Evidence That Onset of Psychosis in the Population Reflects Early Hallucinatory Experiences That Through Environmental Risks and Affective Dysregulation Become Complicated by Delusions

Department of Psychiatry and Psychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University Medical Centre, Maastricht, The Netherlands.
Schizophrenia Bulletin (Impact Factor: 8.45). 10/2010; 38(3):531-42. DOI: 10.1093/schbul/sbq117
Source: PubMed


To examine the hypothesis that the "natural" combination of delusions and hallucinations in psychotic disorders in fact represents a selection of early subclinical hallucinatory experiences associated with delusional ideation, resulting in need for care and mental health service use.
In the Early Developmental Stages of Psychopathology study, a prospective, 10-year follow-up of a representative cohort of adolescents and young adults in Munich, Germany (n = 2524), clinical psychologists assessed hallucinations and delusions at 2 time points (T2 and T3). Analyses compared differences in psychopathology, familial liability for nonpsychotic disorder, nongenetic risk factors, persistence, and clinical outcome between groups characterized by: (1) absence of positive psychotic symptoms, (2) presence of isolated hallucinations, (3) isolated delusions, and (4) both hallucinations and delusions.
Delusions and hallucinations occurred together much more often (T2: 3.1%; T3: 2.0%) than predicted by chance (T2: 1.0%; T3: 0.4%; OR = 11.0; 95% CI: 8.1, 15.1). Content of delusions was contingent on presence of hallucinations but modality of hallucinations was not contingent on presence of delusions. The group with both hallucinations and delusions, compared to groups with either delusions or hallucinations in isolation, displayed the strongest associations with familial affective liability and nongenetic risk factors, as well as with persistence of psychotic symptoms, comorbidity with negative symptoms, affective psychopathology, and clinical need.
The early stages of psychosis may involve hallucinatory experiences that, if complicated by delusional ideation under the influence of environmental risks and (liability for) affective dysregulation, give rise to a poor prognosis hallucinatory-delusional syndrome.

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    • "This may also be useful in knowing which symptom subtypes are more likely to lead to or indicate prolonged impairment in terms of co-morbidities, psychological distress, or suicide risk. Further, persistent hallucinations may be particularly clinically relevant as they potentially lead to threshold psychotic disorder (Smeets et al., 2012). "
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    ABSTRACT: Recent epidemiological evidence suggests that sub-threshold psychotic experiences commonly occur in the general population. When these experiences persist over time, they may increase risk for psychotic disorder or lead to other clinical or functional impairments. The aims of this study were to distinguish the relative importance of sociodemographic factors and clinical factors, including characteristics of the psychotic experiences themselves, in determining the course of psychotic symptoms over time. Participants were drawn from the Collaborative Psychiatric Epidemiology Surveys. We tested for retrospectively-reported predictors of current psychotic experiences among individuals who reported lifetime psychotic experiences, with onset prior to the past year (n=921), using logistic regression. Persistence was primarily related to demographic variables, with lower odds associated with being married and having at least a college education. Individuals reporting prior to the past year auditory hallucinations were more likely to have persistent psychotic experiences than those reporting other types of psychotic experiences. Interventions aiming at strengthening family support and social skills may reduce the likelihood of persistence among individuals with psychotic experiences, thereby reducing risk for psychotic disorders and other related outcomes. Future studies should continue to identify predictors of persistence versus remission and further explore clinical services for those with persistent psychotic experiences.
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    • "Environmental impact as increased connectivity spreading through the psychopathology network It has been suggested that symptoms of psychopathology do not vary in isolation, but rather make an impact on each other over time. For example, there is evidence that affective dysregulation underlies psychosis (Freeman et al. 2013a, b; Hartley et al. 2013), that motivational impairments may predict psychosis (Dominguez et al. 2010) and that abnormal perceptions may make an impact on risk of delusional ideation (Smeets et al. 2012). In non-psychotic affective disorder, expression of psychosis is associated with severity of anxiety and depression (Armando et al. 2013), and there is evidence that the association between environmental risk factors such as cannabis and trauma on the one hand, and psychosis on the other, is mediated by non-psychotic symptoms such as anxiety and depression (Gracie et al. 2007; Freeman & Fowler, 2009; Reeves et al. 2014). "
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    ABSTRACT: Evidence suggests that in affective, non-psychotic disorders: (i) environmental exposures increase risk of subthreshold psychotic experiences (PEs) and strengthen connectivity between domains of affective and subthreshold psychotic psychopathology; and (ii) PEs are a marker of illness severity. In 3021 adolescents from the Early Developmental Stages of Psychopathology cohort, we tested whether the association between PEs and presence of DSM-IV mood disorder (MD)/obsessive-compulsive disorder (OCD) would be moderated by risk factors for psychosis (cannabis use, childhood trauma and urbanicity), using the interaction contrast ratio (ICR) method. Furthermore, we analysed whether the interaction between environment and PEs was mediated by non-psychotic psychopathology. The association between PEs and MD/OCD was moderated by urbanicity (ICR = 2.46, p = 0.005), cannabis use (ICR = 3.76, p = 0.010) and, suggestively, trauma (ICR = 1.91, p = 0.063). Exposure to more than one environmental risk factor increased the likelihood of co-expression of PEs in a dose-response fashion. Moderating effects of environmental exposures were largely mediated by the severity of general non-psychotic psychopathology (percentage explained 56-68%, all p < 0.001). Within individuals with MD/OCD, the association between PEs and help-seeking behaviour, as an index of severity, was moderated by trauma (ICR = 1.87, p = 0.009) and urbanicity (ICR = 1.48, p = 0.005), but not by cannabis use. In non-psychotic disorder, environmental factors increase the likelihood of psychosis admixture and help-seeking behaviour through an increase in general psychopathology. The findings are compatible with a relational model of psychopathology in which more severe clinical states are the result of environment-induced disturbances spreading through a psychopathology network.
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    • "According to him, a large family based cohort of patients, their siblings and parents reveal that selective environmental exposures e.g. cannabis influence familiar correlation of psychosis (Smeets et al., 2010). This suggests that it raised the importance of selective gene– environment interactions in psychosis susceptibility. "
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