Sandra M. Goulding

Stress and neurodevelopmental processes in the emergence of psychosis

The notion that stress plays a role in the etiology of psychotic disorders, especially schizophrenia, is longstanding. However, it is only in recent years that the potential neural mechanisms mediating this effect have come into sharper focus. The introduction of more sophisticated models of the interplay between psychosocial factors and brain function has expanded our opportunities for conceptualizing more detailed psychobiological models of stress in psychosis. Further, scientific advances in our understanding of adolescent brain development have shed light on a pivotal question that has challenged researchers; namely, why the first episode of psychosis typically occurs in late adolescence/young adulthood. In this paper, we begin by reviewing the evidence supporting associations between psychosocial stress and psychosis in diagnosed patients as well as individuals at clinical high risk for psychosis. We then discuss biological stress systems and examine changes that precede and follow psychosis onset. Next, research findings on structural and functional brain characteristics associated with psychosis are presented; these findings suggest that normal adolescent neuromaturational processes may go awry, thereby setting the stage for the emergence of psychotic syndromes. Finally, a model of neural mechanisms underlying the pathogenesis of psychosis is presented and directions for future research strategies are explored.

Confirmation of a four-factor structure of the Schizotypal Personality Questionnaire among undergraduate students

OBJECTIVE Although several exploratory and confirmatory factor analyses have supported the initially proposed factor structure of the Schizotypal Personality Questionnaire (SPQ) in which its nine subscales are grouped into cognitive-perceptual, interpersonal, and disorganized domains, others have revealed different latent structures. This study determined the best-fitting factor structure from among five models that have been proposed in the literature, as well as five additional hierarchically related models. METHODS Undergraduate college students (n=825) completed the SPQ as well as the Perceptual Aberration Scale (PAS) and the Revised Social Anhedonia Scale (SAS). Confirmatory factor analyses involving the nine SPQ subscales were conducted using the Linear Structural Relations Program (LISREL 8.72). RESULTS The best fitting model was a previously described 4-factor model including cognitive-perceptual, paranoid, negative, and disorganized domains. Correlations between the derived SPQ domains and the PAS score ranged r=.26-.39, and correlations between the SPQ domains and the SAS ranged r=.07-.41. CONCLUSIONS The present findings support a 4-factor model over the standard 3-factor model that is typically used to derive SPQ subscale scores. The four derived domains are minimally to moderately correlated with other measures of psychosis-proneness.

Premorbid functioning of patients with first-episode nonaffective psychosis: A comparison of deterioration in academic and social performance, and clinical correlates of Premorbid Adjustment Scale scores

BACKGROUND Motivated by a previous study among male veterans [Allen, D.N., Frantom, L.V., Strauss, G.P., van Kammen, D.P., 2005. Differential patterns of premorbid academic and social deterioration in patients with schizophrenia. Schizophr. Res. 75, 389-397], the present analysis examined: (1) patterns of premorbid academic and social functioning during childhood, early adolescence, and late adolescence, and (2) associations between these premorbid functioning dimensions and a number of clinical variables. METHODS Data on premorbid functioning were collected using the Premorbid Adjustment Scale (PAS) in 95 hospitalized first-episode patients. Analyses were similar to those conducted by Allen and colleagues (2005). RESULTS Deterioration was evident in both academic and social functioning from childhood to early adolescence, along with a pronounced/accelerated deterioration in academic functioning from early adolescence to late adolescence, occurring in both male and female patients. Age at onset of prodromal symptoms was predicted by childhood/early adolescent/late adolescent academic functioning scores, and age at onset of psychotic symptoms was significantly associated only with childhood academic functioning. Severity of negative symptoms was predicted by childhood and late adolescent social functioning scores, and severity of general psychopathology symptoms was predicted by late adolescent academic functioning, as well as childhood and late adolescent social functioning scores. CONCLUSIONS Consistent with prior findings, deterioration in premorbid functioning appears to be more pronounced in the academic than social dimension of the PAS. Some PAS scores are predictive of ages at onset of prodrome/psychosis and severity of psychotic symptoms. Ongoing research on premorbid adjustment in schizophrenia may have implications for future prevention goals.

Prevalence and correlates of school drop-out prior to initial treatment of nonaffective psychosis: Further evidence suggesting a need for supported education

BACKGROUND Because dropping out of high school (i.e., secondary education) contributes prominently to numerous social, economic, and health conditions, formal public health initiatives promoting population health and social justice, especially in at-risk populations, are increasingly encouraged to address high school drop-out. The relative dearth of research attention on school drop-out prior to first treatment contact in young adults with psychotic disorders indicates a need for investigation of the associations between school drop-out and illness-related variables so that interventions may be tailored appropriately to this unique population. METHODS This study provides a descriptive characterization of the prevalence and correlates of high school drop-out in a sample of 109 patients hospitalized for the evaluation and treatment of a first episode of nonaffective psychosis. RESULTS Findings from this urban, socially disadvantaged, predominantly African American sample indicate that school drop-out is a marker of diverse detrimental social problems in first-episode psychosis, and that further research is required to fully characterize the most appropriate interventions for such individuals. CONCLUSIONS Future research might seek to intervene through an integrated treatment approach that incorporates supported education, symptom reduction and management, and comorbid substance use treatment in first-episode patients.

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.

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.

An examination of the factorial structure of the Schizotypal Personality Questionnaire-Brief (SPQ-B) among undergraduate students.

Cognitive-perceptual, interpersonal, and disorganized subscales of the Schizotypal Personality Questionnaire-Brief (SPQ-B), reflecting the three commonly used subscales of the full-version SPQ, have been used in a number of studies. However, the factorial validity of SPQ-B subscales remains to be clarified. Utilizing data from 825 undergraduate students, confirmatory factor analyses involving the 22 items of the SPQ-B were conducted. A significant chi(2) difference test favored the 3-factor over the 1-factor model and fit indices for the 3-factor model were generally satisfactory. However, several of the items may index more than one of the hypothesized factors, so the item-factor separation is not sharp. Thus, more research is needed on the factorial validity of the increasingly used SPQ-B subscales.

Associations among perceptual anomalies, social anxiety, and paranoia in a college student sample

Recent evidence suggests that normal-range paranoid ideation may be particularly likely to develop in individuals disposed to both social anxiety and perceptual anomalies. This study was designed to test the hypothesis that among college students in an unselected sample, social anxiety and experience of perceptual anomalies would not only each independently predict the experience of self-reported paranoid ideation, but would also interact to predict paranoid patterns of thought. A diverse sample of 644 students completed a large battery of self-report measures, as well as the five-factor Paranoia/Suspiciousness Questionnaire (PSQ). We conducted hierarchical multiple regression analyses predicting scores on each PSQ factor from responses on measures of social anxiety, perceptual aberration, and the interaction between the two constructs. Current general negative affect was covaried in all analyses. We found that both social anxiety and perceptual aberrations, along with negative affect, predicted multiple dimensions of paranoia as measured by the PSQ; the two constructs did not, however, interact significantly to predict any dimensions. Our findings suggest that perceptual aberration and anxiety may contribute to normal-range paranoid ideation in an additive rather than an interactive manner.

Cannabis Use, First-Episode Psychosis, and Schizotypy: A Summary and Synthesis of Recent Literature

Schizophrenia currently is conceptualized as a neurodevelopmental disorder, the expression of which is affected by both genetic and environmental factors. Schizotypy is a dimensional personality construct that is the substrate of schizotypal personality disorder (SPD), and its positive, negative, and cognitive features are subclinical manifestations that mirror the symptoms of schizophrenia. Research indicates that both schizophrenia and schizotypy are linked with cannabis use. In this overview, recent literature on the following topics is summarized: (1) cannabis use as a potential risk factor, or component cause, of schizophrenia, (2) prevalence and clinical correlates of cannabis use among individuals in the early course of schizophrenia, (3) clinical and psychosocial outcomes of schizophrenia that are influenced by cannabis use, and (4) associations between cannabis use and schizotypy. Implications and future research directions are discussed. Growing evidence points to the complex and informative interconnections between cannabis use, schizotypy, and firstepisode psychosis.

Developmental mechanisms in the prodrome to psychosis

Psychotic disorders continue to be among the most disabling and scientifically challenging of all mental illnesses. Accumulating research findings suggest that the etiologic processes underlying the development of these disorders are more complex than had previously been assumed. At the same time, this complexity has revealed a wider range of potential options for preventive intervention, both psychosocial and biological. In part, these opportunities result from our increased understanding of the dynamic and multifaceted nature of the neurodevelopmental mechanisms involved in the disease process, as well as the evidence that many of these entail processes that are malleable. In this article, we review the burgeoning research literature on the prodrome to psychosis, based on studies of individuals who meet clinical high risk criteria. This literature has examined a range of factors, including cognitive, genetic, psychosocial, and neurobiological. We then turn to a discussion of some contemporary models of the etiology of psychosis that emphasize the prodromal period. These models encompass the origins of vulnerability in fetal development, as well as postnatal stress, the immune response, and neuromaturational processes in adolescent brain development that appear to go awry during the prodrome to psychosis. Then, informed by these neurodevelopmental models of etiology, we turn to the application of new research paradigms that will address critical issues in future investigations. It is expected that these studies will play a major role in setting the stage for clinical trials aimed at preventive intervention.