Childhood interpersonal trauma and premorbid social adjustment as predictors of symptom remission in first episode psychosis.

BACKGROUND: Childhood interpersonal trauma (CIT) and premorbid adjustment are both associated with poor outcome in psychosis. In this study we investigate the relative impact of CIT and premorbid adjustment on symptom remission in first episode psychosis (FEP) over two years. METHOD: A total of 232 participants with FEP were recruited through the early detection program of the The early detection and Intervention in Psychosis (TIPS)-2 study and followed up after two years. Symptom remission was according to consensus criteria. CIT was assessed with the semi-structured interview Freyd Goldberg Brief Betrayal Trauma Survey, and premorbid adjustment with the Premorbid Adjustment Scale. Generalized estimating equations and multivariate models were used to analyze the associations between remission, symptom levels over time, CIT and premorbid adjustment; and a path analysis of mediation effects of CIT through premorbid adjustment on remission. RESULTS: In this sample with 57% males and a mean age of 26.6 years (SD 10.2), a third of participants had experienced CIT. The participants with CIT had poorer premorbid adjustment compared to those without. Statistical analyses found independent effects of CIT and an interaction effect of CIT with premorbid adjustment on remission after two years, suggesting that CIT moderates the effect of premorbid adjustment. However contrary to expectations, premorbid adjustment did not mediate the effect of CIT. CONCLUSION: Our findings indicate a complex interplay between effects of interpersonal trauma and premorbid social adjustment on remission in psychosis. CIT appeared to moderate the effect of premorbid adjustment such that individuals with CIT and who had poor social functioning in childhood are at greater risk of non-remission. Findings indicate that better premorbid social relations could provide a buffer for the effects of trauma on symptom course.

Sleep disturbance mediates the link between childhood trauma and clinical outcome in severe mental disorders.

BACKGROUND: The experience of childhood trauma is linked to more severe symptoms and poorer functioning in severe mental disorders; however, the mechanisms behind this are poorly understood. We investigate the relationship between childhood trauma and sleep disturbances in severe mental disorders including the role of sleep disturbances in mediating the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning. METHODS: In total, 766 participants with schizophrenia-spectrum (n = 418) or bipolar disorders (n = 348) were assessed with the Childhood Trauma Questionnaire. Sleep disturbances were assessed through the sleep items in the self-reported Inventory of Depressive Symptoms. Clinical symptoms and functioning were assessed with The Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale. Mediation analyses using ordinary least squares regression were conducted to test if sleep disturbances mediated the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning. RESULTS: Symptoms of insomnia, but not hypersomnia or delayed sleep phase, were significantly more frequent in participants with childhood trauma experiences compared to those without. Physical abuse, emotional abuse, and emotional neglect were significantly associated with insomnia symptoms. Insomnia symptoms partly mediate the relationship between childhood trauma and the severity of positive and depressive/anxiety symptoms, in addition to poorer functioning. CONCLUSION: We found frequent co-occurrence of childhood trauma history and current insomnia in severe mental disorders. Insomnia partly mediated the relationship between childhood trauma and the severity of clinical symptoms and functional impairment.

Sexual abuse and physical neglect in childhood are associated with affective theory of mind in adults with schizophrenia.

Whereas childhood trauma is associated with reduced nonsocial cognition in schizophrenia, research on the relationship between childhood trauma and social cognition is limited and mixed. The aim of this study was to examine the association between childhood trauma and theory of mind (ToM) in persons with schizophrenia (n = 68) compared to healthy control participants (n = 70). Childhood trauma was assessed with the Childhood Trauma Questionnaire (CTQ), providing information on physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect. ToM was indexed by the Movie for the Assessment of Social Cognition (MASC), which yields scores for total, cognitive and affective ToM, and for three error types (overmentalizing, undermentalizing, no mentalizing). Persons with schizophrenia had elevated rates of childhood trauma and lower ToM scores than healthy controls. In the schizophrenia group, associations between sexual abuse and affective ToM was statistically significant. In regression analyses, physical neglect was found to be the strongest predictor of affective ToM. In healthy controls, childhood trauma was not associated with ToM. Follow-up analyses comparing individuals with/without clinically significant childhood trauma, confirmed the findings for the schizophrenia group. No causal inferences can be made in this cross-sectional study, but the results suggest an illness-specific association between both sexual abuse and physical neglect in childhood, and adult affective ToM in individuals with schizophrenia.

Vitamin D levels, brain volume, and genetic architecture in patients with psychosis.

BACKGROUND: Lower vitamin D levels are found in people with schizophrenia and depressive disorders, and also associated with neuroimaging abnormalities such as reduced brain volume in both animals and humans. Reduced whole brain and increased ventricular volume are also systematically reported in schizophrenia. Even though vitamin D deficiency has been proposed as a risk mechanism for schizophrenia there exist no studies to date of the association between vitamin D levels and brain volume in this population. Therefore, we investigated the relationship between vitamin D levels and brain phenotypes in psychotic disorders, and assessed possible interactions with genetic variants in vitamin D receptor (VDR) and other genetic variants that play a role in vitamin D levels in the body. METHODS: Our sample consisted of 83 psychosis patients and 101 healthy controls. We measured vitamin D levels as serum 25-hydroxyvitamin D. All participants were genotyped and neuroimaging conducted by structural magnetic resonance imaging. RESULTS: Vitamin D levels were significantly positively associated with peripheral grey matter volume in patients (ß 860.6; 95% confidence interval (CI) 333.4-1466, p < .003). A significant interaction effect of BSML marker (rs1544410) was observed to mediate the association between patient status and both white matter volume (ß 23603.3; 95% CI 2732.8-48708.6, p < .05) and whole brain volume (ß 46670.6, 95% CI 8817.8-93888.3, p < .04). Vitamin D did not predict ventricular volume, which rather was associated with patient status (ß 4423.3, 95% CI 1583.2-7267.8p < .002) and CYP24A1 marker (rs6013897) (ß 2491.5, 95% CI 269.7-4978.5, p < .04). CONCLUSIONS: This is the first study of the association between vitamin D levels and brain volume in patients with psychotic disorders that takes into account possible interaction with genetic polymorphisms. The present findings warrant replication in independent samples.

Psychosis: clinical insight and beliefs in immigrants in their first episode.

AIM: Lack of insight into illness is frequent in psychotic disorders and seen as part of their primary pathology. The recognition of symptoms as psychotic, and beliefs about treatment alternatives, is also influenced by socio-cultural factors. Here we examined clinical insight into illness and beliefs about psychosis in immigrants in their first episode of psychosis compared with a reference group. METHODS: A total of 277 first-episode psychosis participants were recruited to this cross-sectional study; 40 first- and 40 second-generation immigrants from Europe, Americas and Oceania (n = 37), Asia including Turkey (n = 28) or Africa (n = 15). The Birchwood Insight Scale was used to measure clinical insight and 'The Attitudes and Beliefs about Mental Health Problems' schizophrenia version to assess socio-cultural beliefs. RESULTS: Immigrants did not differ from the reference sample in clinical insight. After controlling for education level, first-generation immigrants were less likely to recognize psychotic symptoms (odds ratio (OR) 2.9; Wald = 8.977, degrees of freedom (d.f.) 1, P = 0.003) and viewed hospitalization (OR 5.2; Wald = 20.388, d.f. 1, P = 0.001) and treatment by a psychiatrist (OR 4.9; Wald = 6.609, d.f. 1, P = 0.01)) as less beneficial than the reference group. Immigrants from Asia held more alternative explanations (OR 0.3; Wald = 6.567, d.f. 1, P = 0.010). There were significantly stronger associations between clinical insight and socio-cultural beliefs in the reference group. CONCLUSIONS: Socio-cultural beliefs about psychosis in immigrants in first-episode psychosis call for more tailored information to this group, and emphasize the importance of treatment interventions involving both a cultural and personal perspective of insight.

Early clinical recovery in first-episode psychosis: Symptomatic remission and its correlates at 1-year follow-up.

The aim was to gain more knowledge about early clinical recovery in first-episode psychosis (FEP). The interrelationship between symptomatic remission, poor global functioning and neurocognitive impairment was investigated. FEP participants (n =91) from the TOP study were investigated at baseline and 1-year follow-up. Symptomatic remission was defined by internationally standardized criteria. Poor global functioning was defined as GAF-F score ≤60. Neurocognitive impairment was defined as 1.5 standard deviation below healthy controls on a neuropsychological composite score. Finally, early clinical recovery was defined as symptomatic remission during the last 6 months and functional remission (1. GAF-F score ≥61, 2. at least 50% study/employment, and 3. living independently). At 1-year follow-up 26% were in symptomatic remission, predicted by duration of untreated psychosis and baseline positive symptoms. Significantly fewer in the symptomatic remission group had poor global functioning compared to the non-remission group, with no difference in the rate of neurocognitive impairment. Finally, 14% were considered in early clinical recovery. They had the same rate of neurocognitive impairment as the remaining group. These findings imply that symptomatic remission and early clinical recovery can already be identified at 1-year follow-up, and that this is relatively independent of neurocognitive impairment.

Vitamin D status in psychotic disorder patients and healthy controls--The influence of ethnic background.

Vitamin D deficiency is common among patients with psychotic disorders and could be due to unknown disease mechanisms or contingent factors. However most studies are performed in chronic patients and have often failed to address the influence of ethnicity on vitamin D levels in clinical samples. We investigated serum concentrations of 25-hydroxy vitamin D (S-25 OH D) in first episode patients compared to patients with multi episodes and healthy controls; with a specific focus on differences between visible ethnic minorities and participants from the majority population. A total of 284 participants were included in this cross-sectional study. First episode patients with a DSM-IV psychotic disorder were matched on age, gender and ethnicity to participants from a multi episode patient sample (1:1) and healthy controls (1:2). We did not find any differences between either patient groups or the healthy controls, but participants from visible ethnic minorities had significantly lower S-25 OH D than participants from the majority population. This implies that S-25 OH D should be routinely measured in persons from visible ethnic minorities since low levels are associated with higher levels of depressive symptoms.

Migrant background and ethnic minority status as predictors for duration of untreated psychosis.

AIM: The aim of the study was to explore if patients with migration and/or ethnic minority background have longer duration of untreated psychosis (DUP) than patients from the reference population, and in case to what extent this was best explained by ethnic minority status or migration background, including age at migration. METHODS: Four hundred sixty-two first-episode patients were included. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders was used for diagnostic purposes. Patients were interviewed about migration history and ethnicity using structured questionnaires. RESULTS: Being part of an ethnic minority group had a trend-level significance, and migration after the age of 6 had a statistically significant association with prolonged DUP. CONCLUSIONS: Age at migration has a moderate, but statistically significant effect on DUP. The findings indicate migrating after school start is associated with a longer DUP in immigrant populations.

The impact of immigration and visible minority status on psychosis symptom profile.

PURPOSE: Immigrants have heightened risks of psychotic disorders, and it is proposed that migration influences symptom profiles. The purpose of this study was to investigate if either migration experience and/or visible minority status affected symptom profiles, using a cross-culturally validated five-factor model of the Positive and Negative Syndrome Scale (PANSS), in patients with broadly defined psychotic disorders. METHODS: PANSS was assessed in a large catchment area based sample of patients with psychotic disorders verified with the Structured Clinical Interview for DSM-IV (n = 1,081). Symptom profiles based on Wallwork et al. five-factor model were compared for Norwegians (73 %), white immigrants (10.5 %), and visible minority groups (16.5 %). RESULTS: Visible minorities were significantly younger, had less education, more often a schizophrenia diagnosis and higher PANSS positive, negative and disorganized/concrete factor scores than Norwegians and white immigrants. After controlling for confounders only the items "Delusions" and "Difficulty in abstract thinking" differed between groups. Multivariate analyses indicated that these items were not associated with immigration per se, but rather belonging to a visible minority. CONCLUSION: We found mostly similarities in psychotic symptoms between immigrants and Norwegians when using a cross-culturally validated five-factor model of the PANSS. Immigration did not directly influence psychotic symptom profiles but visible minority groups had higher levels of "Delusions" and "Difficulty in abstract thinking", both symptoms that are partially context dependent.

Neurocognitive features in subgroups of bipolar disorder.

OBJECTIVE: To examine which subgroups of DSM-IV bipolar disorder (BD) [BD type I (BD-I) or BD type II (BD-II), and subgroups based on history of psychosis, presenting polarity, and age at onset] differentiate best regarding neurocognitive measures. METHODS: A total of 199 patients with BD were characterized by clinical and neurocognitive features. The distribution of subgroups in this sample was: BD-I, 64% and BD-II, 36%; 60% had a history of psychosis; 57% had depression as the presenting polarity; 61% had an early onset of BD, 25% had a mid onset, and 14% had a late onset. We used multivariate regression analyses to assess relationships between neurocognitive variables and clinical subgroups. RESULTS: Both BD-I diagnosis and elevated presenting polarity were related to impairments in verbal memory, with elevated presenting polarity explaining more of the variance in this cognitive domain (22.5%). History of psychosis and BD-I diagnosis were both related to impairment in semantic fluency, with history of psychosis explaining more of the variance (11.6%). CONCLUSION: Poor performance in verbal memory appears to be associated with an elevated presenting polarity, and poor performance in semantic fluency appears to be associated with a lifetime history of psychosis.

A cross-sectional study of vitamin D deficiency among immigrants and Norwegians with psychosis compared to the general population.

OBJECTIVE: Vitamin D deficiency is common among immigrants, who, as a group, have heightened risk of psychosis. This study aimed to determine vitamin D levels among immigrants and Norwegians with psychosis compared to the general population and their association to clinical characteristics. METHOD: This study compared vitamin D levels between immigrants and Norwegians within and between samples of patients with psychosis from a catchment area-based cross-sectional study (2002-2007) with a sample from a population-based health study from the same catchment area (2000-2001). The psychosis sample included patients with a Structured Clinical Interview for DSM-IV Axis I Disorders diagnosis of psychotic disorder (67 immigrants, 66 Norwegians). The reference sample consisted of 1,046 subjects (177 immigrants, 869 Norwegians). Serum levels of vitamin D were measured by radioimmunoassay, and results were presented as 25-hydroxyvitamin D levels. RESULTS: Over 80% (n = 55) of immigrant patients with psychosis had insufficient/deficient serum levels of 25-hydroxyvitamin D (< 50 nmol/L). Immigrants had higher rates of 25-hydroxyvitamin D deficiency than Norwegians (P < .001). Norwegians with psychosis had lower serum levels of 25-hydroxyvitamin D than Norwegians in the reference sample from the general public (P < .001). 25-hydroxyvitamin D levels correlated with certain negative/depressive symptoms among patients with psychosis. CONCLUSIONS: An alarmingly high percentage of immigrants and Norwegians with psychotic disorders have 25-hydroxyvitamin D deficiency. This has important clinical implications as it suggests possible beneficial effects of vitamin D medication/heliotherapy within this group.

Depression and depressive symptoms in first episode psychosis.

The aims of this study were to examine the prevalence and pattern of lifetime Diagnostic and Structural Manual of Mental Disorders (fourth version) major depressive episodes, and the relationship between patient characteristics and current severity of depressive symptoms in first episode psychosis patients (FEPP). A total of 122 FEPP from the ongoing longitudinal thematically organized psychosis research study were included at first treatment. A total of 58 patients (48%) had experienced one or more major depressive episodes; 21 (17%) before onset of psychosis and 37 (30%) during or after onset of psychosis. Poor premorbid childhood adjustment, substance abuse, and excitative symptoms at start of treatment were statistically significant associated with higher current severity of depressive symptoms. Alcohol use was significantly associated with current severity of depression in men, while excitative symptoms were associated in women. Thus depressive symptoms are frequent among FEPP, with indications of gender specific differences in patient characteristics that might imply different approaches to treatment.

Age at onset of bipolar disorder in a Norwegian catchment area sample.

BACKGROUND: Early onset of bipolar disorder (BD) is an important clinical predictor of a more severe course and poorer outcome. A higher proportion of childhood onset BD has been reported in studies from USA compared to Europe. We investigated age at onset of first affective episode in a Norwegian sample and compared it to previous European and US findings. In addition, we examined whether age at onset influenced on time to first treatment, and if patient characteristics related to illness severity influenced age at onset. METHODS: Two hundred and twenty five BD patients were recruited consecutively mainly from psychiatric out-patient units at three major hospitals in Oslo, Norway, diagnosed using SCID-I and divided into four groups based on age at onset. RESULTS: Six percent of the patients had onset in childhood, 32% in adolescence, 43% in young adulthood, and 19% as adults. Average age at onset was 22.8 years (SD 9.4). There was a significantly higher age at onset and a significantly shorter time from onset to first treatment in patients with lifetime hospitalization. LIMITATION: Retrospective information which could be confounded by collection bias. CONCLUSION: Age at onset in our sample resembled previous European studies, but not US- or Norwegian studies. The difference in age at onset seems more related to different definitions of onset, than to hospitalization history. This highlights the importance of improving the research criteria and of using similar criteria to ascertain age at onset.