The clinical relevance of formal thought disorder in the early stages of psychosis: results from the PRONIA study

Abstract Background Formal thought disorder (FTD) has been associated with more severe illness courses and functional deficits in patients with psychotic disorders. However, it remains unclear whether the presence of FTD characterises a specific subgroup of patients showing more prominent illness severity, neurocognitive and functional impairments. This study aimed to identify stable and generalizable FTD-subgroups of patients with recent-onset psychosis (ROP) by applying a comprehensive data-driven clustering approach and to test the validity of these subgroups by assessing associations between this FTD-related stratification, social and occupational functioning, and neurocognition. Methods 279 patients with ROP were recruited as part of the multi-site European PRONIA study (Personalised Prognostic Tools for Early Psychosis Management; www.pronia.eu). Five FTD-related symptoms (conceptual disorganization, poverty of content of speech, difficulty in abstract thinking, increased latency of response and poverty of speech) were assessed with Positive and Negative Symptom Scale (PANSS) and the Scale for the Assessment of Negative Symptoms (SANS). Results The results with two patient subgroups showing different levels of FTD were the most stable and generalizable clustering solution (predicted clustering strength value = 0.86). FTD-High subgroup had lower scores in social (pfdr < 0.001) and role (pfdr < 0.001) functioning, as well as worse neurocognitive performance in semantic (pfdr < 0.001) and phonological verbal fluency (pfdr < 0.001), short-term verbal memory (pfdr = 0.002) and abstract thinking (pfdr = 0.010), in comparison to FTD-Low group. Conclusions Clustering techniques allowed us to identify patients with more pronounced FTD showing more severe deficits in functioning and neurocognition, thus suggesting that FTD may be a relevant marker of illness severity in the early psychosis pathway.

Download Full-text

O6.4. ASSOCIATION BETWEEN CLUSTERS OF FORMAL THOUGHT DISORDERS SEVERITY AND NEUROCOGNITIVE AND FUNCTIONAL OUTCOME INDICES IN THE EARLY STAGES OF PSYCHOSIS – RESULTS FROM THE PRONIA COHORT

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa028.033 ◽

2020 ◽

Vol 46 (Supplement_1) ◽

pp. S14-S15

Author(s):

Ömer Faruk Öztürk ◽

Alessandro Pigoni ◽

Julian Wenzel ◽

Shalaila Haas ◽

David Popovic ◽

...

Keyword(s):

Network Analysis ◽

Negative Symptoms ◽

Early Stage ◽

Machine Learning Algorithms ◽

Severe Illness ◽

Cluster Solution ◽

Abstract Thinking ◽

Functional Impairments ◽

Early Stages ◽

Thought Disorders

Abstract Background Formal thought disorder (FThD) has been associated with more severe illness courses and functional deficits in psychosis patients. Given these associations, it remains unclear whether the presence of FThD accounts for the heterogeneous presentation of psychoses, and whether it characterises a specific subgroup of patients showing prominent differential illness severity, neurocognitive and functional impairments already in the early stages of psychosis. Thus, our aim is 1) to evaluate whether there are stable subtypes of patients with Recent-Onset Psychosis (ROP) that are characterized by distinct FThD patterns, 2) to investigate whether this FThD-related stratification is associated with clinical, and neurocognitive phenotypes at an early stage of the disease, and 3) to explore correlation patterns among the FThD-related symptoms, functioning and neurocognition through network analysis. Methods 279 individuals experiencing ROP were recruited for this project as part of multi-site European PRONIA study. In the present study, FThD was assessed with conceptual disorganization, difficulty in abstract thinking, poverty of content of speech, increased latency of response and poverty of speech items from the Positive and Negative Symptom Scale (PANSS) and the Scale for the Assessment of Negative Symptoms (SANS). We first applied a multi-step clustering protocol comparing three clustering algorithms: (i) k-means, (ii) hierarchical clustering, and (iii) partitioning around medoids with the number of clusters ranging from 2 to 10. Our protocol runs following four checkpoints; (i) validity [ClValid package], (ii) re-evaluation of validity results and unbiased determination of the winning algorithm [NbClust package], (iii) stability test [ClusterStability package] and (iv) generalizability [predict.strength package] testing for the most optimal clustering solution. Thereafter, we investigated whether the identified FThD subgrouping solution was associated with neurocognitive performance, social and occupational functioning by using Welch’s two-sample t-test or Mann-Whitney-U test based on the distribution of data, and explored the interrelation of these domains with network analysis by using qgraph package with the spearman correlation matrix among variables. All analyses and univariate statistical comparisons were conducted with R version 3.5.2. We used the False Discovery Rate (FDR)37 to correct all P-values for the multiple comparisons. Results The k-means algorithm-based on two-cluster solution (FThD high vs. low) surviving these validity, stability and generalizability tests was chosen for further association tests and network analysis with core disease phenotypes. Patients in FThD high subgroup had lower scores in global (pfdr = 0.0001), social (pfdr < 0.0001) and role (pfdr < 0.0001) functioning, in semantic (pfdr < 0.0001) and phonological verbal fluency (pfdr = 0.0004), verbal short-term memory (pfdr = 0.0018) and abstract thinking (pfdr = 0.0099). Cluster assignment was not informed by the global disease severity (pfdr = 0.7786) but was associated with more pronounced negative symptoms (pfdr = 0.0001) in the FThD high subgroup. Discussion Our findings highlight how the combination of unsupervised machine learning algorithms with network analysis techniques may provide novel insight about the mappings between psychopathology, neurocognition and functioning. Furthermore, they point how FThD may represent a target variable for individualized psycho-, socio-, logotherapeutic interventions aimed at improving neurocognition abilities and functioning. Prospective studies should further test this promising perspective.

Download Full-text

Sex Differences in Verbal Memory Predict Functioning Through Negative Symptoms in Early Psychosis

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa054 ◽

2020 ◽

Vol 46 (6) ◽

pp. 1587-1595 ◽

Cited By ~ 2

Author(s):

Gabriella Buck ◽

Katie M Lavigne ◽

Carolina Makowski ◽

Ridha Joober ◽

Ashok Malla ◽

...

Keyword(s):

Sex Differences ◽

Verbal Memory ◽

Visual Memory ◽

Parental Education ◽

Negative Symptoms ◽

Early Psychosis ◽

First Episode ◽

Severe Illness ◽

Cognitive Domains

Abstract Verbal memory (VM) is one of the most affected cognitive domains in first-episode psychosis (FEP) and is a robust predictor of functioning. Given that healthy females demonstrate superior VM relative to males and that female patients show less-severe illness courses than male patients, this study examined whether normative sex differences in VM extend to FEP and influence functioning. Four hundred and thirty-five patients (299 males, 136 females) with affective or nonaffective psychosis were recruited from a catchment-based specialized FEP intervention service and 138 nonclinical controls (96 males, 42 females) were recruited from the same community. One of the two neurocognitive batteries comprising six cognitive domains (VM, visual memory, working memory, attention, executive function, processing speed) were administered at baseline. In patients, positive and negative symptoms were evaluated at baseline and functioning was assessed at 1-year follow-up. Patients were more impaired than controls on all cognitive domains, but only VM showed sex differences (both patient and control males performed worse than females), and these results were consistent across batteries. In patients, better baseline VM in females was related to better functioning after 1 year, mediated through fewer baseline negative symptoms. Supplemental analyses revealed these results were not driven by affective psychosis nor by age and parental education. Thus, normative sex differences in VM are preserved in FEP and mediate functioning at 1-year follow-up via negative symptoms. This study highlights the importance of investigating sex effects for understanding VM deficits in early psychosis and suggests that sex may be a disease-modifying variable with important treatment implications.

Download Full-text

Evidence for feasibility of mobile health and social media-based interventions for early psychosis and clinical high risk (Preprint)

10.2196/preprints.30230 ◽

2021 ◽

Author(s):

Olivia H. Franco ◽

Monica E. Calkins ◽

Salvatore Giorgi ◽

Lyle H. Ungar ◽

Raquel E. Gur ◽

...

Keyword(s):

Social Media ◽

Mobile Health ◽

Mental Health Treatment ◽

Negative Symptoms ◽

Psychotic Disorders ◽

Early Psychosis ◽

Categorical Variables ◽

Continuous Variables ◽

Care Clinic ◽

Access To Technology

BACKGROUND Digital technology, the internet and social media are increasingly investigated as a promising means for monitoring symptoms and delivering mental health treatment. These apps and interventions have demonstrated preliminary acceptability and feasibility, but previous reports suggests that access to technology may still be limited among individuals with psychotic disorders relative to the general population. OBJECTIVE We evaluated and compared access and use of technology and social media in young adults with psychotic disorders (PD), clinical risk for psychosis (CR), and psychosis-free youths (PF). METHODS Participants were recruited through a coordinated specialty care clinic dedicated towards early psychosis as well as ongoing studies. We surveyed 21 PD, 23 CR, and 15 PF participants regarding access to technology and use of social media, specifically Facebook and Twitter. Statistical analyses were conducted in R. Categorical variables were compared among groups Fisher’s exact test, continuous variables were compared using one-way ANOVA, and multiple linear regressions were used to evaluate for covariates. RESULTS Access to technology and social media were similar among PD, CR and PF. Individuals with PD, but not CR, were less likely to post at a weekly or higher frequency compared to psychosis-free individuals. We found that decreased active social media posting was unique to psychotic disorders and did not occur with other psychiatric diagnoses or demographic variables. Additionally, variation in age, sex, Caucasian vs. non-Caucasian race did not affect posting frequency. CONCLUSIONS For young people with psychosis spectrum disorders, there appears to be no “technology gap” limiting the implementation of digital and mobile health interventions. Active posting to social media was reduced for individuals with psychosis, which may be related to negative symptoms or impairment in social functioning.

Download Full-text

S55. PRAGMATIC INFERENCES IN SCHIZOPHRENIA: RELATIONSHIP WITH SYMPTOM DOMAINS, THEORY OF MIND AND NEUROCOGNITIVE FUNCTIONS

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa031.121 ◽

2020 ◽

Vol 46 (Supplement_1) ◽

pp. S53-S54

Author(s):

Berna Yalincetin ◽

Emre Bora ◽

Berna Binnur Akdede ◽

Köksal Alptekin

Keyword(s):

Negative Symptoms ◽

Thought Disorder ◽

Pragmatic Language ◽

Healthy Controls ◽

Schizophrenia Spectrum Disorders ◽

Formal Thought Disorder ◽

Intended Meaning ◽

Significant Group ◽

Neurocognitive Dysfunction ◽

Neurocognitive Functions

Abstract Background Severe impairment in interpersonal functioning is a common feature of schizophrenia. Deficits in communicative abilities are likely to be among the important factors contributing to social dysfunction in schizophrenia. Difficulties in pragmatic language abilities including understanding intended meaning, beyond explicit and literal content of conversational statements can significantly hamper interpersonal and occupational functioning. An important aspect of pragmatic inference is the ability to derive scalar implicatures (SIs), which are based on linguistic expressions like some, or, often etc. For deriving SIs, one need to go beyond simple semantic and logical level. To date, only a single study has investigated SIs in schizophrenia (Wampers et al 2018). In this study, people with psychosis were less likely to derive SIs than controls. A preliminary analysis of 17 patients with schizophrenia in the same study also showed that better ToM was associated with a higher ability to derive SIs Importantly, the association with schizophrenia and abnormalities in pragmatic infererence might be mediated by clinical features of this illness including formal thought disorder and negative symptoms. Also, difficulties in pragmatic inferences might potentially be secondary to neurocognitive dysfunction rather than being primary deficits. No previous study has investigated clinical and neurocognitive correlates of impairment in ability to derive SIs in schizophrenia. Methods The study included 79 patients with schizophrenia-spectrum disorders (66 schizophrenia and 13 schizoaffective disorder) and 49 healthy controls who completed a SI task. SAPS, SANS were also administered. Comprehension of irony, metaphor and faux pas were assessed using verbal story tasks. A subgroup of patients were also administered a comprehensive neuropsychological battery and two ToM tasks (Hinting task and RMET (Reading the Mind from the Eyes). Results There were no significant group difference between schizophrenia and healthy controls for age (F=0.69, p=0.41) and gender (Chi square=2.2, p=0.13). The schizophrenia sample had a shorter duration of education compared to the healthy controls (F=27.2, p<0.001). The patients with schizophrenia had significant impairment in understanding the SIs (F=8.2, p=0.005). Comprension impairment of SIs were significantly associated with SANS negative symptoms (r=-0.29, p= 0.009) but not with SAPS positive formal thought disorder (r=-0.09, p=0.44) and symptoms ratings for hallucinations and delusions. Understanding SIs in schizophrenia was significantly related to better performance in RMET (r=0.34, p=0.036) and irony comprehension (r=-0.38, p=0.001). Discussion Schizophrenia is associated with significant deficits in understanding pragmatic utterances. These deficits were significantly related to some aspects of social cognition but not neurocognition. Current findings do not support the proposed relationship between formal thought disorder and pragmatic abnormalities in schizophrenia. These findings might have implications in management of social functioning deficits in schizophrenia.

Download Full-text

Symptoms of Psychoses

The British Journal of Psychiatry ◽

10.1192/bjp.166.2.236 ◽

1995 ◽

Vol 166 (2) ◽

pp. 236-240 ◽

Cited By ~ 54

Author(s):

Toshinori Kitamura ◽

Yuji Okazaki ◽

Akira Fujinawa ◽

Masahiro Yoshino ◽

Yomishi Kasahara

Keyword(s):

Negative Symptoms ◽

Psychotic Disorders ◽

Current Knowledge ◽

Psychiatric Patients ◽

Psychotic Symptoms ◽

Formal Thought Disorder ◽

Affective Symptoms ◽

Five Factors ◽

Thought Disorders ◽

Positive And Negative Symptoms

BackgroundThe literature on the statistical analysis of symptoms of psychoses was limited to positive and negative symptoms in schizophrenia. The present study explored the relationship between positive and negative symptoms as well as affective symptoms in a wider category of psychotic disorders.MethodThe symptoms of 584 psychiatric patients, consecutively admitted to any of the 95 mental hospitals in Japan, were studied. They manifested at least one of the following: (a) delusions, (b) hallucinations, (c) formal thought disorder, (d) catatonic symptoms, or (e) negative (defect) symptoms.ResultsFactor analysis yielded five factors interpretable as (a) manic symptoms, (b) depressive symptoms, (c) negative (defect) symptoms and formal thought disorders, (d) positive (psychotic) symptoms, and (e) catatonic symptoms.ConclusionThese results suggest that although major symptoms seen among psychotic patients can be categorised into positive, negative, manic, and depressive groups, corresponding to current knowledge of phenomenology, catatonic symptoms constitute a discrete syndrome, while formal thought disorders merge into the negative syndrome.

Download Full-text

Tardive Dyskinesia and Type II Schizophrenia

The British Journal of Psychiatry ◽

10.1192/bjp.160.2.253 ◽

1992 ◽

Vol 160 (2) ◽

pp. 253-256 ◽

Cited By ~ 18

Author(s):

Elizabeth J. B. Davis ◽

Milind Borde ◽

L. N. Sharma

Keyword(s):

Cognitive Impairment ◽

Negative Symptoms ◽

Chronic Schizophrenia ◽

Thought Disorder ◽

Control Group ◽

Positive Symptoms ◽

Type Ii ◽

Formal Thought Disorder ◽

Schizophrenic Patients ◽

Male Patients

Cognitive impairment, negative and positive symptoms, primitive release reflexes, and age/temporal disorientation were assessed in 20 male patients meeting the DSM–III–R criteria for chronic schizophrenia and Schooler & Kane's criteria for TD. The control group comprised 20 age-matched male chronic schizophrenic patients without TD. Significant associations were found between TD, cognitive impairment, some negative symptoms, and formal thought disorder. These associations were independent of other illness and treatment variables. The severity of TD correlated significantly with that of cognitive impairment.

Download Full-text

M96. A NEW ASSESSMENT TOOL FOR FORMAL THOUGHT DISORDER IN SCHIZOPHRENIA: DOKUZ EYLUL THOUGHT DISORDER SCALE

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa030.408 ◽

2020 ◽

Vol 46 (Supplement_1) ◽

pp. S171-S171

Author(s):

Berna Yalincetin ◽

Emre Bora ◽

Berna Binnur Akdede ◽

Köksal Alptekin

Keyword(s):

Factor Analysis ◽

Negative Symptoms ◽

Assessment Tool ◽

Reliability And Validity ◽

Thought Disorder ◽

Clinical Use ◽

Structured Interviews ◽

Formal Thought Disorder ◽

Good Test ◽

Pragmatic Comprehension

Abstract Background Current scales of formal thought disorder (FTD) in schizophrenia have been shown to hold considerable inadequacies: 1. The concept of FTD is usually limited to positive and negative symptoms of schizophrenia 2. There is no much consideration about pragmatic disturbances. 3. There are significant inconsistencies in measurements of posFTD and negFTD dimensions (eg, merely focusing on the positive dimension); 4. As to the comprehensive scales of posFTD and negFTD, administration or assessment is time-consuming for routine clinical use and they are not user friendly. Besides, some of the FTD scales include the utilization of materials such as pictures, figures, or extended structured interviews to be able to provide speech samples of the patient. Developing a new FTD assessment tool that can be practically applied in clinic might help clinicans in diagnosis, treatment and follow-up. The aim of our study was to develop a new scale for assessment of FTD and evaluate the reliability and validity of this scale. We named our new FTD scale as Dokuz Eylul Thought Disorder Scale (DETDS). The originality of this scale is based on the fact that it involves assessment of pragmatic comprehension as well as positive and negative FTD and it can be administered and scored practically in routine clinical examination. Methods This study included 130 patients with schizophrenia and 35 controls. For assessing the reliability of this new scale, internal consistency, test-retest and interrater reliability analyses were conducted. The validity of the scale was assessed with concurrent validity and factor analysis methods. Results In the study, Cronbach’s was 0.86. The new scale has a good test-retest (r=0.83) and interrater (ICC=0.985) reliability. The posFTD subscale of the new scale showed high correlation with the posFTD subscale of the Scale for the Assessment of Positive Symptoms (SAPS) (r=0.95, p<0.001) and negFTD subscale of our scale showed high correlation with the alogia subscale of the Scale for the Assessment of Negative Symptoms (SANS) (r=0.95, p<0.001) and impoverishment of thought subscale of the Thought and Language Index (TLI) (r=0.66, p<0.001). The factor analysis revealed a 3-factor solution which explained 74.6% of the variance: 1. Positive Formal Thought Disorder, 2. Negative Formal Thought Disorder, 3. Pragmatic Comprehension Disorder. Discussion Our findings showed that DETDS is a reliable and valid scale which can be used in assessing FTD in patients with schizophrenia in routine clinical use. Unlike most scales of FTD that are available in the literature, but similar to SANS, SAPS, and PANSS, it is practical to use because it is based on clinical interview. Another strength of DETDS is that it intensifies the posFTD and negFTD dimensions and scores them hierarchically in terms of severity. The fact that the new scale covers pragmatic comprehension disorders also presents an innovation to the literature.

Download Full-text

The Assessment of Negative and Positive Features in Schizophrenia

The British Journal of Psychiatry ◽

10.1192/s0007125000291460 ◽

1989 ◽

Vol 155 (S7) ◽

pp. 41-44 ◽

Cited By ~ 14

Author(s):

Eve C. Johnstone

Keyword(s):

Negative Symptoms ◽

Normal Function ◽

Thought Disorder ◽

List Type ◽

Type Number ◽

Formal Thought Disorder ◽

Clinical Correlates ◽

Schizophrenic Patients ◽

The Relationship ◽

Positive And Negative Symptoms

It has become customary to classify the typical abnormalities of the mental state of schizophrenic patients into positive and negative features, with reference to behavioural excesses and deficits. Positive features are pathological by their presence and negative features represent the loss of some normal function. Positive features are generally considered to include delusions, hallucinations and positive formal thought disorder (Fish, 1962). Some studies (e.g. Johnstone et al, 1978) have also included incongruity of affect under this heading. Negative features include affective flattening, poverty of speech, retardation, apathy, lack of sociability. There is some evidence that the clinical correlates of positive and negative features may not be the same (Owens & Johnstone, 1980). Some workers (Andreasen & Olsen, 1982) but not others (Pogue-Geile & Harrow, 1984) have found that among schizophrenic patients positive and negative symptoms were negatively correlated. Although the nature of the relationship between positive and negative features is not entirely established and may not be simple (Wing, 1978) certain generalisations may be applied: (a)Positive features are characteristic of earlier and negative of later phases of the illness (Pfohl & Winokur, 1982).(b)The effects of drugs upon positive features are greater than those upon negative features. Thus neuroleptics produce more marked improvement (Johnstone et al, 1978; Angrist et al, 1980) and amphetamine more marked exacerbation (Angrist et al, 1980) of positive than of negative features.(c)Positive features have been said to be relatively variable and negative features relatively stable (Ovchinnikov, 1968; Snezhnevsky, 1968).

Download Full-text

The Positive: Negative Dichotomy in Schizophrenia

The British Journal of Psychiatry ◽

10.1192/bjp.157.1.41 ◽

1990 ◽

Vol 157 (1) ◽

pp. 41-49 ◽

Cited By ~ 65

Author(s):

A. M. Mortimer ◽

C. E. Lund ◽

P. J. McKenna

Keyword(s):

Cognitive Impairment ◽

Negative Symptom ◽

Negative Symptoms ◽

Thought Disorder ◽

Motor Disorder ◽

Positive Symptoms ◽

Formal Thought Disorder ◽

Symptom Scores ◽

Schizophrenic Patients ◽

Positive And Negative Symptoms

Two studies are reported. In the first, of 62 schizophrenic patients, no correlation between negative symptom scores (rated blindly) and any measure of positive symptoms was found. This independence was confirmed by factor and cluster analyses, which left the question of a third ‘disorganisation’ class of schizophrenic symptoms open. In the second study, of 80 patients, formal thought disorder separated unequivocally into ‘positive formal thought disorder’ and ‘alogia’ syndromes on the basis of correlations with positive and negative symptoms. Catatonic motor disorder also showed evidence of a corresponding positive: negative division, although this only emerged when severity or chronicity of illness was controlled for. Cognitive impairment showed a broad range of affiliations and its particular correlation with negative symptoms was perhaps artefactual.

Download Full-text

Formal Thought Disorder and Self-Disorder: An Empirical Study

Frontiers in Psychiatry ◽

10.3389/fpsyt.2021.640921 ◽

2021 ◽

Vol 12 ◽

Author(s):

Julie Nordgaard ◽

Mette Gravesen-Jensen ◽

Marlene Buch-Pedersen ◽

Josef Parnas

Keyword(s):

Empirical Study ◽

Negative Symptoms ◽

Systematic Approach ◽

Close Relation ◽

Thought Disorder ◽

Formal Thought Disorder ◽

Schizophrenia Spectrum ◽

Two Measures ◽

Original Concept ◽

Self Disorder

Background: Formal thought disorder was constitutively linked to the original concept of schizophrenia and has since been one of central features supporting its diagnosis. Bleuler considered formal thought disorder as a fundamental symptom of schizophrenia among other fundamental symptoms, including ego disorders. The contemporary concept of self-disorder represents a more developed, nuanced, and systematic approach to disturbances of self-experience than the Bleulerian concept of ego disorders. As fundamental symptoms, on Bleuler's account, are persistently present in every case, an association between these symptoms could be expected. The purpose of this study was to examine the association between self-disorder and formal thought disorder.Methods: A sample of 94 diagnostically heterogeneous patients was examined for formal thought disorder using clinical rating and a proverb test. The proverb test was analyzed for two different aspects of formal thought disorder: literal responses and bizarre responses. The sample was comprehensively assessed for psychopathology, including self-disorder as measured with the Examination of Anomalous Self-Experience scale.Results: The patients, who provided bizarre responses, had a higher level of self-disorder, more negative symptoms, lower level of social functioning, and lower level of intelligence. Bizarre answers aggregated in patients diagnosed within the schizophrenia spectrum compared with patients outside the schizophrenia spectrum. We found moderate correlations between the two measures of formal thought disorder (clinically rated and bizarre responses) and self-disorder (0.454 [p < 0.01] and 0.328 [p < 0.01]). Literal responses did not differ between diagnostic groups and also did not correlate with bizarre responses. Specificity of bizarre responses for a diagnosis within schizophrenia spectrum was 86.89%, whereas sensitivity was 40.85%.Conclusion: The close relation between formal thought disorder and self-disorder further adds to the notion of self-disorder as a unifying psychopathological core beneath the apparently heterogeneous symptoms of schizophrenia.

Download Full-text