Prodromal and autistic symptoms in schizotypal personality disorder and 22q11.2 deletion syndrome.

Despite clear diagnostic distinctions, schizophrenia and autism share symptoms on several dimensions. Recent research has suggested the two disorders overlap in etiology, particularly with respect to inherited and noninherited genetic factors. Studying the relationship between psychotic-like and autistic-like symptoms in risk groups such as 22q11 deletion syndrome (22q11DS) and schizotypal personality disorder (SPD) has the potential to shed light on such etiologic factors; thus, the current study examined prodromal symptoms and autistic features in samples of 22q11DS and SPD subjects using standardized diagnostic measures, including the Structured Interview for Prodromal Symptoms (SIPS) and the Autism Diagnostic Inventory-Revised (ADI-R). Results showed that SPD subjects manifested significantly more severe childhood and current social as well as stereotypic autistic features, as well as more severe positive prodromal symptoms. The two groups did not differ on negative, disorganized, or general prodromal symptoms, but were distinguishable based on correlations between prodromal and autistic features; the relationships between childhood autistic features and current prodromal symptoms were stronger for the SPD group. The results suggest that childhood autistic features are less continuous with subsequent prodromal signs in 22q11DS patients relative to those with SPD, and the findings highlight the importance of studying the overlap in diagnostic phenomenology in groups at risk for developing psychosis and/or autism.

Patient-level predictors and clinical correlates of duration of untreated psychosis among hospitalized first-episode patients.

OBJECTIVE: Duration of untreated psychosis (DUP) has been associated with poor early course outcomes of nonaffective psychotic disorders; however, less is known about predictors of DUP. This study examined patient-level predictors of DUP and clinical correlates of both DUP and duration of untreated illness (DUI), both of which have been implicated as prognostic indicators. METHOD: Participants included 109 first-episode patients hospitalized in 3 public-sector inpatient psychiatric units serving an urban, socially disadvantaged, predominantly African American community. DUP, DUI, and a number of clinical and psychosocial variables were measured using standardized methods. Patients were diagnosed with schizophrenia and related psychotic disorders according to the Structured Clinical Interview for DSM-IV Axis I Disorders. RESULTS: The median DUP and DUI were 22.3 and 129.9 weeks, respectively. Survival analyses revealed that, at any given time point, patients not living with family members were, on average, about 1.5 times as likely to be hospitalized as those living with family when controlling for mode of onset of psychosis. Patients not living in poverty were, on average, about 1.6 times as likely to be hospitalized as those living in poverty when controlling for mode. A greater burden of negative symptoms was associated with longer DUP (r = 0.23, P = .02), and poorer insight was associated with longer DUI (r = -0.24, P = .01). Longer DUP and DUI were associated with diverse adverse clinical characteristics, such as greater impairment in global functioning, poorer social functioning, and more psychosocial problems. CONCLUSIONS: There is a need for early intervention efforts to be directed to families (and their loved ones who live with them with emerging psychotic disorders or frank untreated psychotic syndromes), particularly families facing major socioeconomic challenges.

Cluster A Personality Disorders: Schizotypal, Schizoid and Paranoid Personality Disorders in Childhood and Adolescence.

Cluster A personality disorders (PD), including schizotypal personality disorder (SPD), paranoid personality disorder (PPD), and schizoid PD, are marked by odd and eccentric behaviors, and are grouped together because of common patterns in symptomatology as well as shared genetic and environmental risk factors. The DSM-IV-TR describes personality disorders as representing stable and enduring patterns of maladaptive traits, and much of what is understood about Cluster A personality disorders in particular stems from research with adult populations. Less in known about these disorders in children and adolescents, and controversy remains regarding diagnosis of personality disorders in general in youth. The current paper reviews the available research on Cluster A personality disorders in childhood and adolescence; specifically, we discuss differentiating between the three disorders and distinguishing them from other syndromes, measuring Cluster A disorders in youth, and the nature and course of these disorders throughout childhood and adolescence. We also present recent longitudinal data from a sample of adolescents diagnosed with Cluster A personality disorders from our research laboratory, and suggest directions for future research in this important but understudied area.

The impact of a family history of psychosis on age-at-onset and positive and negative symptoms of schizophrenia: a meta-analysis.

The results of research on the relation of family history (FH) of psychosis with clinical presentation in schizophrenia have been mixed. To date, there have been no comprehensive reviews that have examined this body of research. The current review quantitatively evaluates research on the relation of FH with two aspects of schizophrenia, age-at-onset and symptom presentation. Studies investigating the influence of a FH on age-at-onset (N=15 studies), age-at-onset and sex (N=12 studies), and/or positive (N=11 studies) and negative symptoms (N=12 studies) in patients with schizophrenia were included in the meta-analyses. Results showed that FH has a small but significant impact on age-at-onset as well as negative symptoms. Of most interest was the finding that sex differences in age-at-onset are not observed in samples with a FH. Furthermore, there was a significant interaction between FH and sex with respect to negative symptoms. The findings of the current review are discussed in light of the diathesis-stress model. Theoretical assumptions and empirical research are reviewed to support the notion that FH influences susceptibility and presentation through similar mechanisms. Implications of the current findings, limitations of the review, and directions for future research are highlighted.

Association of pre-onset cannabis, alcohol, and tobacco use with age at onset of prodrome and age at onset of psychosis in first-episode patients.

OBJECTIVE: Several reports suggest that cannabis use is associated with an earlier age at onset of psychosis, although not all studies have operationalized cannabis use as occurring prior to onset of symptoms. This study addressed whether pre-onset cannabis use, alcohol use, and tobacco use are associated with an earlier age at onset of prodromal and psychotic symptoms. Effects of the progression of frequency of use were examined through time-dependent covariates in survival analyses. METHOD: First-episode patients (N=109) hospitalized in three public-sector inpatient psychiatric units underwent in-depth cross-sectional retrospective assessments. Prior substance use and ages at onset of prodromal and psychotic symptoms were determined by standardized methods, and analyses were conducted using Cox regression modeling. RESULTS: Whereas classifying participants according to maximum frequency of use prior to onset (none, ever, weekly, or daily) revealed no significant effects of cannabis or tobacco use on risk of onset, analysis of change in frequency of use prior to onset indicated that progression to daily cannabis and tobacco use was associated with an increased risk of onset of psychotic symptoms. Similar or even stronger effects were observed when onset of illness or prodromal symptoms was the outcome. A gender-by-daily-cannabis-use interaction was observed; progression to daily use resulted in a much larger increased relative risk of onset of psychosis in females than in males. CONCLUSIONS: Pre-onset cannabis use may hasten the onset of psychotic as well as prodromal symptoms. Age at onset is a key prognostic factor in schizophrenia, and discovering modifiable predictors of age at onset is crucial.

The psychosis continuum and categorical versus dimensional diagnostic approaches.

This overview briefly presents recent thinking on the dimensional approach to understanding psychotic experiences. First, evidence is provided for a continuum of psychosis ranging from self-reported infrequent psychotic symptoms in the general population, to schizotypal traits, to schizotypal personality disorder, and finally to full-blown psychosis resulting in a diagnosable primary psychotic disorder. Variation within each of these types of psychotic experience is discussed. Then, a comparison is presented between categorical and dimensional approaches to the diagnosis of psychosis by highlighting four advantages of each approach. In doing so, it is emphasized that the categorical approach is beneficial primarily in terms of reliability, whereas the dimensional approach would enhance validity.

Schizotypy and nicotine, alcohol, and cannabis use in a non-psychiatric sample.

Schizotypy is a multidimensional personality construct that is characterized by perceptual abnormalities, social withdrawal, mild suspiciousness, and odd thinking patterns. This study examined the relationship between four dimensions of self-reported schizotypy and substance use involving nicotine, alcohol, and cannabis, in undergraduate students. Results showed that higher levels of disorganized schizotypy, or odd thinking and behavior, were associated with greater indices of use of all three substances. Furthermore, higher cognitive-perceptual schizotypy was selectively associated with cannabis use. Results confirm findings of recent research that has discovered associations among schizotypy and substance use, highlighting links between behavioral traits and use of nicotine, alcohol, and cannabis. This study is one of the first to examine a wide range of schizotypy domains, and to show selective effects of the disorganized domain of schizotypy.

Childhood and current autistic features in adolescents with schizotypal personality disorder.

The diagnostic boundaries between autistic- and schizophrenia-spectrum disorders have varied over the years, and some overlap in diagnostic criteria persists. The present study examined childhood and current signs of autistic disorder (AD) in adolescents with schizotypal personality disorder (SPD) or other personality disorders, as well as healthy controls. A structured interview was administered to rate participants' current symptoms. Participants' guardians were interviewed with the Autism Diagnostic Inventory-Revised (ADI-R), a clinical assessment of childhood and current autistic signs. Compared to both the other personality-disordered and healthy groups, adolescents with SPD were rated as having significantly more impairment on childhood and current social functioning, and having more unusual interests and behaviors. For the entire sample, impaired childhood social functioning and unusual interests and behaviors were associated with higher negative symptom scores. Current impairments in social functioning, unusual interests and behaviors, and communication were also linked with greater negative symptoms. However, neither childhood nor current autistic features significantly predicted later conversion to an Axis I psychotic disorder over the course of three years of follow-up. The findings indicate that past and current autistic signs are more common in adolescents with SPD, but neither current nor childhood autistic features are linked with conversion to psychosis.

Knowledge about schizophrenia and social distance toward individuals with schizophrenia: a survey among predominantly low-income, urban, African American community members.

This study surveyed 111 urban African American community members regarding their level of familiarity with mental illness, knowledge about schizophrenia, and social distance toward individuals with schizophrenia. The participants were predominantly Protestant, with relatively low educational attainment and low income. Knowledge and social distance scores were not significantly correlated. Independently significant predictors of knowledge about schizophrenia, which accounted for 49% of the variance in scores, included level of educational attainment, gender, having a friend with a history of psychiatric treatment, and having known someone with schizophrenia. Independent predictors of social distance scores included family history of psychiatric treatment and family history of schizophrenia, which accounted for 14% of variance in scores. Further research involving specific racial, ethnic, cultural, and socioeconomic groups is needed to better understand the complex associations underlying knowledge about schizophrenia and stigma.

Causes of schizophrenia reported by urban African American lay community members.

Although mental health professionals' "etiologic beliefs" concerning schizophrenia have evolved in accordance with diathesis-stress and neurodevelopmental models, little is known about etiologic attributions in nonclinical general population samples in the United States. Yet, course and outcome for people with the illness may be indirectly influenced by beliefs about causes in the larger community. Because of very limited research in this area, especially among African Americans in particular, this descriptive study investigated the causes of schizophrenia reported by 127 urban African Americans from the general population. The aim of this study was to assess the most commonly reported causes of schizophrenia, as well as the frequency of endorsing items from a list of 30 factors, some of which are congruent with current psychiatric conceptualizations of schizophrenia, whereas others are not. Results of this report complement previously reported findings from the same setting involving family members of patients with schizophrenia [Esterberg ML, Compton MT. Causes of schizophrenia reported by family members of urban African American hospitalized patients with schizophrenia. Compr Psychiatry 2006;47:221-226]. The 5 most commonly reported causes were disturbance of brain biochemistry (49.6%), drug/alcohol abuse (42.5%), hereditary factors (40.9%), brain injury (40.2%), and avoidance of problems in life (37.8%). The mean number of likely or very likely causes endorsed by participants was 7.5 +/- 5.7. Some 47.9% reported one or more esoteric factors as a cause. Of the 6 esoteric factors, possession by evil spirits (28.3%), radiation (20.2%), and punishment by God (19.7%) were most common. Esoteric causes were more commonly chosen by male participants, those with 12 years of education or less, and participants who reported never having known someone with schizophrenia. Future research should seek to better understand how esoteric beliefs about causation affect attitudes toward people with mental illnesses and acceptance of mental health treatment by those individuals. Beliefs about debunked personality, societal, family, and esoteric causes in this nonclinical sample indicate the need for improved psychoeducation of the community at large.

Nicotine consumption and schizotypy in first-degree relatives of individuals with schizophrenia and non-psychiatric controls.

Individuals with schizophrenia have very high rates of cigarette smoking, and much has been discovered about the influence of nicotine on brain functioning in schizophrenia. However, less is understood about the relationship between nicotine consumption and milder phenotypes related to schizophrenia, specifically schizotypy. This study examined the relationship between nicotine consumption and schizotypy in two unmedicated samples that included first-degree relatives and non-psychiatric controls. Forty-two first-degree relatives and 50 control participants were administered a self-report questionnaire on schizotypal features as well as a self-report questionnaire on smoking behavior. A positive relationship was found between smoking status and level of schizotypy, and higher levels of schizotypy significantly predicted the odds of being a smoker after controlling for gender and group status. Interestingly, group status was a significant moderator in the relationship between level of schizotypy and smoking status, such that the relationship between these two variables was only significant in the first-degree relatives. This is the first study to investigate the relationship between these variables in a sample of first-degree relatives of individuals with schizophrenia. Those individuals with more schizotypal features are presumably at greater risk for schizophrenia-spectrum disorders and thus may be more likely to smoke cigarettes given the known biochemical effects of nicotine on overt positive and negative symptoms of schizophrenia. Although relatives did not differ from controls in their level of self-reported schizotypy, the significant relationship between smoking status and schizotypy in the former group is likely explained by their genetic vulnerability to schizophrenia-spectrum disorders.

Neurological soft signs and minor physical anomalies in patients with schizophrenia and related disorders, their first-degree biological relatives, and non-psychiatric controls.

BACKGROUND: Subtle neurological impairments and inconsequential minor anomalies of the face and limbs are manifestations of neurodevelopmental and ontogenic abnormalities that are consistently found at higher rates in individuals with schizophrenia compared to healthy controls. Limited research has been conducted on these traits among biological relatives of patients with schizophrenia. This study hypothesized that the mean NSS score and the mean MPA score would be greater in patients than controls and that first-degree relatives would have intermediate scores. Furthermore, it was hypothesized that NSS scores and MPA scores would not be correlated. This study also explored correlations between patients' NSS and MPA scores and their relatives' respective scores and sought to replicate the finding that NSS are associated with negative and disorganized symptoms of schizophrenia, whereas MPAs are not. METHODS: Patients with schizophrenia and related psychotic disorders (n=73), first-degree relatives (n=44), and non-psychiatric controls (n=54) were assessed. Measures included the Neurological Evaluation Scale, a structured examination for MPAs, and the Positive and Negative Syndrome Scale in patients. Analyses accounted for clustering within families. RESULTS: Both NSS and MPAs were greater in patients than controls, and first-degree relatives had intermediate scores. Furthermore, NSS and MPA scores were independent in all three groups. Correlations were found between patients' and their relatives' scores on one NES subscale (sensory integration) and total MPA score and several MPA regions (eyes, ears, and hands). This study replicated previous findings that in patients with schizophrenia, NSS are associated with negative, disorganized, and other domains of symptoms. Associations between MPAs and symptoms were sparse and inconsistent. CONCLUSION: These findings suggest that NSS and MPAs represent two quite distinct markers of risk for schizophrenia that may stem from genetic factors, as well as from environmental/developmental influences. Future research on multivariable risk prediction models may benefit from the use of somewhat independent risk markers or endophenotypes.

Associations between schizotypal features and indicators of neurological and morphological abnormalities.

OBJECTIVE: Limited research suggests that subtle neurological and morphological abnormalities that have been documented in patients with schizophrenia also may be associated with schizotypal traits in non-psychiatric samples. Based on the notion that neurological soft signs (NSS) may mark a genetic diathesis, this study hypothesized that NSS scores would be related to the level of schizotypy in relatives of schizophrenia patients and in controls. Additionally, associations between MPA scores and schizotypy were explored in these two groups. METHOD: Twenty-six first-degree relatives of schizophrenia patients and 38 controls with no personal or family history of psychosis were assessed for schizotypy using the Structured Clinical Interview for DSM-IV Axis II Disorders schizotypal personality disorder module, as well as the self-administered Schizotypal Personality Questionnaire. The Neurological Evaluation Scale and a structured examination for MPAs also were administered. RESULTS: Mean schizotypy scores did not differ between relatives and controls. Both NSS and MPAs were associated with the level of interviewer-assessed schizotypal features in controls but not in relatives of patients with schizophrenia. NSS and MPAs were not associated with self-reported schizotypy in either group. CONCLUSIONS: These findings demonstrate that both NSS and MPAs are associated with interview-based schizotypal traits, at least in non-psychiatric participants. Future research should seek to replicate these results in other samples of relatives and controls.

Assessing knowledge of schizophrenia: development and psychometric properties of a brief, multiple-choice knowledge test for use across various samples.

Psychosocial research on schizophrenia would benefit from reliable and valid measures of knowledge about schizophrenia. Although a variety of instruments have been developed to assess the effects of specific family psychoeducational programs, little research has been conducted on the psychometric properties of scales measuring knowledge about schizophrenia. This study assessed reliability and validity of a brief, easily administered, multiple-choice knowledge test completed by 441 participants from several samples: 144 lay community members, 77 family members of inpatients with schizophrenia, 170 police officers involved in a training program on mental illnesses, and 50 mental health professionals. After item analysis, good internal consistency reliability and construct validity were demonstrated for an 18-item version of this test. The findings demonstrate that knowledge about schizophrenia - a construct with potentially broad applicability in psychosocially oriented schizophrenia research - can be assessed with brief, self-administered, multiple-choice knowledge tests.

Brief reports: crisis intervention team training: changes in knowledge, attitudes, and stigma related to schizophrenia.

OBJECTIVE: Crisis intervention team (CIT) training provides police officers with knowledge and skills to improve their responses to individuals with mental illnesses. This study determined changes in knowledge, attitudes, and social distance related to schizophrenia among police officers after CIT training. METHODS: A survey was administered to 159 officers immediately before and after a 40-hour CIT training program in Georgia. Pre- and posttest data were gathered from surveys taken between December 2004 and July 2005. RESULTS: After the training, officers reported improved attitudes regarding aggressiveness among individuals with schizophrenia, became more supportive of treatment programs for schizophrenia, evidenced greater knowledge about schizophrenia, and reported less social distance toward individuals with schizophrenia. CONCLUSIONS: This study supports the hypothesis that an educational program for law enforcement officers may reduce stigmatizing attitudes toward persons with schizophrenia.

Associations between olfactory identification and verbal memory in patients with schizophrenia, first-degree relatives, and non-psychiatric controls.

OBJECTIVE: Olfactory identification deficits and verbal memory impairments may represent trait markers for schizophrenia. The aims of this study were to: (1) assess olfactory identification in patients, first-degree relatives, and non-psychiatric controls, (2) determine differences in verbal memory functioning in these three groups, and (3) study correlations between olfactory identification and three specific verbal memory domains. METHOD: A total of 106 participants-41 patients with schizophrenia or related disorders, 27 relatives, and 38 controls-were assessed with the University of Pennsylvania Smell Identification Test (UPSIT) and the Wechsler Memory Scale-Third Edition. Linear mixed models, accounting for clustering within families and relevant covariates, were used to compare scores across groups and to examine associations between olfactory identification ability and the three verbal memory domains. RESULTS: A group effect was apparent for all four measures, and relatives scored midway between patients and controls on all three memory domains. UPSIT scores were significantly correlated with all three forms of verbal memory. Age, verbal working memory, and auditory recognition delayed memory were independently predictive of UPSIT scores. CONCLUSIONS: Impairments in olfactory identification and verbal memory appear to represent two correlated risk markers for schizophrenia, and frontal-temporal deficits likely account for both impairments.

A descriptive study of pathways to care among hospitalized urban African American first-episode schizophrenia-spectrum patients.

BACKGROUND: Studying pathways to care, or contacts made during the period of time from the onset of illness until the first initiation of treatment, is critical for understanding how to improve the early recognition and treatment of mental disorders. However, little is known about pathways to care among patients with first-episode psychosis in the United States. The objectives of this study were to examine the pathways to care and number of help contacts prior to hospitalization in first-episode patients, and to ascertain the frequency of contact with primary care providers and police. METHOD: Pathways to care, including all contacts for help from the onset of prodromal symptoms until first hospital admission, were assessed in 25 urban African American patients. Other measures were obtained as part of an ongoing study of predictors of the duration of untreated psychosis. RESULTS: The median durations from the onset of illness to hospital admission and from the emergence of positive psychotic symptoms to hospital admission were 128.0 weeks (range 0.6-476.9) and 32.9 weeks (range 0.4-337.7), respectively. Of the 83 total contacts, 17 were with police, whereas only four were with primary care providers. While the number of contacts per patient ranged from one to eight, 16 of the 25 patients were admitted within 1 week of their first contact for help. CONCLUSIONS: The findings indicate that pathways to care in this population are highly variable, and there is a need for additional research to better understand the nature and determinants of these pathways. Such investigations may provide insights into service enhancements that can promote early detection and intervention, thus improving illness outcomes.

Causes of schizophrenia reported by family members of urban African American hospitalized patients with schizophrenia.

Family members often provide psychosocial support and assistance in seeking treatment for individuals with schizophrenia. It is crucial to understand what family members believe to be the causes of schizophrenia, as this likely influences the family's help-seeking decisions. The aim of this descriptive study was to investigate the causes of schizophrenia reported by family members of African Americans hospitalized with schizophrenia. Sixty-one family members of 38 patients with a first episode or an acute exacerbation of persistent illness were administered a survey containing 30 possible causes of schizophrenia from 5 categories. The sample endorsed predominantly biologic causes. Many family members also endorsed personality and societal causes, as well as family and esoteric causes. Compared with family members in the persistent group, family members in the first-episode group were more likely to select personality or societal causes in addition to biologic causes. These results provide insight into the etiologic beliefs of a sample of African American family members. Further research is needed to assess the potential influence of these beliefs on treatment seeking on the part of the family.

Treatment delay in first-episode nonaffective psychosis: a pilot study with African American family members and the theory of planned behavior.

This pilot study examined associations between three central constructs of the theory of planned behavior and the length of treatment delay among patients hospitalized for a first episode of nonaffective psychosis. The sample consisted of 21 relatives directly involved in initiating hospitalization for 14 first-episode patients. Spearman correlation coefficients were calculated to test associations between length of treatment delay and the hypothesized predictors. One of the 3 theory of planned behavior constructs, perceived behavioral control (PBC), was significantly inversely correlated with treatment delay (p = -0.44, P = .04). The other 2 theory constructs were not significant correlates. Perceived stigma was significantly inversely correlated with PBC (p = -0.51, P = .02). There has been no prior research using health behavior theories to study potential predictors of treatment delay or the duration of untreated psychosis. Findings from this pilot study indicate that some health behavior theory constructs, including PBC, may be useful in future early intervention efforts.

Smoking behavior in persons with a schizophrenia-spectrum disorder: a qualitative investigation of the transtheoretical model.

Smoking rates among persons with schizophrenia are up to three times the rates of the general US population, and research has shown that it is difficult to design cessation programs for people with schizophrenia that take into account their various cognitive and social deficits. More research is needed on the attitudes and priorities of people with schizophrenia in order to design and implement effective smoking cessation programs. Additionally, more research should be conducted with first-episode psychosis and chronic schizophrenia patients to investigate possible differences between these two groups. The purpose of this study, conducted in Atlanta, USA, was to use qualitative methodology to assess the Transtheoretical Model (TTM) in the context of smoking behavior in a sample of participants with schizophrenia-spectrum disorders. Data were obtained via interviews with 12 participants with either first-episode or chronic schizophrenia-spectrum disorders who smoked cigarettes. Differences between the two subsets of the sample were assessed. Results clustered into the following prevalent themes: (1) pros and cons of smoking; (2) beliefs about smoking cessation; (3) external influences on smoking and quitting; and (4) negative attitudes toward nicotine replacement therapies (NRT). Findings indicate that the majority of participants were in the precontemplation stage of quitting smoking, and that the primary advantages of smoking for this sample were relief from anxiety and negative symptoms. Important differences were found between chronic and first-episode participants in the areas of readiness-to-quit and beliefs about smoking cessation. Other findings indicate a lack of cessation programs offered to this sample, and overall negative attitudes toward NRT. Future interventions should take into account the reported pros and cons of smoking in this population, as well as other beliefs and attitudes regarding smoking behavior.