be poorly served by existing services.

Formalising social representation to explain psychiatric symptoms.

Recent work in social cognition has moved beyond a focus on how people process social rewards to examine how healthy people represent other agents and how this is altered in psychiatric disorders. However, formal modelling of social representation has not kept pace with these changes, impeding our understanding of how core aspects of social cognition function, and fail, in psychopathology. Here, we suggest that belief-based computational models provide a basis for an integrated sociocognitive approach to psychiatry, with the potential to address important but unexamined pathologies of social representation, such as maladaptive schemas and illusory social agents.

Neuropsychiatric Features of Fregoli Syndrome: An Individual Patient Meta-Analysis.

OBJECTIVE: Fregoli syndrome is a rare delusion characterized by the belief that familiar people are presenting themselves disguised as others to the affected person. Theories of delusional misidentification have suggested secondary ("organic") underlying mechanisms; however, the pathoetiology of Fregoli syndrome has not been systematically evaluated. The investigators aimed to compare the neuropsychiatric features of Fregoli syndrome in primary and secondary psychoses. METHODS: A systematic review and patient-level meta-analysis were conducted. Five databases were searched, ultimately yielding 83 studies that met selection criteria. Demographic characteristics, diagnosis, delusional content, neuropsychiatric features, investigations, and treatment information were extracted. Random-effects models were calculated, and odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. RESULTS: A total of 119 patients with Fregoli syndrome were identified: 62 patients (52%) with primary psychosis, 50 (42%) with secondary psychosis, and seven (6%) with an unclear etiology. Patients with secondary psychosis were less likely than patients with primary psychosis to experience persecutory features (OR=0.26, 95% CI=0.10, 0.67; p=0.0057). Moreover, patients with secondary psychosis were more likely to experience Fregoli syndrome during a first episode of psychosis (OR=11.00, 95% CI=2.45, 49.39; p=0.0017). Right-sided brain lesions were more prominent than left-sided brain lesions in the total sample (χ2=5.0, df=1, p=0.025) and in the secondary psychosis subgroup (χ2=4.26, df=1, p=0.039). CONCLUSIONS: This is the first meta-analysis to investigate Fregoli syndrome. An estimated 42% of the reported cases involved a secondary etiology. These findings provide clinicians with a better understanding of the symptomatology of Fregoli syndrome and have potential to be applied in future research and clinical practice.

Sleep disorders predict the 1-year onset, persistence, but not remission of psychotic experiences in preadolescence: a longitudinal analysis of the ABCD cohort data.

The relationship between sleep disorder and psychotic experiences in preadolescence has not been extensively studied despite the potential for intervention. The current study addressed this relationship using the Adolescent Brain and Cognitive Development (ABCD) cohort, which provided baseline data from 11,830 10- to 11-year-old; for 4910 of these, 1-year follow-up data were also available. A set of pre-registered multi-level regression models were applied to test whether (a) sleep disorder is associated with psychotic experiences at baseline; (b) baseline sleep disorder predicts psychotic experiences at follow-up; (c) the persistence of sleep disorder predicts persistence of psychotic experiences at follow-up; d) the remission of sleep disorder predicts the remission of psychotic experiences at follow-up. After controlling for potential confounders, sleep disorder was associated with psychotic experiences cross-sectionally (OR = 1.40, 95% CI 1.20-1.63), at 1-year follow-up (OR = 1.32, 95% CI 1.11-1.57), and the persistence of sleep disorder predicted the persistence of psychotic experiences (OR = 1.72, 95% CI 1.44-2.04). However, remission of sleep problems did not predict remission of psychotic experiences (OR = 1.041, 95% CI 0.80-1.35). The results indicate that sleep disorders in preadolescence are common and associated with psychotic experiences, although the lack of co-remission raises questions about the mechanism of association. However, given these findings, and existing evidence in later adolescence and adults, further investigation of sleep as a preventative mental health intervention target in this age group is warranted.

Reward Processing in Children With Psychotic-Like Experiences.

Alterations to striatal reward pathways have been identified in individuals with psychosis. They are hypothesized to be a key mechanism that generate psychotic symptoms through the production of aberrant attribution of motivational salience and are proposed to result from accumulated childhood adversity and genetic risk, making the striatal system hyper-responsive to stress. However, few studies have examined whether children with psychotic-like experiences (PLEs) also exhibit these alterations, limiting our understanding of how differences in reward processing relate to hallucinations and delusional ideation in childhood. Consequently, we examined whether PLEs and PLE-related distress were associated with reward-related activation in the nucleus accumbens (NAcc). The sample consisted of children (N = 6718) from the Adolescent Brain Cognitive Development (ABCD) study aged 9-10 years who had participated in the Monetary Incentive Delay (MID) task in functional MRI. We used robust mixed-effects linear regression models to investigate the relationship between PLEs and NAcc activation during the reward anticipation and reward outcome stages of the MID task. Analyses were adjusted for gender, household income, ethnicity, depressive symptoms, movement in the scanner, pubertal development, scanner ID, subject and family ID. There was no reliable association between PLEs and alterations to anticipation- or outcome-related striatal reward processing. We discuss the implications for developmental models of psychosis and suggest a developmental delay model of how PLEs may arise at this stage of development.

The roles of coalitional threat and safety in paranoia: A network approach.

OBJECTIVE: Paranoia is known to vary with levels of coalitional threat and safety present in the social environment. However, it remains underexplored whether threat and safety are differentially associated with paranoia, if these relationships vary with the source of threat and safety, and whether such effects hold across the continuum of severity of paranoid thoughts. METHODS: We employed a network analysis approach with community analysis on a large dataset (n = 6,337), the UK Adult Psychiatric Morbidity Survey 2007, to explore these questions. We included one node to capture paranoia typical in the general population, and one pertaining to thought interference common in persecutory delusions in psychosis. RESULTS: Nodes reflecting paranoia in the general population as well as persecution-related concerns in psychosis shared the strongest positive edges with nodes representing threat stemming from close social relationships. Paranoia common in the general population was negatively associated with both safety stemming from the wider social environment, and safety in close relationships, where the former association was strongest. CONCLUSIONS: Our results suggest that threat from within one's immediate social group is more closely linked to paranoid thoughts than is safety from either one's social group or the wider social environment. Further, our results imply that coalitional threat may be a particularly associated with concerns common in psychosis, whereas paranoid ideation more common in the general population is also associated with reduced coalitional safety. Overall, this network analysis offers a broad view of how paranoia relates to multiple aspects of our coalitional environment and provides some testable predictions for future research in this area. PRACTITIONER POINTS: Individuals with paranoia more typical of delusions may find threat in close social relationships most challenging Variation in paranoia in the general population may be attributed to feeling safe in the wider social environment more than in close social relationships.

Illusory social agents within and beyond voices: A computational linguistics analysis of the experience of psychosis.

OBJECTIVES: Psychosis has a strong social component and often involves the experience of being affected by 'illusory social agents'. However, this experience remains under-characterized, particularly for social agents in delusions and non-vocal hallucinations. One useful approach is a form of computational linguistics called corpus linguistics that studies texts to identify patterns of meaning encoded in both the semantics and linguistic structure of the text. METHODS: Twenty people living with psychosis were recruited from community and inpatient services. They participated in open-ended interviews on their experiences of social agents in psychosis and completed a measure of psychotic symptoms. Corpus linguistics analysis was used to identify key phenomenological features of vocal and non-vocal social agents in psychosis. RESULTS: Social agents i) are represented with varying levels of richness in participants' experiences, ii) are attributed with different kinds of identities including physical characteristics and names, iii) are perceived to have internal states and motivations that are different from those of the participants, and iv) interact with participants in various ways including through communicative speech acts, affecting participants' bodies, and moving through space. These representations were equally rich for agents associated with hallucinated voices and those associated with non-vocal hallucinations and delusions. CONCLUSIONS: We show that the experience of illusory social agents is a rich and complex social experience reflecting many aspects of genuine social interaction and is not solely present in auditory hallucinations, but also in delusions and non-vocal hallucinations. PRACTITIONER POINTS: The experience of being affected by illusory social agents in psychosis extends beyond hallucinated voices. They are a rich and complex social experience reflecting many aspects of genuine social interaction. These are also likely to be a source of significant distress and disability.

Family functioning but not social capital is associated with better mental health in adolescents affected by violence and displacement by armed conflict in Colombia.

BACKGROUND: The effect of the Colombian armed conflict on the mental health of adolescents is still poorly understood. AIMS: Given social interventions are most likely to inform policy, we tested whether two potential intervention targets, family functioning and social capital, were associated with mental health in Colombian adolescents, and whether this was moderated by experience of violence and displacement. METHODS: We examined the cross-sectional association between family functioning, cognitive social capital, structural social capital and 12-month prevalence of Composite International Diagnostic Interview (CIDI) diagnosed psychiatric disorder, using data on 12 to 17-year-old adolescents (N = 1,754) from the 2015 National Mental Health Survey of Colombia, a nationally representative epidemiological study. We tested whether associations survived cumulative adjustment for demographic confounders, experience of non-specific violence and harm and displacement by armed conflict. RESULTS: Neither structural nor cognitive social capital were associated with better mental health. Better family functioning was associated with reduced risk of poor mental health in an unadjusted analysis (OR 0.90 [0.85-0.96]), and after cumulative adjustments for demographic confounders (OR 0.91 [0.86-0.97]), non-specific violence and harm (OR 0.91 [0.86-0.97]) and social capital variables (OR 0.91 [0.85-0.97]). In the final model, each additional point on the family APGAR scale was associated with a 9% reduced odds of any CIDI diagnosed disorder in the last 12 months. CONCLUSIONS: Better family functioning was associated with better mental health outcomes for all adolescents. This effect remained present in those affected by the armed conflict even after accounting for potential confounders.

Trusting and learning from others: immediate and long-term effects of learning from observation and advice.

Social learning underpins our species's extraordinary success. Learning through observation has been investigated in several species, but learning from advice-where information is intentionally broadcast-is less understood. We used a pre-registered, online experiment (n = 1492) combined with computational modelling to examine learning through observation and advice. Participants were more likely to immediately follow advice than to copy an observed choice, but this was dependent upon trust in the adviser: highly paranoid participants were less likely to follow advice in the short term. Reinforcement learning modelling revealed two distinct patterns regarding the long-term effects of social information: some individuals relied fully on social information, whereas others reverted to trial-and-error learning. This variation may affect the prevalence and fidelity of socially transmitted information. Our results highlight the privileged status of advice relative to observation and how the assimilation of intentionally broadcast information is affected by trust in others.

Item-specific overlap between hallucinatory experiences and cognition in the general population: A three-step multivariate analysis of international multi-site data.

Hallucinatory experiences (HEs) can be pronounced in psychosis, but similar experiences also occur in nonclinical populations. Cognitive mechanisms hypothesized to underpin HEs include dysfunctional source monitoring, heightened signal detection, and impaired attentional processes. Using data from an international multisite study on non-clinical participants (N = 419), we described the overlap between two sets of variables - one measuring cognition and the other HEs - at the level of individual items. We used a three-step method to extract and examine item-specific signal, which is typically obscured when summary scores are analyzed using traditional methodologies. The three-step method involved: (1) constraining variance in cognition variables to that which is predictable from HE variables, followed by dimension reduction, (2) determining reliable HE items using split-halves and permutation tests, and (3) selecting cognition items for interpretation using a leave-one-out procedure followed by repetition of Steps 1 and 2. The results showed that the overlap between HEs and cognition variables can be conceptualized as bi-dimensional, with two distinct mechanisms emerging as candidates for separate pathways to the development of HEs: HEs involving perceptual distortions on one hand (including voices), underpinned by a low threshold for signal detection in cognition, and HEs involving sensory overload on the other hand, underpinned by reduced laterality in cognition. We propose that these two dimensions of HEs involving distortions/liberal signal detection, and sensation overload/reduced laterality may map onto psychosis-spectrum and dissociation-spectrum anomalous experiences, respectively.

Correlates of Hallucinatory Experiences in the General Population: An International Multisite Replication Study.

Hallucinatory experiences can occur in both clinical and nonclinical groups. However, in previous studies of the general population, investigations of the cognitive mechanisms underlying hallucinatory experiences have yielded inconsistent results. We ran a large-scale preregistered multisite study, in which general-population participants (N = 1,394 across 11 data-collection sites and online) completed assessments of hallucinatory experiences, a measure of adverse childhood experiences, and four tasks: source memory, dichotic listening, backward digit span, and auditory signal detection. We found that hallucinatory experiences were associated with a higher false-alarm rate on the signal detection task and a greater number of reported adverse childhood experiences but not with any of the other cognitive measures employed. These findings are an important step in improving reproducibility in hallucinations research and suggest that the replicability of some findings regarding cognition in clinical samples needs to be investigated.

Derationalizing Delusions.

Because of the traditional conceptualization of delusion as "irrational belief," cognitive models of delusions largely focus on impairments to domain-general reasoning. Nevertheless, current rationality-impairment models do not account for the fact that (a) equivalently irrational beliefs can be induced through adaptive social cognitive processes, reflecting social integration rather than impairment; (b) delusions are overwhelmingly socially themed; and (c) delusions show a reduced sensitivity to social context both in terms of how they are shaped and how they are communicated. Consequently, we argue that models of delusions need to include alteration to coalitional cognition-processes involved in affiliation, group perception, and the strategic management of relationships. This approach has the advantage of better accounting for both content (social themes) and form (fixity) of delusion. It is also supported by the established role of mesolimbic dopamine in both delusions and social organization and the ongoing reconceptualization of belief as serving a social organizational function.