Open Access
Controversies surrounding the diagnosis of schizophrenia and other psychoses
(Taylor and Francis, 2009) Cuesta, Manuel J.; Basterra, Virginia; Sánchez Torres, Ana María; Peralta Martín, Víctor; Ciencias de la Salud; Osasun Zientziak
The diagnosis of schizophrenia and other psychotic disorders in current psychiatric classifications identifies individuals who are severely ill but who have few clinical characteristics in common. The usual picture of psychotic patients is a mixture of mood and psychotic symptoms. Fortunately, clinicians do not base their therapeutic strategies exclusively on diagnosis, but also on symptom predominance. Thus, clinicians’ treatments have been dimensional in nature for years, although, until recently, their psychiatric classifications had been mainly categorical. The main principle in psychosis classification has been the Kraepelinian dichotomy, despite its lack of enduring empirical validation. Without doubt, current psychiatric classifications have made great strides in reliability and clinical utility, although these advantages have not been enough to compensate for their shortcomings concerning validity. It has recently been suggested that the Kraepelinian dichotomy may be hindering progress in neurobiological research within psychosis. Mounting evidence is now fuelling a paradigm shift in the ongoing process of review of psychiatric classifications toward the introduction of complementary dimensional indicators of psychiatric categorical diagnoses. This new approach will allow us to understand psychosis as prototypical extremes of a severity continuum. The gradients of this continuum may begin with subtle expressions in the general population, continue with milder forms in relatives of psychotic patients and subclinical cases and finally reach the prototypical forms of psychosis at the other extreme. Future complementary dimensional indicators will require sound instruments capable of reflecting a multidimensional assessment of psychopathological symptoms, polydiagnostic interviews and the assessment of a wide range of nonsymptomatic domains. These new methods of assessment merging created by the shift toward a dimensional paradigm will be applied in the forthcoming new diagnostic criteria and may allow for a phenome-wide scanning for psychosis.
Open Access
The effect of anticholinergic burden of psychiatric medications on major outcome domains of psychotic disorders: a 21-year prospective cohort study
(Elsevier, 2024) Peralta Martín, Víctor; García de Jalón, Elena; Moreno-Izco, Lucía; Peralta, David; Janda-Galán, Lucía; Sánchez Torres, Ana María; Cuesta, Manuel J.; SEGPEPs Group; Ciencias de la Salud; Osasun Zientziak
Background: Most medications used to treat psychotic disorders possess anticholinergic properties. This may result in a considerable anticholinergic burden (ACB), which may have deleterious effects on long-term outcomes. The extent to which cumulative ACB over years of treatment with psychotropic medications impacts different outcome domains remains unknown. Methods: This was a naturalistic study of 243 subjects with first-episode psychosis aimed at examining the cumulative effect of ACB of psychotropic medications administered over the illness course (ACB-years exposure) on several outcome domains assessed after a mean 21-year follow-up. Associations between ACB and the outcomes were modelled accounting for relevant confounding factors by using hierarchical linear regression analysis. Results: Over the study period, 81.9 % of the participants were dispensed at least one drug with strong anticholinergic effects for at least 1 year; at the follow-up visit, 60.5 % of the participants continued to take medications with strong ACB. ACB-years exposure was uniquely related to severity of negative symptoms (β = 0.144, p = 0.004), poor psychosocial functioning (β = 0.186, p < 0.001) and poor cognitive performance (β = − 0.273, p < 0.001). This association pattern was independent of a schizophrenia diagnosis. Most of the associations between ACB at the follow-up visit and the outcomes were accounted for ACB-years exposure. Conclusion: Lifetime ACB of psychotropic medications has deleterious effects on the outcome of psychotic disorders. Clinicians should avoid prescribing medications with strong ACB, since there are numerous alternatives within each psychotropic drug group for prescribing medications with low ACB.
Embargo
Neurocognitive and social cognitive correlates of social exclusion in psychotic disorders: a 20-year follow-up cohort study
(Springer, 2024-08-02) Peralta Martín, Víctor; Sánchez Torres, Ana María; Gil Berrozpe, Gustavo José; García de Jalón, Elena; Moreno-Izco, Lucía; Peralta, David; Janda-Galán, Lucía; Cuesta, Manuel J.; SEGPEPs Group; Ciencias de la Salud; Osasun Zientziak; Gobierno de Navarra / Nafarroako Gobernua
Purpose: Little is known about the relationship between social exclusion and cognitive impairment in psychosis. We conducted a long-term cohort study of first-episode psychosis to examine the association between comprehensive measures of cognitive impairment and social exclusion assessed at follow-up. Methods: A total of 173 subjects with first-episode psychosis were assessed after a 20-year follow-up for 7 cognitive domains and 12 social exclusion indicators. Associations between sets of variables were modeled using multivariate regression, where social exclusion indicators were the dependent variables, cognitive domains were the independent variables, and age, gender, and duration of follow-up were covariates. Results: The total scores on the measures of cognition and social exclusion were strongly associated (β = −.469, ∆R2 = 0.215). Participants with high social exclusion were 4.24 times more likely to have cognitive impairment than those with low social exclusion. Verbal learning was the cognitive function most related to social exclusion domains, and legal capacity was the exclusion domain that showed the strongest relationships with individual cognitive tests. Neurocognition uniquely contributed to housing, work activity, income, and educational attainment, whereas social cognition uniquely contributed to neighborhood deprivation, family and social contacts, and discrimination/stigma. Neurocognition explained more unique variance (11.5%) in social exclusion than social cognition (5.5%). Conclusion: The domains of cognitive impairment were strongly and differentially related to those of social exclusion. Given that such an association pattern is likely bidirectional, a combined approach, both social and cognitive, is of paramount relevance in addressing the social exclusion experienced by individuals with psychotic disorders.
Open Access
Executive functioning in schizophrenia spectrum disorder patients and their unaffected siblings: a ten-year follow-up study
(Elsevier, 2013) Sánchez Torres, Ana María; Basterra, Virginia; Moreno-Izco, Lucía; Rosa, Araceli; Fañanás, Lourdes; Zarzuela, Amalia; Peralta Martín, Víctor; Cuesta, Manuel J.; Ciencias de la Salud; Osasun Zientziak
Executive dysfunction represents a core deficit that is associated with schizophrenia spectrum disorders (SSDs). However, the longitudinal course of executive deficits in SSDs is still controversial. The aim of this study was to examine the executive performance of 34 SSD patients in relation to 34 of their unaffected siblings over a period of 10 years. Both groups completed psychopathological and executive assessments. Thirteen healthy controls were assessed using the same instruments. At baseline, the SSD patients differed significantly from siblings and controls in their performance on the Trail Making Test-B (TMT-B) and the number of categories in which they succeeded in the Wisconsin Card Sorting Test (WCST). They also differed significantly from the controls in the total number of errors in the WCST. The siblings did not differ in executive functioning from the controls over the follow-up. Longitudinally, the patients demonstrated significant improvement only for the TMT-B. However, only 14.71% of the patients showed reliable and clinically significant improvements for the TMT-B, and 8.82% made more errors on the WCST at the follow-up evaluation. Less than 3% of the patients showed either improved or worse results on the remaining measures of the WCST. A stabilisation pattern for the WCST was observed in the three groups. The patients performed worse than their siblings and controls on both executive tests. Some patients exhibited significant improvements in the TMT-B over time, but this improvement was reliable and clinically significant for less than 15% of the sample. Thus, we conclude that the patients exhibited stable impairments over time in the executive functions assessed.
Open Access
Utility of the MoCA for cognitive impairment screening in long-term psychosis patients
(Elsevier, 2020) Gil Berrozpe, Gustavo José; Sánchez Torres, Ana María; García de Jalón, Elena; Moreno-Izco, Lucía; Fañanás, Lourdes; Peralta Martín, Víctor; Cuesta, Manuel J.; SEGPEPs Group; Ciencias de la Salud; Osasun Zientziak
Cognitive impairment is a key feature in patients with psychotic disorders. The Montreal Cognitive Assessment (MoCA) is a brief tool that has been shown to be effective in identifying mild cognitive impairment and early dementia. This study explores the usefulness of this instrument to detect cognitive impairment in long-term psychotic disorders. One hundred-forty stabilized patients were re-evaluated more than 15 years after a First Episode of Psychosis (FEP). Patients were psychopathologically assessed, and the MoCA test and MATRICS Consensus Cognitive Battery (MCCB) were administered. Two cut-off scores for cognitive impairment using the MCCB were applied (T score <40 and < 30). Concurrent validation was found between the total scores of the MoCA and MCCB. We also found significant associations between 5 out of 7 MoCA subtests (visuospatial-executive, attention, language, abstraction and delayed recall) and MCCB subtests but not for the naming and orientation MoCA subtests. Receiver operating characteristic (ROC) analysis suggested a <25 cut-off for cognitive impairment instead of the original <26. Our results suggest that the MoCA test is a useful screening instrument for assessing cognitive impairment in psychotic patients and has some advantages over other available instruments, such as its ease-of-use and short administration time.
Open Access
Assessment of cognitive impairment in psychosis spectrum disorders through self-reported and interview-based measures
(Springer, 2022) Sánchez Torres, Ana María; Moreno-Izco, Lucía; Gil Berrozpe, Gustavo José; Lorente Omeñaca, Ruth; Zandio, María; Zarzuela, Amalia; Peralta Martín, Víctor; Cuesta, Manuel J.; Ciencias de la Salud; Osasun Zientziak
Self-reported and interview-based measures can be considered coprimary measures of cognitive performance. We aimed to ascertain to what extent cognitive impairment in psychotic disorders, as assessed with a neuropsychological battery, is associated with subjective cognitive complaints compared to difficulties in daily activities caused by cognitive impairment. We assessed 114 patients who had a psychotic disorder with a set of neuropsychological tests and two additional measures: the Cognitive Assessment Interview-Spanish version (CAI-Sp) and the Frankfurt Complaint Questionnaire (FCQ). Patients also underwent a clinical assessment. The CAI-Sp correlated significantly with all the clinical dimensions, while the FCQ correlated only with positive and depressive symptoms. The CAI-Sp correlated significantly with all cognitive domains, except for verbal memory and social cognition. The FCQ was associated with attention, processing speed and working memory. The combination of manic and depressive symptoms and attention, processing speed, working memory and explained 38–46% of the variance in the patients’ CAI-Sp. Education and negative symptoms, in combination with attention, processing speed, and executive functions, explained 54–59% of the CAI-Sp rater’s variance. Only negative symptoms explained the variance in the CAI-Sp informant scores (37–42%). Depressive symptoms with attention and working memory explained 15% of the FCQ variance. The ability to detect cognitive impairment with the CAI-Sp and the FCQ opens the possibility to consider these instruments to approximate cognitive impairment in clinical settings due to their ease of application and because they are less time-consuming for clinicians.
Open Access
Social exclusion as a major outcome domain of psychotic disorders: early predictors, and associations with non-recovery and clinical staging 21 years after a first episode of psychosis
(Springer, 2024) Peralta Martín, Víctor; García de Jalón, Elena; Moreno-Izco, Lucía; Peralta, David; Janda-Galán, Lucía; Sánchez Torres, Ana María; Cuesta, Manuel J.; SEGPEPs Group; Ciencias de la Salud; Osasun Zientziak; Gobierno de Navarra / Nafarroako Gobernua
Purpose People with psychotic disorders have high levels of social exclusion; however, little is known about its early predictors. We present a long-term observational cohort study aimed at examining early risk factors for later social exclusion. Methods A total of 243 subjects were assessed at their frst psychotic episode for early risk factors including sociodemographic variables, familial risk of major mental disorders, perinatal complications, childhood factors, and adolescent factors and re-assessed after a mean follow-up of 21 years for 12 social exclusion domains: leisure activities, housing, work, income, neighborhood deprivation, educational attainment, physical and mental health, family and social support, legal competence, and discrimination. The ability of risk factors to predict social exclusion was examined using hierarchical linear regression. Results Overall social exclusion was independently predicted by low parental socio-economic status, length of follow-up, familial risk of schizophrenia, obstetric complications, neurodevelopmental delay, poor childhood adjustment, childhood adversity, poor adolescent social networks, poor adolescent adjustment, and low premorbid IQ. The model explained 58.2% of the variance in total social exclusion score. Each social exclusion domain was predicted by a diferent set of variables, which explained between 17.8 and 57.0% of their variance, although low socio-economic status, familial risk of schizophrenia, obstetric complications, childhood adversity, and poor social networks predicted most of the social exclusion domains. Conclusion Early risk factors strongly predicted later social exclusion. A multifaceted approach to preventing later social exclusion is crucial in people with a frst episode of psychosis and early risk factors of social exclusion.
Open Access
Familial liability to schizophrenia and mood disorders and cognitive impairment in psychosis
(Elsevier, 2015) Cuesta, Manuel J.; Zarzuela, Amalia; Sánchez Torres, Ana María; Lorente Omeñaca, Ruth; Moreno-Izco, Lucía; Sanjuán, Julio; Peralta Martín, Víctor; Ciencias de la Salud; Osasun Zientziak
Schizophrenia and other psychoses are complex disorders with high rates of cognitive impairment and a considerable degree of genetic and environmental influence on its etiology. Whether cognitive impairment is related to dimensional scores of familial liability is still matter of debate. We conducted a cross-sectional study including 169 patients with psychotic disorders and 26 healthy controls. Attention, memory and executive functions were assessed, and familial loading scores for schizophrenia and mood disorders were calculated. The relationships between familial liability and neuropsychological performance were examined with Spearman's correlation coefficients. In addition, patients were classified into three groups by family loading tertiles, and comparisons were performed between the patients in the top and bottom tertiles. Low familial loading scores for schizophrenia showed a significant association with poor executive functioning and delayed visual memory. And these results were also achieved when the subset of psychotic patients in the two extreme tertiles of family loadings of schizophrenia and mood disorders were compared. Low familial liability to schizophrenia seems to be a contributing factor for the severity of cognitive impairment in patients with a broad putative schizophrenia spectrum diagnosis.
Open Access
Treatment response of neurological soft signs in drug-naïve patients with a first psychotic episode
(Elsevier, 2012) Cuesta, Manuel J.; Campos, María S.; García de Jalón, Elena; Sánchez Torres, Ana María; Peralta Martín, Víctor; Ciencias de la Salud; Osasun Zientziak; Gobierno de Navarra / Nafarroako Gobernua
Background: Neurological soft signs (NSS) are intrinsic features of psychosis that appear years before beginning a drug treatment. However, whether NSS respond to antipsychotics and whether these changes are clinically reliable and significant remains to be seen. Objective: We sought to determine the effect of antipsychotics on NSS in a first-episode psychosis (FEP) sample who had never exposed to antipsychotics. Methods: We included 100 antipsychotic-naïve patients with FEP in this study. 77 patients completed the study assessments at baseline, 1 month and 6 months. The Neurological Evaluation Scale (NES) evaluated NSS. Patients were alternatively selected to receive risperidone or olanzapine treatments and continued participation in their mental health setting during follow-up with one of four treatment groups: risperidone, olanzapine, mixed antipsychotics or no medication. We also included a control group of 28 healthy volunteers. Results: Treatment groups showed a statistically significant improvement on total NES scores and most NES subscales except for ‘frontal signs’, regardless of antipsychotic allocation. NSS changes were reliable; however, there was great variation in the total NES scores between treatment groups, ranging from 4% to 24%. Clinically meaningful changes (CMCs) on total NES scores ranged from 25% to 50%. Six patients (7.8%) demonstrated a reliable change (RC) and CMC on total NES scores. Conclusions: NSS improved significantly over follow up regardless of the treatment regimen assigned to antipsychotic-naïve patients with a FEP. However, only 6 (7.8%) achieved a reliable and clinically meaningful improvement. The pattern of response of NSS to antipsychotic drugs evidenced both state and trait characteristics.
Open Access
A comparative study of the working memory multicomponent model in psychosis and healthy controls
(Elsevier, 2015) Sánchez Torres, Ana María; Elosúa, M. Rosa; Lorente Omeñaca, Ruth; Moreno-Izco, Lucía; Cuesta, Manuel J.; Ciencias de la Salud; Osasun Zientziak
Working memory deficits are considered nuclear deficits in psychotic disorders. However, research has not found a generalized impairment in all of the components of working memory. We aimed to assess the components of the Baddeley and Hitch working memory model: the temporary systems—the phonological loop, the visuospatial sketchpad and the episodic buffer (introduced later by Baddeley)—and the central executive system, which includes four executive functions: divided attention, updating, shifting and inhibition. We assessed working memory performance in a sample of 21 patients with a psychotic disorder and 21 healthy controls. Patients also underwent a clinical assessment. Both univariate and repeated measures ANOVAs were applied to analyze performance in the working memory components between groups. Patients with a psychotic disorder underperformed compared to the controls in all of the working memory tasks, but after controlling for age and premorbid IQ, we only found a difference in performance in the N-Back task. Repeated measures ANCOVAs showed that patients also underperformed compared to the controls in the Digit span test and the TMT task. Not all of the components of working memory were impaired in the patients. Specifically, patients' performance was impaired in the tasks selected to assess the phonological loop and the shifting executive function. Patients' also showed worse performance than controls in the N-Back task, representative of the updating executive function. However, we did not find higher impairment in the patients' performance respect to controls when increasing the loading of the task.