Psychosocial dysfunction was a nettlesome problem of schizophrenia even in their prodromal phase as well as in their first-episode. In addition, its relations with psychopathology were not determined. The aim of the present study was to examine whether the social and role function impairment was found in ultra-high risk for psychosis (UHR) individuals as well as first-episode schizophrenia patients and to explore its relations with psychopathology.
Thirty-seven normal controls, 63 UHR participants and 28 young, first-episode schizophrenia patients were recruited. Psychosocial functioning was examined by using Global function: Social and Role scale. Psychopathologies of positive, negative and depressive symptom were also measured.
Social and role functioning in UHR were compromised at the equivalent level of those of first-episode schizophrenia patients. Multiple linear regression analysis revealed that social and role dysfunction was associated with negative symptoms in each UHR and first-episode schizophrenia group.
These findings suggest that the significant impairment of social and role function may be appeared before the active psychosis onset at the level of extent to those of first-episode schizophrenia patients. The psychosocial intervention strategy especially targeting the negative symptoms should be developed and provided to individuals from their prepsychotic stage of schizophrenia.
Schizophrenia is a disorder with impaired functioning for a significant portion of the time since the onset of the disturbance.
There were some different pictures of psychosocial dysfunction depending on the phase of illness and domains of functioning. The social function in UHR was shown to be significantly compromised, and the extent of impairment was comparable to that of first-episode and multi-episode schizophrenia patients. Meanwhile, role function in UHR was significantly declined to that of first-episode patients but better than that of multi-episode patients.
In schizophrenia, there were heterogeneous findings on the relationship of psychosocial disability with psychopathologies including negative symptoms
The aim of the study was to examine whether the social and role function impairment was found in UHR individuals as well as first-episode schizophrenia patients and to explore its relations with psychopathology. Based on the previous studies, our hypothesis was that both clinical groups showed social and role functioning deficits and the extent of these deficits in both groups may be comparable. In addition, we also expected that social and role disability may be associated with negative symptoms rather than positive and depressive symptoms. For explorative purpose, we observed the relations of social and role dysfunction with two major negative items of affective flattening and avolition, which have not yet been studied extensively in these clinical groups.
The participants were consisted of normal controls (NC), individuals at UHR for psychosis, and first-episode schizophrenia patients. 37 NC were recruited from internet advertisements. The 63 UHR participants were from the ‘Clinic FORYOU’ at Severance Hospital of Yonsei University Health System between July 2007 and June 2009. The Clinic FORYOU was established in March 2007 as an UHR research clinic of the ‘GRAPE (Green Program for Recognition and Prevention of Early Psychosis)’ project. The 28 young first-episode patients with schizophrenia enrolled in our study were recruited from both the outpatient (15) and inpatient (13) service units of Severance Hospital and Severance Mental Health Hospital of Yonsei University Health System during the same time period. All patients with schizophrenia were in clinically stable or stabilization phase. All participants met the inclusion criteria of being between 15–35 years old and having more than nine years of education. Participants were evaluated by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
The UHR participants were diagnosed by the Criteria of the Prodromal Syndromes of SIPS.
In this article, we used the Global functioning: Social (GF: Social)
The GF: Social scale rated quantity and quality of age appropriate intimate relationships, peer relationships, level of peer conflict, and involvement with family members. Interactions with people other than family members got higher score than interactions limited only to family members. Etiology of social dysfunction or levels of clinical symptomatology were not considered when rating the scale. The GF: Role scale emphasized the level of support provided within the individual's environment and the individual's performance given such support in addition to age appropriateness. The ratings were based on performance in school, work, or home.
To assess psychopathologies and symptom severities, the scale for the assessment of positive symptoms (SAPS),
Clinical interviews and assessments were administered by a psychiatrist within a week after recruitment into the study.
To compare the GF: Social and GF: Role between the three groups, multivariate analyses of variance (ANOVA) were used. Post-hoc analysis was done also with Bonferroni correction. Pearson correlations of two GF scales with psychopathologies were conducted by using the SANS, SAPS, MADRS in each clinical group. All variables significantly correlated with GF: Social and GF: Role scores were analyzed subsequently using a multiple linear regression to evaluate their independent and primary contributions to each GF: Social and GF: Role scores. Stepwise method was utilized in the regression model, and pairwise deletion was utilized for missing data. For exploration of association with specific negative symptom items such as affective flattening or blunting and avolition-apathy, the same statistical analysis was also conducted. A significance level of p less than 0.05 was used for all tests.
There was no difference between the three groups in age, total durations of education, or distribution of sex (
The GF: Social and GF: Role in normal controls, ultra-high risk (UHR) patients for psychosis, and first-episode schizophrenia patients are shown in
Pearson's correlation analysis revealed that in UHR patients (
In first-episode schizophrenia patients (
In UHR, overall full regression model was significant and the negative symptoms accounted for 35% of the variance in social dysfunction (β=−0.60, t=−5.76, p<0.001) and for 17% of the variance in role dysfunction (β=−0.42, t=−3.60, p=0.001). The positive symptoms (for social dysfunction: β=−0.08, t=−0.77, p=0.445; for role dysfunction: β=−0.01, t=−0.10, p=0.992) and depressive symptoms (for social dysfunction: β=−0.26, t=−1.87, p=0.066; for role dysfunction: β=−0.20, t=−1.22, p=0.227) were excluded. For specific negative items, overall full regression model was significant and the avolition-apathy item accounted for 26% of the variance in social dysfunction (β=−0.51, t=−4.55, p<0.001) and for 16% of the variance in role dysfunction (β=−0.51, t=−4.55, p<0.001). The affective flattening or blunting item (for social dysfunction: β=−0.13, t=−0.96, p=0.343; for role dysfunction: β=0.18, t=0.13, p=0.900) was excluded.
In first-episode schizophrenia patients, the negative symptoms accounted for 21% of the variance in social dysfunction (β=−0.49, t=−2.66, p=0.014) and for 17% of the variance in role dysfunction (β=−0.46, t=−2.41, p=0.025). The positive symptoms (for social dysfunction: β=0.04, t=0.21, p=0.839; for role dysfunction: β=0.07, t=−0.34, p=0.737) and depressive symptoms (for social dysfunction: β=−0.31, t=−1.59, p=0.127; for role dysfunction: β=0.16, t=0.75, p=0.460) were excluded. For specific negative items, overall full regression model was significant and the avolition-apathy item accounted for 19% of the variance in social dysfunction (β=−0.47, t=−2.74, p=0.011) and for 19% of the variance in role dysfunction (β=−0.44, t=−2.48, p=0.020). The affective flattening or blunting item (for social dysfunction: β=−0.05, t=−0.20, p=0.840; for role dysfunction: β=0.14, t=0.56, p=0.580) was excluded. The tolerance among the predictors did not indicate multi-collinearity (all VIF <1.1). A summary of regression analysis was shown in
The aim of the present study was first, to examine whether UHR individuals as well as first-episode schizophrenia patients would show significantly impaired social and role function, and second was to explore the relations between each function and psychopathologies such as positive, negative, and depressive symptoms. Our main findings were that UHR participants and first-episode patients exhibited a significantly impaired social and role functioning than normal controls did. Meanwhile, decline of the social and role functioning in UHR were not different from those of first-episode schizophrenia patients, which matched with our hypothesis. Social and role function impairment were primarily and independently associated with negative symptoms but not associated with depressive nor positive symptomin each UHR and first-episode schizophrenia group.
UHR participants as well as first-episode schizophrenia patients showed marked impairment in social and role function than normal control group. More importantly, the extent of impairment in UHR group was comparable to that of first-episode schizophrenia patients. These findings were compatible to those of previous studies.
Psychosocial functional deficits for social and role domains were primarily associated with negative symptoms of SANS but not associated with depressive nor positive symptoms in each clinical group. At first, depressive symptoms and psychosocial functioning seemed to have association with simple correlation, but it turned out to be not primarily related when we did the regression analysis. These findings were generally compatible to those of previous studies in first-episode schizophrenia
The limitations of our study should be noticed. First, the first-episode groups were in clinically stabilized state. Thus, our findings of association of functioning with the negative symptom not with the positive one cannot be generalized into the whole schizophrenia patients populations regardless of their psychotic symptoms status. Second, there was no follow-up data to elucidate the causal relations of psychosocial functional impairment and psychopathologies. Long-term follow-up studies are needed to be our understanding of the important contributions of psychopathology to social and role dysfunction in UHR and first-episode schizophrenia patients. Lastly, the other variables such as neurocognitive and social cognitive function are not assessed. These factors may be differentially interacted with negative symptoms for developing impairment of social and role functioning in these clinical groups. For long-term follow-up studies, all these factors should be promote our understanding of the whole pictures of psychosocial dysfunction in schizophrenia from their early prepsychotic stage.
In conclusions, our study found that UHR participants showed significantly impaired social and role functioning at the level of the first-episode schizophrenia patients. In addition, in each stabilized clinical group, social and role dysfunction were primarily and independently associated with negative symptoms but not with depressive and positive symptoms. These findings implicate that the significant impairment of social and role function may be appeared before the active psychosis onset in schizophrenia and thus the psychosocial intervention especially targeting the negative symptoms should be actively provided in their prepsychotic stage and in their stabilized states of schizophrenia. In near future, it is needed to be examined whether the improving the negative symptoms or psychosocial functioning would be play an important role for preventing the transition of UHR states into overt psychotic disorder.
We thank the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI14C2242).
SAPS (Andreason, 1983): Scale for Assessment of Positive Symptoms; 2 UHR data are missing; SANS (Andreason, 1983): Scale for Assessment of Negative Symptoms; 2 UHR data are missing; SIPS (McGlashan et al., 2003): Structured Interview for Prodromal Syndromes; MADRS (Montgomery and Asberg, 1979): Montgomery-Åsberg Depression Rating Scale; 4 First-episode schizophrenics data are missing. *significant difference between normal controls and UHR patients for psychosis (p<0.05), †significant difference between normal controls and first-episode schizophrenia patients (p<0.05), ‡significant difference between UHR for psychosis and first-episode schizophrenia patients (p<0.05). BIPS: Brief Intermittent Psychotic Symptom Prodromal Syndrome, APS: Attenuated Positive Symptom Prodromal Syndrome, GRDS: Genetic Risk and Deterioration Prodromal Syndrome
Corrected p=uncorrected p×3. UHR: ultra-high risk
SAPS: Scale for Assessment of Positive Symptoms; 2 UHR data are missing; SANS: Scale for Assessment of Negative Symptoms; 2 UHR data are missing; MADRS: Montgomery-Åsberg Depression Rating Scale; 4 First-episode schizophrenics data are missing. UHR: ultra-high risk
All VIF <1.1. *standardized coefficient, †changed variance, ΔR2, ‡adjusted R2, explained variance by model. UHR: ultra-high risk
All VIF <1.1. *standardized coefficient, †changed variance, ΔR2, ‡adjusted R2, explained variance by model. UHR: ultra-high risk