Similarities and Differences in Associations Between Duration of Untreated Psychosis (DUP) and Demographic, Premorbid, and Symptom Severity Measures in Two Samples of First-Episode Psychosis Patients from Mexico and the United States.

Early-psychosis researchers have documented that duration of untreated psychosis (DUP) is an important predictor of outcomes in first-episode psychosis. Very few cross-national studies have been conducted, and none have been carried out involving patients from both Mexico and the U.S. We collaborated to answer three questions: (1) Are DUP estimates similar in two very different settings and samples? (2) Are demographic variables, premorbid adjustment, and symptom severity similarly related to DUP in the two different settings? (3) Does the same set of variables account for a similar proportion of variance in DUP in the two settings? Data on sociodemographic characteristics, premorbid adjustment, symptom severity, and DUP were available for 145 Mexican and 247 U.S. first-episode psychosis patients. DUP was compared, and bivariate analyses and multiple linear regressions were carried out in each sample. DUP estimates were similar (medians of 35 weeks in Mexico and 38 weeks in the U.S.). In the Mexican sample, DUP was associated with gender, employment status, premorbid social adjustment, and positive symptom severity (explaining 18% of variance). In the U.S. sample, DUP was associated with age, employment status, premorbid social adjustment, and positive symptom severity (but in the opposite direction of that observed in the Mexican sample), accounting for 25% of variance. Additional cross-national collaborations examining key facets of early-course psychotic disorders, including DUP, will clarify the extent of generalizability of findings, strengthen partnerships for more internationally relevant studies, and support the global movement to help young people struggling with first-episode psychosis and their families.

Disfiguring facial lesions and loss of sensation.

Hansen disease (leprosy) continues to be prevalent in some regions of Africa, Asia, and South America, and each year 100 to 300 cases are reported in the United States, especially in immigrants and patients exposed to armadillos. Treatment depends on patient presentation. Hansen disease remains highly stigmatized, though it is now clear that it is not readily transmitted through casual physical contact.

Associations between duration of untreated psychosis and domains of positive and negative symptoms.

AIM: The duration of untreated psychosis (DUP) has been established as an independent and significant predictor of negative outcomes in first-episode psychosis samples. Whereas literature has supported the association between DUP and severity of positive and negative symptoms, surprisingly little research to date has explored specifically what types of positive and negative symptoms are most associated with DUP. METHODS: DUP, Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) data were collected in 247 first-episode psychosis participants (mean age: 23.9 ± 4.8) between August 2008 and June 2013. RESULTS: DUP was significantly but modestly associated with the severity of hallucinations (ρ = 0.222; P = 0.001), delusions (r = 0.202; P = 0.003) and formal thought disorder (ρ = 0.138; P = 0.043) but was not associated with bizarre behaviour. DUP was significantly but modestly associated with SANS avolition-apathy (ρ = 0.164; P = 0.016) and anhedonia-asociality (r = 0.321; P < 0.001) subscales but was not associated with affective flattening or blunting, alogia or attention. CONCLUSIONS: DUP is a complex and multifaceted phenomenon that is associated with early-course illness development. In efforts to improve early intervention services, prognoses and outcomes, it is vital to understand both the factors that contribute to lengthy untreated psychosis as well as the illness characteristics that are impacted by untreated psychosis.

Marijuana use in the immediate 5-year premorbid period is associated with increased risk of onset of schizophrenia and related psychotic disorders.

OBJECTIVES: Several studies suggest that adolescent marijuana use predicts earlier age at onset of schizophrenia, which is a crucial prognostic indicator. Yet, many investigations have not adequately established a clear temporal relationship between the use and onset. METHODS: We enrolled 247 first-episode psychosis patients from six psychiatric units and collected data on lifetime marijuana/alcohol/tobacco use, and ages at onset of prodrome and psychosis in 210 of these patients. Cox regression (survival analysis) was employed to quantify hazard ratios (HRs) for effects of diverse premorbid use variables on psychosis onset. RESULTS: Escalation of premorbid use in the 5years prior to onset was highly predictive of an increased risk for onset (e.g., increasing from no use to daily use, HR=3.6, p<0.0005). Through the analysis of time-specific measures, we determined that daily use approximately doubled the rate of onset (HR=2.2, p<0.0005), even after controlling for simultaneous alcohol/tobacco use. Building on previous studies, we were able to determine that cumulative marijuana exposure was associated with an increased rate of onset of psychosis (p=0.007), independent of gender and family history, and this is possibly the reason for age at initiation of marijuana use also being associated with rate of onset in this cohort. CONCLUSIONS: These data provide evidence of a clear temporal relationship between escalations in use in the five years pre-onset and an increased rate of onset, demonstrate that the strength of the association is similar pre- and post-onset of prodromal symptoms, and determine that early adult use may be just as important as adolescent use in these associations.

Personality domains, duration of untreated psychosis, functioning, and symptom severity in first-episode psychosis.

OBJECTIVES: Early-course psychotic disorders have been extensively studied in terms of phenomenology, but little is known about the influence of personality traits on clinical features of first-episode psychosis. The aim of this study was to explore how the "big five" personality domains (neuroticism, extraversion, openness, agreeableness, and conscientiousness) are associated with treatment delay (duration of untreated psychosis, DUP), functioning, and positive and negative symptom severity. METHODS: Data for these analyses were obtained from 104 participants enrolled from psychiatric inpatient units in Atlanta, Georgia, between August 2008 and March 2011. The NEO Five-Factor Inventory (NEO-FFI) was used to assess personality domains, and all other variables were measured in a standardized and rigorous manner using psychometrically sound instruments. Correlational analyses and multiple linear regressions were carried out to examine the strength of associations between variables of interest. RESULTS: Findings indicated that except for openness, all of the other personality variables contributed to some extent to the variance in DUP. Conscientiousness was positively correlated with functioning. Agreeableness was independently negatively associated with positive symptom severity and extraversion was independently negatively correlated with negative symptom severity. CONCLUSIONS: We report the first evidence suggesting that DUP is in part driven by personality domains. Functioning and symptom severity are also associated with those domains. Personality should be taken into account in order to better understand the phenomenology of early-course psychotic disorders as well as treatment-seeking behaviors.

Abnormal movements in first-episode, nonaffective psychosis: dyskinesias, stereotypies, and catatonic-like signs.

Motor abnormalities represent a neurobehavioral domain of signs intrinsic to schizophrenia-spectrum disorders, though they are commonly attributed to medication side effects and remain understudied. Individuals with first-episode psychosis represent an ideal group to study innate movement disorders due to minimal prior antipsychotic exposure. We measured dyskinesias, stereotypies, and catatonic-like signs and examined their associations with: (1) age at onset of psychotic symptoms and duration of untreated psychosis; (2) positive, negative, and disorganized symptoms; (3) neurocognition; and (4) neurological soft signs. Among 47 predominantly African American first-episode psychosis patients in a public-sector hospital, the presence and severity of dyskinesias, stereotypies, and catatonic-like features were assessed using approximately 30-min video recordings. Movement abnormalities were rated utilizing three scales (Dyskinesia Identification System Condensed User Scale, Stereotypy Checklist, and Catatonia Rating Scale). Correlational analyses were conducted. Scores for each of three movement abnormality types were modestly inter-correlated (r=0.29-0.40). Stereotypy score was significantly associated with age at onset of psychotic symptoms (r=0.32) and positive symptom severity scores (r=0.29-0.41). There were no meaningful or consistent associations with negative symptom severity, neurocognition, or neurological soft signs. Abnormal movements appear to represent a relatively distinct phenotypic domain deserving of further research.

Measuring insight through patient self-report: an in-depth analysis of the factor structure of the Birchwood Insight Scale.

Little research has focused on item analysis and factor structure of the most commonly used measures of insight. We examined the factorial structure of the Birchwood Insight Scale (BIS), a brief, easy-to-administer, self-report measure. We studied the BIS in 327 first-episode psychosis patients, including a test sample (n=163) and a validation sample (n=164). We then used data from 100 patients with chronic serious mental illnesses as a second, external validation sample. Exploratory factor analysis was conducted with the test subsample, and confirmatory factor analyses with the two validation samples. Confirmatory factor analyses (in both the first-episode psychosis validation sample and the chronic serious mental illness sample) indicated that a single-factor solution, with seven items loading on a single factor-with item 1 ("Some of your symptoms are made by your mind") eliminated-was the best-fitting model. Seven of the eight original BIS items loading on a single factor fit the data well in these samples. Researchers using this efficient measure of patient-reported insight should assess the item distributions and factor structure of the BIS in their samples, and potentially consider eliminating item 1.

Demographic, socio-environmental, and substance-related predictors of duration of untreated psychosis (DUP).

OBJECTIVE: Longer duration of untreated psychosis (DUP) is associated with poorer early-course and long-term outcomes, and is a target of early detection and intervention efforts. Given the paucity of research on childhood and adolescent stressors (e.g., maltreatment and neighborhood disorder) as potential predictors of DUP, limited research on premorbid substance use as a determinant of DUP, and inconclusive findings on the association between DUP and neurocognition, we conducted three sets of analyses to address these issues. Mode of onset of psychosis was also considered, given its established role as an illness-level correlate of DUP. METHODS: We rigorously assessed DUP and other pertinent variables in 180 predominantly African American, low-income, and socially disadvantaged first-episode psychosis patients hospitalized in five psychiatric units. RESULTS: Mode of onset of psychosis, prior incarceration, and the level of childhood/adolescent maltreatment were all significant independent predictors of DUP. Regarding premorbid substance use, having ever used cannabis and the amount of premorbid alcohol use were significantly associated with DUP. None of the seven neurocognitive domains assessed were even modestly, or clinically meaningfully, associated with DUP. CONCLUSIONS: These and other findings on DUP may be informative for early detection and intervention services. For example, such services might benefit from special outreach to criminal justice settings and disadvantaged neighborhoods, and to young people likely to have a history of childhood/adolescent maltreatment and gradually developing psychotic symptoms.

An examination of associations between the inability to taste phenylthiocarbamide (PTC) and clinical characteristics and trait markers in first-episode, nonaffective psychotic disorders.

Research findings are mixed as to whether or not the inability to taste phenylthiocarbamide (PTC) might represent an endophenotypic trait marker for schizophrenia. We hypothesized associations between PTC-tasting status and select clinical characteristics and trait markers in patients with psychotic disorders that, if present, would provide support for the inability to taste PTC as a trait marker. In a first-episode psychosis sample (n=93), we measured PTC tasting, family history of psychosis, age at onset of prodrome and psychosis, severity of positive and negative symptoms, global impairment in functioning, neurological soft signs, and four neurocognitive domains (verbal learning/memory, visual learning/memory, verbal working memory, and spatial working memory). Associations between PTC-non-tasting and clinical/neurocognitive variables were examined with χ(2) tests and independent samples t tests. Among participants, 67.7% tasted PTC in comparison to a strip of control paper, and 25.8% were non-tasters. Tasters and non-tasters did not show statistically significant differences with respect to family history, age at onset, severity of symptoms, neurological soft signs, or the four neurocognitive domains. In conjunction with other findings, it is unlikely that PTC-non-tasting is a trait marker of schizophrenia, though a conclusive study is warranted.

Phonetic measures of reduced tongue movement correlate with negative symptom severity in hospitalized patients with first-episode schizophrenia-spectrum disorders.

BACKGROUND: Aprosody, or flattened speech intonation, is a recognized negative symptom of schizophrenia, though it has rarely been studied from a linguistic/phonological perspective. To bring the latest advances in computational linguistics to the phenomenology of schizophrenia and related psychotic disorders, a clinical first-episode psychosis research team joined with a phonetics/computational linguistics team to conduct a preliminary, proof-of-concept study. METHODS: Video recordings from a semi-structured clinical research interview were available from 47 first-episode psychosis patients. Audio tracks of the video recordings were extracted, and after review of quality, 25 recordings were available for phonetic analysis. These files were de-noised and a trained phonologist extracted a 1-minute sample of each patient's speech. WaveSurfer 1.8.5 was used to create, from each speech sample, a file of formant values (F0, F1, F2, where F0 is the fundamental frequency and F1 and F2 are resonance bands indicating the moment-by-moment shape of the oral cavity). Variability in these phonetic indices was correlated with severity of Positive and Negative Syndrome Scale negative symptom scores using Pearson correlations. RESULTS: A measure of variability of tongue front-to-back position-the standard deviation of F2-was statistically significantly correlated with the severity of negative symptoms (r=-0.446, p=0.03). CONCLUSION: This study demonstrates a statistically significant and meaningful correlation between negative symptom severity and phonetically measured reductions in tongue movements during speech in a sample of first-episode patients just initiating treatment. Further studies of negative symptoms, applying computational linguistics methods, are warranted.

Which came first, delusions or hallucinations? An exploration of clinical differences among patients with first-episode psychosis based on patterns of emergence of positive symptoms.

Remarkably little is known about patterns of emergence of specific symptoms in the early course of nonaffective psychotic disorders. Some 159 well-characterized first-episode psychosis patients were categorized into those with: (1) delusions only (n=29, 18.2%); (2) delusions that emerged at least 1 month before hallucinations (n=31, 19.5%); (3) hallucinations that began at least 1 month before delusions (n=26, 16.4%); and (4) delusions and hallucinations that emerged concomitantly, within the same month (n=73, 45.9%). These four groups were compared across a number of clinical features, including duration of untreated psychosis, symptom severity, insight, and functioning, while controlling for potential confounders. Patients with delusions and hallucinations emerging within the same month had a shorter duration of untreated psychosis than those in whom one psychotic symptom emerged greater than one month before the other. The delusions-only group had significantly less severe positive, negative, and general psychopathology symptom scores, as well as better social and occupational functioning. Replication and further elucidation of specific patterns of symptom emergence would deepen the field's understanding of early-course phenomenology, and may inform efforts to improve upon nosology, prognostication, and treatment selection.