Motor abnormalities in first-episode psychosis patients and long-term psychosocial functioning
Introduction
Schizophrenia and related psychoses are severe mental disorders with a large proportion of non-recovered cases (Jääskeläinen et al., 2013) and huge elevated mortality compared to their corresponding general population (Schoenbaum et al., 2017). Intervention from the early states of the illness is now a good pathway to achieve better outcomes (Randall et al., 2015). and recovery is now understood from a wider approach than before by acknowledging a differentiation between clinical and functional remissions (Harvey et al., 2007, Leung et al., 2008) and between functional capacity and real world functioning (Green et al., 2000, Bowie et al., 2006, Patterson and Mausbach, 2010, Sánchez-Torres et al., 2016). The difference between competence (what a person is able to do) and performance (what they actually do) is very relevant to evaluate the determinants of everyday functioning in schizophrenia patients. The former is referred to as functional capacity, while the latter is known as real-world functioning (Bowie et al., 2006).
Different groups of variables, such as premorbid, familial, demographic and clinical variables have consistently demonstrated predictive value for long-term psychosocial impairment in follow-up studies of schizophrenia and related psychosis (Strauss and Carpenter, 1974, Strauss and Carpenter, 1977). Poor premorbid adjustment and low intellectual quotient, male gender, unemployment, an early onset and long duration of untreated illness or long length of current episode, severe negative symptoms and cognitive impairment, among others, were related to a poor outcome in schizophrenia patients (Bland, 1982, Harrison et al., 2001, Haro et al., 2008, Schennach-Wolff et al., 2009). And regarding FEP patients, low intellectual background and poor social and academic premorbid adjustment seem to be related to cognitive impairment and to a lower premorbid intellectual reserve (Cuesta et al., 2014). In addition, a schizophrenia or schizoaffective diagnosis, negative symptoms and early age at onset were predictive factors of symptom remission, functioning and recovery, 10 years after diagnosis in OPUS trial (Austin et al., 2013) and other studies (Amminger et al., 2011, Verma et al., 2012). However, the extent to which motor examination might be predictors of long-term psychosocial functioning (PF) is unknown.
Motor abnormalities (MAs) of severe mental diseases have been traditionally neglected in both clinical practice and research (Peralta and Cuesta, 2017, Schizophr. Bulletin in press). A set of heterogeneous groups of symptoms and signs integrate the MAs that can be classified into three different domains, namely catatonic, extrapyramidal (parkinsonism, dyskinesia and akathisia), and neurological soft signs (NSS). MAs have been demonstrated to be already present long before the beginning of illness, show strong associations with severity of negative symptomatology and cognitive impairment and are related to poor outcomes in schizophrenia patients (Bowie and Harvey, 2005, Peralta and Cuesta, 2017).
In addition, the different domains of MAs convey not only diagnostic problems in new versions of classifications of psychiatric disorders but also therapeutic ones (Francis et al., 2010). Indeed, catatonic symptoms may have better response to benzodiazepines and electroconvulsive therapy (ECT) than to antipsychotic drugs, which may even increase the risk of neuroleptic malignant syndrome (Francis et al., 2010). On the other side, catatonic symptoms have an excellent response to benzodiazepines and even ECT (Sienaert et al., 2014). Besides, the value of other non-catatonic MAs in terms of diagnostic and therapeutic issues remains understudied (Peralta and Cuesta, 2017).
The aim of this study was to examine the association between motor domains at the first-episode of psychosis (FEP) and the long-term outcome in psychosocial functioning, and particularly whether motor assessment in FEP patients both before starting antipsychotic medication and after 6-months of treatment was predictive of time-varying measures of functional outcomes in capacity or real-word functioning from 6-month to 10 years of follow-up.
Section snippets
Methods
100 consecutive patients with first-episode psychosis (FEP) not previously exposed to antipsychotic drugs were included in the study. The sample and assessment procedures used were described in detail elsewhere (Cuesta et al., 2009). Diagnoses included were schizophrenia or other non-purely affective psychotic disorders (DSM-IV-TR criteria). Patients were between 16 and 65 years old and did not assess adolescent and young adult population.
Exclusion criteria were evidence of antecedents of
Results
Sociodemographic characteristics of patients and 10-year final DSM-5 diagnosis are shown in Table 1. 77% of patients completed the two neurological examinations at baseline and at the 6-month follow-up of the index episode and between 85 and 92% of patients had enough and reliable information to be scored in the psychosocial functioning measures over the 10-year follow-up. A final DSM-5 diagnosis could also be ascertained in 95% of the sample by collecting all available information. Four
Discussion
The primary findings of this study indicate that catatonic signs and dyskinesia at drug-naïve state were significantly associated with poor psychosocial functioning. Catatonic signs were associated with measures of long-term functional capacity and real-world functioning and dyskinesia with measures of real-world functioning. In addition, higher scores on neurological soft-signs, parkinsonism and akathisia at 6 months of follow-up of FEP were significantly associated with poorer scores on
Conclusion
The motor examination of patients with FEP should be encouraged to emphasize their role as core manifestations of the illness. They also conform to an inexpensive way of evaluating ‘core’ manifestations of illness that not only may help in the prediction of poor functional outcomes but also give relevance to understanding the neurobiological pathophysiology of illness. Thus, motor domain may serve as a bridge and is a confluence of flows between RDoC basic domains, cognitive functioning and
Limitations
Several caveats should be kept in mind concerning our results. The motor assessment was carried out during the index episode and no re-assessment of motor domains was carried out during the follow-up. Moreover, MAs should not be considered as the unique factor but taken together with other potential factors predicting outcome in psychosis. However, the contribution of this study might serve to emphasize the inclusion of motor abnormalities in future studies as simple and less time-consuming
Funding
This work was supported by the Department of Health of the Government of Navarra (grants 55/2007 and 11/101), the Carlos III Health Institute (FEDER Funds) from the Spanish Ministry of Economy and Competitivity (grant 08/I/1026) and the Spanish Ministry of Science and Innovation (grant SAF2008-05674-C03-02).
Contributors
Drs. Cuesta and Peralta designed the study, made final diagnosis, conducted analyses and drafted the manuscript. Drs. García de Jalon and Campos carried on the motor evaluations and drafted the manuscript. Dr. Moreno-Izco aided in directing data collection. Dr. García de Jalón and Mss. Sánchez-Torres and Lorente-Omeñaca carried on the assessment of psychosocial functioning, conducted analyses and drafted the manuscript.
Conflict of interest
None.
Acknowledgements
We thank the patients for their important contribution.
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