Greg Perlman

Depression and reduced neural response to emotional images: Distinction from anxiety, and importance of symptom dimensions and age of onset.

Abnormal patterns of attention to threat and reward have been proposed as potential mechanisms of dysfunction in anxiety and unipolar depressive disorders. However, few studies have simultaneously examined whether these patterns of attention are shared among disorders or distinguish between them. In the present study, we recorded the Late Positive Potential (LPP), an event-related potential and putative index of motivated attention, from 145 patients with anxiety and unipolar depressive disorders and 32 controls, as they viewed blocks of rewarding and threatening images, respectively. We found that a current diagnosis of depression was associated with a reduced LPP to rewarding visual stimuli. This appeared to be specific to a subgroup of individuals with early onset depression; this subgroup was also characterized by a reduced LPP to threatening images. Anxiety diagnosis and age of onset of anxiety, whether comorbid with depression or not, was unrelated to the magnitude of the LPP. Finally, a transdiagnostic symptom dimension measuring current severity of suicidal ideation was related to a reduced LPP to both rewarding and threatening images. These data suggest that dysfunction in neural markers of attention to threat and reward can effectively distinguish features of depression from anxiety, particularly early onset depression, and may track suicidal ideation across disorders.

The 20-Year Longitudinal Trajectories of Social Functioning in Individuals With Psychotic Disorders

OBJECTIVE Social impairment is a long-recognized core feature of schizophrenia and is common in other psychotic disorders. Still, to date the long-term trajectories of social impairment in psychotic disorders have rarely been studied systematically. METHODS Data came from the Suffolk County Mental Health Project, a 20-year prospective study of first-admission patients with psychotic disorders. A never-psychotic comparison group was also assessed. Latent class growth analysis was applied to longitudinal data on social functioning from 485 respondents with schizophrenia spectrum disorders and psychotic mood disorders, and associations of the empirically derived trajectories with premorbid social adjustment, diagnosis, and 20-year outcomes were examined. RESULTS Four mostly stable trajectories of preserved (N=82; 59th percentile of comparison group sample distribution), moderately impaired (N=148; 17th percentile), severely impaired (N=181; 3rd percentile), and profoundly impaired (N=74; 1st percentile) functioning best described the 20-year course of social functioning across diagnoses. The outcome in the group with preserved functioning did not differ from that of never-psychotic individuals at 20 years, but the other groups functioned significantly worse. Differences among trajectories were already evident in childhood. The two most impaired trajectories started to diverge in early adolescence. Poorer social functioning trajectories were strongly associated with other real-world outcomes at 20 years. Multiple trajectories were represented within each disorder. However, more participants with schizophrenia spectrum disorders had impaired trajectories, and more with mood disorders had better functioning trajectories. CONCLUSIONS The results highlight substantial variability of social outcomes within diagnoses-albeit overall worse social outcomes in schizophrenia spectrum disorders-and show remarkably stable long-term impairments in social functioning after illness onset across all diagnoses.

The structure and short-term stability of the emotional disorders: a dimensional approach

BACKGROUND Factor-analytic studies have found that depressive, bipolar, post-traumatic, obsessive-compulsive, and anxiety disorders - jointly referred to as the emotional disorders - form an internalizing spectrum that includes distress and fear subfactors. However, placement of some disorders is uncertain. Also, prior research analysed dichotomous interview-based diagnoses or dimensional self-report measures. We investigated this structure using a third-generation measure - the Interview for Mood and Anxiety Symptoms (IMAS) - that combines strengths of a clinical interview with dimensional assessment. METHOD The interview was administered to 385 students and 288 psychiatric out-patients. Participants were reinterviewed 2 months later. RESULTS Exploratory and confirmatory factor analyses identified three factors: distress (depression, generalized anxiety, post-traumatic stress, irritability, and panic syndrome); fear (social anxiety, agoraphobia, specific phobia, and obsessive-compulsive); and bipolar (mania and obsessive-compulsive). The structure was consistent over time and across samples, except that panic and agoraphobia had higher factor loadings in patients. Longitudinal analyses revealed high temporal stability of the factors (test-retest r = 0.72 to 0.87), but also substantial disorder-specific stability. CONCLUSIONS This investigation - which bridges diagnostic and self-report studies - found three subfactors of internalizing psychopathology. It provided support for a new subfactor, clarified the placement of obsessive-compulsive and bipolar disorders, and demonstrated that this model generalizes across populations. The accumulating research suggests the need to recognize formally the close links among the emotional disorders, as well as empirical clusters within this spectrum. The IMAS demonstrated strong psychometric properties and can be useful for various research and clinical applications by providing dimensional, interview-based assessment of the emotional disorders.

Personality and emotional processing: A relationship between extraversion and the late positive potential in adolescence

Neuroticism and extraversion are multifaceted affective-laden personality traits that have been associated with major depressive disorder (MDD). Research and theory have argued that extraversion, and particularly its facet positive emotionality, is specific to MDD, while neuroticism is common across internalizing disorders. Converging evidence has suggested that MDD is associated with reduced engagement with emotional stimuli, but it remains unclear whether either extraversion, neuroticism, or both modulate reactivity to emotional cues. The late positive potential (LPP) is an event-related brain potential that is uniquely suited to assess engagement with emotional stimuli because it reflects sustained attention toward emotional content. The current study examined the LPP in relation to personality traits that may confer risk for depression by examining the relationship between the LPP and both neuroticism and extraversion in never-depressed adolescent girls. Specifically, 550 girls aged 13.5-15.5 with no lifetime history of depression completed an emotional picture-viewing task, and the LPP was measured in response to neutral, pleasant, and unpleasant pictures. Personality traits were gathered via self- and informant report. Results indicated that high extraversion was associated with a potentiated LPP to emotional pictures-and this effect was accounted for by positive emotionality in particular. In contrast, there was no association between the LPP and neuroticism or its facets. The present study is one of the first to demonstrate that extraversion is associated with variation in neural indices of emotional picture processing, similar to what has been observed among individuals with depression and at high risk for depression.

Inter-rater reliability of the PIPES tool: validation of a surgical capacity index for use in resource-limited settings.

AbstractIntroductionIn response to the need for simple, rapid means of quantifying surgical capacity in low resource settings, Surgeons OverSeas (SOS) developed the personnel, infrastructure, procedures, equipment and supplies (PIPES) tool. The present investigation assessed the inter-rater reliability of the PIPES tool.MethodsAs part of a government assessment of surgical services in Santa Cruz, Bolivia, the PIPES tool was translated into Spanish and applied in interviews with physicians at 31 public hospitals. An additional interview was conducted with nurses at a convenience sample of 25 of these hospitals. Physician and nurse responses were then compared to generate an estimate of reliability. For dichotomous survey items, inter-rater reliability between physicians and nurses was assessed using the Cohen’s kappa statistic and percent agreement. The Pearson correlation coefficient was used to assess agreement for continuous items. ResultsCohen’s kappa was 0.46 for infrastructure, 0.43 for procedures, 0.26 for equipment, and 0 for supplies sections. The median correlation coefficient was 0.91 for continuous items. Correlation was 0.79 for the PIPES index, and ranged from 0.32 to 0.98 for continuous response items.ConclusionsReliability of the PIPES tool was moderate for the infrastructure and procedures sections, fair for the equipment section, and poor for supplies section when comparing surgeons’ responses to nurses’ responses—an extremely rigorous test of reliability. These results indicate that the PIPES tool is an effective measure of surgical capacity but that the equipment and supplies sections may need to be revised.

Declining Clinical Course of Psychotic Disorders Over the Two Decades Following First Hospitalization: Evidence From the Suffolk County Mental Health Project

OBJECTIVE Kraepelin considered declining course a hallmark of schizophrenia, but others have suggested that outcomes usually stabilize or improve after treatment initiation. The authors investigated this question in an epidemiologically defined cohort with psychotic disorders followed for 20 years after first hospitalization. METHOD The Suffolk County Mental Health Project recruited first-admission patients with psychosis from all inpatient units of Suffolk County, New York (response rate, 72%). Participants were assessed in person six times over two decades; 373 completed the 20-year follow-up (68% of survivors); 175 had schizophrenia/schizoaffective disorder. Global Assessment of Functioning (GAF), psychotic symptoms, and mood symptoms were rated at each assessment. Month 6, when nearly all participants were discharged from the index hospitalization, was used as a reference. RESULTS In the schizophrenia group, mean GAF scores declined from 49 at month 6 to 36 at year 20. Negative and positive symptoms also worsened (Cohens d values, 0.45-0.73). Among participants without schizophrenia, GAF scores were higher initially (a mean of approximately 64) but declined by 9 points over the follow-up period. Worsening began between years 5 and 8. Neither aging nor changes in antipsychotic treatment accounted for the declines. In all disorders, depression improved and manic symptoms remained low across the 20 years. CONCLUSIONS The authors found substantial symptom burden across disorders that increased with time and ultimately may undo initial treatment gains. Previous studies have suggested that better health care delivery models may preempt this decline. In the United States, these care needs are often not met, and addressing them is an urgent priority.

Impaired error processing in late-phase psychosis: Four-year stability and relationships with negative symptoms.

Error processing is impaired in psychosis, and numerous event-related potential studies have found reductions in the error-related negativity (ERN) and, more recently, the error positivity (Pe). The stability of reduced ERN/Pe in psychosis, however, is unknown. In a previous cross-sectional report, reduced ERN was associated with negative symptom severity and reduced Pe with a diagnosis of schizophrenia versus other psychosis. Here, we test the stability of impaired error processing over a four-year follow-up and relationships with subdimensions of negative symptoms. The ERN and Pe were recorded from individuals with psychotic disorders twice: 79 individuals were assessed 15years after first hospitalization, and 69 were assessed at 19years; 59 (26 with schizophrenia, 33 with other psychotic disorders) had data at both assessments. At 19years the Pe was blunted in schizophrenia. The ERN and Pe exhibited temporal stability over the four years (r=0.59 and 0.60, respectively). Reduced ERN and Pe correlated with the negative symptom subdimensions of inexpressivity and avolition, respectively, and not with psychotic or disorganized symptoms. Moreover, 15-year ERN predicted an increase in inexpressivity by year 19. No evidence was found for the reverse: negative symptoms did not predict change in ERN/Pe. Similar to non-clinical samples, the ERN and Pe show impressive four-year stability in late-phase psychosis. The ERN and Pe are promising neural measures for capturing individual differences in psychotic disorders, particularly with regard to negative symptomatology. They may prove to be useful clinically for forecasting illness course and as treatment targets.

Parent-Reported Developmental Regression in Autism: Epilepsy, IQ, Schizophrenia Spectrum Symptoms, and Special Education

Examined the psychiatric and clinical correlates of loss of previously acquired skills (regression) as reported by parents of youth with autism spectrum disorder (ASD). Study sample comprised 6- to 18-year old (N = 213) children and adolescents with ASD. Parents reported regression in 77 (36%) youth. A more homogeneous subgroup with regression between 18 and 36 months (n = 48) had higher rates of intellectual disability, epilepsy, and special education, more socially restrictive educational settings, and more severe ASD communication deficits and schizophrenia spectrum symptoms than non-regressed youth (n = 136). Similar results were obtained for a more inclusive definition of regression (n = 77). A brief parent report of developmental regression may be a useful clinical indicator of later general functioning.

Social support buffers the effect of interpersonal life stress on suicidal ideation and self-injury during adolescence.

BACKGROUND The effect of life stress on suicidal symptoms during adolescence is well documented. Stressful life events can trigger suicidality, but most adolescents are resilient and it is unclear which factors protect against the deleterious impact of stress. Social support is thought to be one such factor. Therefore, we investigated the buffering effect of specific sources of social support (parental and peer) on life stress (interpersonal and non-interpersonal) in predicting suicidal symptoms during adolescence. In order to test the specificity of this stress buffering, we also examined it with regard to dysphoric mood. METHOD Data come from the Adolescent Development of Emotions and Personality Traits (ADEPT) Project, a cohort of 550 adolescent females aged 13.5-15.5 recruited from Long Island. Self-reported social support, suicidality, and dysphoria were assessed at baseline and suicidality and dysphoria were assessed again at 9-month follow-up. Life stress was assessed by interview at the follow-up. RESULTS High levels of parental support protected adolescent girls from developing suicidal symptoms following a stressor. This effect was less pronounced for peer support. Also, social support did not buffer the pathogenic effects of non-interpersonal stress. Finally, social support did not buffer the effect of life stress on dysphoric symptoms. CONCLUSIONS Altogether, our results highlight a distinct developmental pathway for the development of suicidal symptoms involving parental support that differs from the development of dysphoria, and signifies the importance and specificity of social support in protecting against suicidality in adolescent girls.

Cortical thickness is not associated with current depression in a clinical treatment study

Reduced cortical thickness is a candidate biological marker of depression, although findings are inconsistent. This could reflect analytic heterogeneity, such as use of region‐wise cortical thickness based on the Freesurfer Desikan–Killiany (DK) atlas or surface‐based morphometry (SBM). The Freesurfer Destrieux (DS) atlas (more, smaller regions) has not been utilized in depression studies. This could also reflect differential gender and age effects.