What makes the psychosis 'clinical high risk' state risky: psychosis itself or the co-presence of a non-psychotic disorder?
Hasmi, Laila; Pries, Lotta-Katrin; Ten Have, Margreet; de Graaf, Ron; van Dorsselaer, Saskia; Bak, Maarten; Kenis, Gunter; Richards, Alexander; Lin, Bochao D; O'Donovan, Michael C; Luykx, Jurjen J; Rutten, Bart P F; Guloksuz, Sinan; van Os, Jim
(2021) Epidemiology and Psychiatric Sciences, volume 30
(Article)
Abstract
AIMS: Although attenuated psychotic symptoms in the psychosis clinical high-risk state (CHR-P) almost always occur in the context of a non-psychotic disorder (NPD), NPD is considered an undesired 'comorbidity' epiphenomenon rather than an integral part of CHR-P itself. Prospective work, however, indicates that much more of the clinical psychosis incidence
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is attributable to prior mood and drug use disorders than to psychosis clinical high-risk states per se. In order to examine this conundrum, we analysed to what degree the 'risk' in CHR-P is indexed by co-present NPD rather than attenuated psychosis per se. METHODS: We examined the incidence of early psychotic experiences (PE) with and without NPD (mood disorders, anxiety disorders, alcohol/drug use disorders), in a prospective general population cohort (n = 6123 at risk of incident PE at baseline). Four interview waves were conducted between 2007 and 2018 (NEMESIS-2). The incidence of PE, alone (PE-only) or with NPD (PE + NPD) was calculated, as were differential associations with schizophrenia polygenic risk score (PRS-Sz), environmental, demographical, clinical and cognitive factors. RESULTS: The incidence of PE + NPD (0.37%) was lower than the incidence of PE-only (1.04%), representing around a third of the total yearly incidence of PE. Incident PE + NPD was, in comparison with PE-only, differentially characterised by poor functioning, environmental risks, PRS-Sz, positive family history, prescription of antipsychotic medication and (mental) health service use. CONCLUSIONS: The risk in 'clinical high risk' states is mediated not by attenuated psychosis per se but specifically the combination of attenuated psychosis and NPD. CHR-P/APS research should be reconceptualised from a focus on attenuated psychotic symptoms with exclusion of non-psychotic DSM-disorders, as the 'pure' representation of a supposedly homotypic psychosis risk state, towards a focus on poor-outcome NPDs, characterised by a degree of psychosis admixture, on the pathway to psychotic disorder outcomes.
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Keywords: Anxiety Disorders, Humans, Mood Disorders, Prospective Studies, Psychotic Disorders/epidemiology, Schizophrenia/epidemiology, risk, Epidemiology, prevention, psychosis, Public Health, Environmental and Occupational Health, Psychiatry and Mental health, Epidemiology, Journal Article
ISSN: 2045-7960
Publisher: Cambridge University Press
Note: Publisher Copyright: © The Author(s), 2021. Published by Cambridge University Press.
(Peer reviewed)