Psychosis superspectrum II: neurobiology, treatment, and implications.

Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.

The Hierarchical Taxonomy of Psychopathology (HiTOP) in psychiatric practice and research.

The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.

The Hierarchical Taxonomy of Psychopathology (HiTOP): A Quantitative Nosology Based on Consensus of Evidence.

Traditional diagnostic systems went beyond empirical evidence on the structure of mental health. Consequently, these diagnoses do not depict psychopathology accurately, and their validity in research and utility in clinicalpractice are therefore limited. The Hierarchical Taxonomy of Psychopathology (HiTOP) consortium proposed a model based on structural evidence. It addresses problems of diagnostic heterogeneity, comorbidity, and unreliability. We review the HiTOP model, supporting evidence, and conceptualization of psychopathology in this hierarchical dimensional framework. The system is not yet comprehensive, and we describe the processes for improving and expanding it. We summarize data on the ability of HiTOP to predict and explain etiology (genetic, environmental, and neurobiological), risk factors, outcomes, and treatment response. We describe progress in the development of HiTOP-based measures and in clinical implementation of the system. Finally, we review outstanding challenges and the research agenda. HiTOP is of practical utility already, and its ongoing development will produce a transformative map of psychopathology.

Anomalous self-experiences in cognition are negatively associated with neurocognitive functioning in schizophrenia.

INTRODUCTION: Anomalous self-experiences (ASEs) are disturbances in the subjective experience of the self and are common in people with schizophrenia. Theorists have suggested that ASEs may underlie the neurocognitive deficits that are also common in people with schizophrenia; however, few studies have empirically investigated the relationship between these variables. Thus, the current study aimed to determine whether self-reported ASEs, particularly disturbances in cognitive or mental experiences, are meaningfully related to neurocognitive performance in individuals with schizophrenia. METHODS: 48 individuals with schizophrenia and 34 healthy comparison participants completed the Inventory of Psychotic-Like Anomalous Experiences (IPASE), which is composed of five subscales including disturbances in cognition, and the MATRICS Consensus Cognitive Battery (MCCB). RESULTS: Participants with schizophrenia performed worse than controls on each MCCB domain and had higher ASE scores on the total IPASE and all five subscales. Only the IPASE-Cognition subscale was associated with cognitive performance. Specifically, IPASE-Cognition was negatively correlated with scores in attention, visual learning, reasoning, and working memory. CONCLUSIONS: These results suggest that self-reported subjective disturbances in cognition may be meaningfully associated with several objectively-measured domains of neurocognition. Severity of ASEs may therefore be an important consideration when analysing the extent of cognitive deficits in schizophrenia.

Assessing aberrant salience in young community help-seekers with early psychosis: The approved Italian version of the Aberrant Salience Inventory.

OBJECTIVES: Aberrant salience (AS) has a crucial role in the onset of psychosis. The Aberrant Salience Inventory (ASI) is the only self-report instrument specifically developed for the assessment of AS. Aim of this study was to examine the reliability and the validity of the approved Italian version of the ASI in a clinical sample of young help-seekers. METHODS: The ASI was completed by 204 individuals, aged 13-35 years. Reliability was assessed examining internal consistency and test-retest reliability. Concordant validity was established with CAARMS ("Comprehensive Assessment of At-Risk Mental States"). RESULTS: The ASI showed high test-retest reliability and excellent internal consistency. The ASI total score had significant positive correlations with CAARMS "Positive Symptoms" subscores. CONCLUSIONS: The ASI showed satisfactory psychometric properties and seems to be a suitable instrument for early detection of psychosis in Italian mental health services.

Les progrès dans la réalisation de la classification quantitative de la psychopathologie.

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

Criterion A of the AMPD in HiTOP.

The categorical model of personality disorder classification in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]; American Psychiatric Association, 2013 ) is highly and fundamentally problematic. Proposed for DSM-5 and provided within Section III (for Emerging Measures and Models) was the Alternative Model of Personality Disorder (AMPD) classification, consisting of Criterion A (self-interpersonal deficits) and Criterion B (maladaptive personality traits). A proposed alternative to the DSM-5 more generally is an empirically based dimensional organization of psychopathology identified as the Hierarchical Taxonomy of Psychopathology (HiTOP; Kotov et al., 2017 ). HiTOP currently includes, at the highest level, a general factor of psychopathology. Further down are the five domains of detachment, antagonistic externalizing, disinhibited externalizing, thought disorder, and internalizing (along with a provisional sixth somatoform dimension) that align with Criterion B. The purpose of this article is to discuss the potential inclusion and placement of the self-interpersonal deficits of the DSM-5 Section III Criterion A within HiTOP.

The role of ethnic identity, self-concept, and aberrant salience in psychotic-like experiences.

OBJECTIVES: Social-cognitive models of psychosis suggest that aberrant salience and self-concept clarity are related to the development and maintenance of psychoticlike experiences (PLEs). People with high aberrant salience but low self-concept clarity tend to have the highest levels of PLEs. Ethnic identity may also be related to PLEs. The current research aimed to (a) replicate the interaction between aberrant salience and self-concept clarity in their association with PLEs in an ethnically diverse sample, (b) examine whether ethnic identity and aberrant salience interact in their association with PLEs, and (c) determine if self-concept clarity and ethnic identity independently interact with aberrant salience in their association with PLEs. METHOD: An ethnically diverse group of undergraduates (n = 663) completed self-report measures of aberrant salience, self-concept clarity, ethnic identity, and PLEs. RESULTS: There was an interaction between aberrant salience and self-concept clarity such that people with high levels of aberrant salience and low levels of self-concept clarity had the highest levels of PLEs. Similarly, there was an interaction between aberrant salience and ethnic identity such that people with high aberrant salience but low ethnic identity had the highest PLEs. These interactions independently contributed to explaining variance in PLEs. This interaction was present for the Exploration but not Commitment subscales of ethnic identity. CONCLUSION: These results suggest that, in addition to low self-concept clarity, low ethnic identity may be a risk factor for the development of psychosis. (PsycINFO Database Record

Disruptive Behavior Treatment Progress as a Function of Therapy Focus and Youth Diagnosis in a Community Mental Health Setting.

Monthly disruptive behavior treatment progress for 613 youth ages 7-18 receiving intensive in-home services was examined. Multilevel modeling indicated carrying a depressive mood diagnosis predicted less disruptive behavior progress compared to youth with only externalizing diagnoses. Paradoxically, more monthly focus on disruptive behavior treatment targets predicted lower concurrent progress ratings, while greater focus on depressive mood targets predicted greater disruptive behavior progress for youth with a depressive mood diagnosis. Findings held when other predictors of disruptive behavior progress were included as covariates, including episode length, youth age, and functional impairment. Treatment and research implications are discussed.

Eating disorder features and quality of life: Does gender matter?

PURPOSE: This study examined whether gender moderates the associations between eating disorder features and quality-of-life impairment and whether eating disorder features can explain gender differences in quality of life in a sample of undergraduate students. METHODS: The SF-12 Physical and Mental Component Summary Scales were used to measure health-related quality of life (HRQoL), and the Eating Disorders Examination Questionnaire (EDE-Q) was used to quantify eating disorder behaviors and cognitions. These self-report forms were completed by undergraduate men and women (n = 709). RESULTS: Gender was a significant predictor of mental HRQoL, such that women in this sample reported poorer mental HRQoL than men. Eating disorder cognitions were the strongest predictor of undergraduate students' mental and physical HRQoL, while binge eating negatively predicted their physical HRQoL only. Gender was not found to moderate the associations between eating disorder features and HRQoL, and eating disorder cognitions were found to mediate the association between gender and mental HRQoL such that a proportion of the difference between undergraduate men and women's mental HRQoL was attributable to eating disorder cognitions. CONCLUSION: This study provided further evidence of the significant impact of eating disorder features, particularly eating disorder cognitions, on HRQoL. The finding that gender did not moderate the relationships between eating disorder features and HRQoL indicates the importance of investigating these features in both men and women in future research.

Self-reported ambivalence in schizophrenia and associations with negative mood.

One instrument potentially useful for schizophrenia research is the Revised Schizotypal Ambivalence Scale (rSAmb). However, previous research has not examined the construct validity of this instrument in people with schizophrenia. In the current study, people with schizophrenia-spectrum disorders (n = 47) and bipolar disorder (BPD; n = 19) completed the rSAmb along with current symptom and other clinical data. As a group, the people with schizophrenia/schizoaffective disorder reported significantly less ambivalence on the rSAmb than did the people with BPD. In addition, the rSAmb was not significantly related to any schizophrenia symptom (all correlations < 0.15). Instead, the rSAmb was significantly associated with negative mood symptoms in the past week, a diagnosis of schizoaffective disorder rather than schizophrenia, and the number of negative terms used in speech. These results suggest that the rSAmb may be associated with negative mood and not with schizophrenia, although systematic examination of larger cohorts is warranted.

Measurement invariance of the Personality Inventory for the DSM-5 across U.S. East Asian, Southeast Asian, and White participants.

The Personality Inventory for the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition (PID-5) was developed as a measure of the traits included in the alternative model of personality disorders (AMPD) in Section III of the DSM. The PID-5 is composed of 25 scales measuring each trait in the AMPD across five domains: negative affectivity, detachment, disinhibition, antagonism, and psychoticism. Previous research suggests that there may be important differences in the expression of personality pathology across race and culture, particularly between people with eastern and western cultural heritages. The goal of the current research was to examine the measurement invariance of the PID-5 across these groups. In the current study, 865 young men and women who identified as White, East Asian, or Southeast Asian completed the PID-5 and international personality item pool (IPIP). On the domain level, a multigroup exploratory structural equation model found that the PID-5 had configural and metric invariance, but lacked complete scalar invariance. On an item level, all scales had configural invariance, one lacked metric invariance, and 11 of the 25 scales lacked scalar invariance across race. For the invariant scales, East and Southeast Asians tended to have higher mean scores than White participants. The PID-5 scales had similar relations with IPIP scales across groups. These results suggest that the PID-5 scales are measuring similar constructs across groups on a global, structural level, but that mean scores may represent different levels of latent personality pathology across groups. The PID-5 may be confidently used in these groups, but mean comparisons should be interpreted with caution. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Measurement invariance of the Child Behavior Checklist (CBCL) across race/ethnicity and sex in the Adolescent Brain and Cognitive Development (ABCD) study.

There are numerous studies examining differences in the experience of disorders and symptoms of psychopathology in adolescents across racial or ethnic groups and sex. Though there is substantial research exploring potential factors that may influence these differences, few studies have considered the potential contribution of measurement properties to these differences. Therefore, this study examined whether there are differences across racial or ethnic groups and sex in the measurement of psychopathology, assessed in mother-reported behavior of 9-11 year old youth from the Adolescent Brain Cognitive Development study sample using updated Child Behavior Checklist scales (CBCL; Achenbach & Rescorla, 2001). Tests of measurement invariance of the CBCL utilized the higher order factor structure identified by Michelini et al. (2019) using this same Adolescent Brain Cognitive Development cohort. The dimensions include internalizing, somatoform, detachment, externalizing, and neurodevelopmental problems. The configural model had a good-to-excellent fit on all subscales of the CBCL across racial or ethnic groups and sex. The metric and scalar models fit just as well as the configural models, indicating that the scales are measuring the same constructs across racial or ethnic groups and sex and are not influenced by measurement properties of items on the CBCL, although some high-severity response options were not endorsed for youth in all racial or ethnic groups. These findings support the use of the CBCL in research examining psychopathology in racially or ethnically diverse samples of youth. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Differential Risk: Gender and Racial Differences in the Relationship between Trauma, Discrimination, and Schizotypy.

Traumatic experiences are associated with increased experiences of positive schizotypy. This may be especially important for People of Color, who experience higher rates of trauma and racial discrimination. No study to date has examined how racial disparities in traumatic experiences may impact schizotypy. Furthermore, of the studies that have examined the relationship between trauma and schizotypy, none have examined racial discrimination as a potential moderator. The present study examined if racial discrimination moderates the relationship between trauma and multidimensional (positive, negative, and disorganized) schizotypy. In a sample of 770 college students, we conducted chi-squared analyses, analyses of variance, and stepwise regressions. We found that Black students experienced significantly higher racial discrimination and trauma than Latinx and Asian students. Furthermore, Black and Latinx students experienced significantly more multidimensional schizotypy items than Asian students. Trauma and racial discrimination explained 8 to 23% of the variance in each dimension of schizotypy. Racial discrimination did not moderate the relationships between trauma and multidimensional schizotypy. Our findings suggest that we need to examine risk factors that may prevent recovery from psychotic disorders. Additionally, disorganized schizotypy showed the most robust associations and may be a critical site of intervention.

Principles and procedures for revising the hierarchical taxonomy of psychopathology.

Quantitative, empirical approaches to establishing the structure of psychopathology hold promise to improve on traditional psychiatric classification systems. The Hierarchical Taxonomy of Psychopathology (HiTOP) is a framework that summarizes the substantial and growing body of quantitative evidence on the structure of psychopathology. To achieve its aims, HiTOP must incorporate emerging research in a systematic, ongoing fashion. In this article, we describe the historical context and grounding of the principles and procedures for revising the HiTOP framework. Informed by strengths and shortcomings of previous classification systems, the proposed revisions protocol is a formalized system focused around three pillars: (a) prioritizing systematic evaluation of quantitative evidence by a set of transparent criteria and processes, (b) balancing stability with flexibility, and (c) promoting inclusion over gatekeeping in all aspects of the process. We detail how the revisions protocol will be applied in practice, including the scientific and administrative aspects of the process. Additionally, we describe areas of the HiTOP structure that will be a focus of early revisions and outline challenges for the revisions protocol moving forward. The proposed revisions protocol is designed to ensure that the HiTOP framework reflects the current state of scientific knowledge on the structure of psychopathology and fulfils its potential to advance clinical research and practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Measurement invariance of commonly used psychosis-screening scales in U.S. Spanish- and English-speaking Hispanic participants.

Two of the most commonly used psychosis screening measures are the Prodromal Questionnaire-Brief (PQ-B) and the Youth Psychosis at Risk Questionnaire-Brief (YPARQ-B). Both scales have considerable support for the reliability and validity of their scores for use with English- and Spanish-speaking participants, with measurement equivalence established across a subset of demographic characteristics. However, measurement invariance has not been examined across several important demographic variables, including native language, language of the scales used with Hispanic participants, education, occupation, income, birth country, and generation status. In the present study, (N = 1,191) measurement invariance was examined for each of these variables across three samples (ns = 505, 714, and 126). The PQ-B total scores and YPARQ-B were found to demonstrate configural and scalar invariance, while PQ-B Distress scores displayed configural, metric, and scalar invariance across most tested demographic variables. Psychosis scores were associated with social determinants of health (SDoH) including major and everyday experiences of discrimination, food insecurity, financial insecurity, acculturation, and ethnic identity. The associations between psychosis and SDoH were mostly consistent across groups. Compared to White-non-Hispanic participants, Hispanic participants had higher scores on all psychosis measures and tended to have higher scores on discrimination, food and housing insecurity, affirmation aspects of ethnic identity, and acculturative stress. Despite differences in psychosis levels, the groups did not differ in history of treatment. Overall, these results provide strong evidence that the PQ-B and YPARQ provide equivalent, nonbiased, valid, and reliable scores in Hispanic and Non-Hispanic participants in both English and Spanish. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cognitive control components and speech symptoms in people with schizophrenia.

Previous schizophrenia research suggests poor cognitive control is associated with schizophrenia speech symptoms. However, cognitive control is a broad construct. Two important cognitive control components are poor goal maintenance and poor verbal working memory storage. In the current research, people with schizophrenia (n=45) performed three cognitive tasks that varied in their goal maintenance and verbal working memory storage demands. Speech symptoms were assessed using clinical rating scales, ratings of disorganized speech from typed transcripts, and self-reported disorganization. Overall, alogia was associated with both goal maintenance and verbal working memory tasks. Objectively rated disorganized speech was associated with poor goal maintenance and with a task that included both goal maintenance and verbal working memory storage demands. In contrast, self-reported disorganization was unrelated to either amount of objectively rated disorganized speech or to cognitive control task performance, instead being associated with negative mood symptoms. Overall, our results suggest that alogia is associated with both poor goal maintenance and poor verbal working memory storage and that disorganized speech is associated with poor goal maintenance. In addition, patients' own assessment of their disorganization is related to negative mood, but perhaps not to objective disorganized speech or to cognitive control task performance.

Momentary assessment of aberrant salience, anomalous self-experiences, and psychotic-like experiences.

To improve understanding of emerging psychosis, researchers have identified potential precursory mechanisms that may momentarily precede psychotic-like experiences, including aberrant salience and anomalous self-experiences. Aberrant salience is the misattribution of significance to neutral stimuli and may be linked to atypical dopamine transmission. Anomalous self-experiences include changes in the experience of the self, which may alter top-down cognitive processes. The present study extends previous research on these phenomena by examining the momentary dynamics of aberrant salience, anomalous self-experiences, and psychotic-like experiences in daily life. Participants were 246 young adults who were prompted to complete 6 smartphone surveys daily for 7 days. Baseline measures of aberrant salience and anomalous self-experiences each predicted occurrence of the same phenomena in daily life, supporting the use of these measures to examine within-subject changes. Dynamic structural equation modeling was used to examine lagged effects. Both aberrant salience and anomalous self-experiences exhibited carryover effects across timepoints. Furthermore, aberrant salience and anomalous self-experiences were each associated with psychotic-like experiences at subsequent timepoints, above and beyond the carryover effects of psychotic-like experiences. These temporal relationships provide preliminary support consistent with social-cognitive models of psychosis and support further examination of the within-subject dynamics of aberrant salience and anomalous self-experiences at the momentary scale. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Development of the Thought Disorder Measure for the Hierarchical Taxonomy of Psychopathology.

The Hierarchical Taxonomy of Psychopathology consortium aims to develop a comprehensive self-report measure to assess psychopathology dimensionally. The current research describes the initial conceptualization, development, and item selection for the thought disorder spectrum and related constructs from other spectra. The thought disorder spectrum is defined primarily by the positive and disorganized traits and symptoms of schizophrenia-spectrum disorders. The Thought Disorder Sub-Workgroup identified and defined 16 relevant constructs and wrote 10 to 15 items per each construct. These items were administered, along with detachment and mania items, to undergraduates and people with serious mental illness. Three hundred and sixty-five items across 25 scales were administered. An exploratory factor analysis of the scale scores suggested a two-factor structure corresponding to positive and negative symptoms for two samples. The mania scales loaded with the positive factor, while the detachment scales loaded with the negative factor. Item-level analyses resulted in 19 preliminary scales, including 215 items that cover the range of thought disorder pathology, and will be carried forward for the next phase of data collection/analysis.

Answering questions about the Hierarchical Taxonomy of Psychopathology (HiTOP): Analogies to whales and sharks miss the boat.

This commentary discusses questions and misconceptions about HiTOP raised by Haeffel et al. (2021). We explain what the system classifies and why it is descriptive and atheoretical, highlighting benefits and limitations of this approach. We clarify why the system is organized according to patterns of covariation or comorbidity among signs and symptoms of psychopathology, and we discuss how it is designed to be falsifiable and revised in a manner that is responsive to data. We refer to the body of evidence for HiTOP's external validity and for its scientific and clinical utility. We further describe how the system is currently used in clinics. In sum, many of Haeffel et al.'s concerns about HiTOP are unwarranted, and for those concerns that reflect real current limitations of HiTOP, our consortium is working to address them, with the aim of creating a nosology that is comprehensive and useful to both scientists and clinicians.