The relationship of psychosis high-risk syndrome in bipolar disorder with cognitive functions and functionality

Objective: Disorders in the schizo-bipolar spectrum, which seriously affect functioning throughout life, present with similar clinical manifestations in the prodromal period and in the first episode. There is a significant overlap between these diseases, given the shared biological basis, genetic evidence, the results of neuroimaging studies, and neurodevelopmental hypothesis. For this reason, there are difficulties in making an accurate diagnosis in the early stages of these disorders. However, disorders such as bipolar disorder, schizoaffective disorder, and schizophrenia begin in young adulthood and adolescence and lead to serious disabilities. Making a correct diagnosis during this period is critical for early intervention because professional and social formation takes place in these years. It was observed that even cases diagnosed with typical schizophrenia or bipolar disorder received different diagnoses at a rate of 10-15 percent in the clinical course. Individuals diagnosed with bipolar disorder may develop a psychotic disorder in the future. These two diseases show significant clinical and cognitive overlap with each other. On the other hand, there is a significant heterogeneity among them in terms of clinical course, psychosocial functionality and cognition. Although psychotic symptoms during mood episodes have been studied in bipolar disorder, the mild positive and negative symptoms and schizotypal features that persist between attacks have not been adequately investigated. Some euthymic bipolar disorder patients present with psychosis high-risk syndrome, schizotypy, thought disorder, and negative symptoms in the early stages of the disease. Considering the diagnostic instability in the clinical follow-up studies and the heterogeneity within bipolar disorder, it is thought that these symptoms and features can predict the transition to psychotic disorder or schizoaffective disorder. These features can also predict the loss of function. It is important to define this subgroup within bipolar disorder, which we think will be associated with schizophrenia-like cross-sectional features. In this study, we defined a syndrome as 'Psychosis High Risk Syndrome in Bipolar Disorder'. We created this subgroup by determining criteria based on psychosis high risk syndrome, negative symptoms, positive thought disorder and schizotypal features. The aim of this study is to examine the neurocognitive and social cognitive functions and psychosocial functioning in this subgroup and compare them with the group without this syndrome. In addition to these main variables, impulsivity, insight, premorbid functioning, apathy, and positive formal thought disorder were also evaluated. It is also thought that the psychotic high-risk syndrome found in the early phase of the disorder can be a precursor of a transition to psychotic disorder in the future. Method: We included 77 participants diagnosed with bipolar disorder within the last 10 years. In the first stage, the researcher administered the Structured Interview for Prodromal Symptoms (SIPS), the Scale for the Assessment of Positive Symptoms (SAPS), the Brief Negative Symptoms Scale (BNSS) and gave the Schizotypal Personality Questionnaire (SCQ). According to the results of this interviews and the questionnaire, the research groups of the participants were determined. Except for bipolar disorder attack periods, according to the Structured Interview for Prodromal Symptoms (SIPS), participants who can be defined as "Brief Intermittent Psychotic Symptom Syndrome (BLIPS)", "Mild Psychosis-Risk Syndrome APS), or "Genetic Risk and Decreased Functionality Psychosis-Risk Syndrome (GRIAS) )'' criteria within the last 3 years, those with a 'Schizotypal Personality Scale (SCS) score of 42 and above, participants who scored 3 or more on the 2 subscales of Brief Negative Symptoms Scale (BNSS) ('Avolition' or 'Blunted Affect') and those who scored 2 or more on the positive formal thought disorder questions on the Scale for the Assessment of Positive Symptoms (SAPS) were included in the 'Psychosis High-Risk Syndrome in Bipolar Disorder'. According to the specified criteria, the group with 'Psychosis High-Risk Syndrome in Bipolar Disorder' included 34 participants, and the group without 'Psychosis High-Risk Syndrome in Bipolar Disorder' included 43 participants. In the clinical evaluation, a case report form, Hamilton Depression Rating Scale (HDRS), Young Mania Rating Scale (YMRS), Comprehensive Assessment of Symptoms and History (CASH), Sydney Melancholia Prototype Index and Scale to assess Unawareness of Mental Disorder (SUMD) were applied. Participants were administered the Screen for Cognitive Impairment in Psychiatry (SCIP), Wisconsin Card Sorting Test (WCST), BeadsTask, Effort Expenditure for Reward Task (EEFRT), WAIS general knowledge subtest, and DEU SCAN LAB Social Cognition Battery for neurocognitive and social cognitive evaluation. Thought disorder was evaluated with the Thought and Language Index (TLI) by audio recordings. Functionality was measured with the Premorbid Adjustment Scale (PAS) and the Personal and Social Performance Scale (PSP). Dimensional Apathy Scale (DAS) and Barratt Impulsiveness Scale (BIS) were given to the patients as self-report scales. Results: It was found that subthreshold depressive symptoms started at an earlier age in the group with 'Psychosis High-Risk Syndrome in Bipolar Disorder' and they showed more psychotic symptoms during depressive periods. It was determined that this group showed more Schneiderian symptoms during psychotic mania periods. Apathy and impulsivity scores evaluated with self-report scales were found to be significantly higher in 'Psychosis High-Risk Syndrome in Bipolar Disorder' group. No significant differences were shown between the groups in terms of TLI scores, neurocognitive test scores and total scores of social cognitive tests. It was only shown that in the Internal Personal Situational Attributions Scale (IPSAQ) the group without 'Psychosis High-Risk Syndrome in Bipolar Disorder' made more spontaneous negative external situational and spontaneous external situational attributions. However, by including the entire sample, the factors that could be dimensionally related to social cognition were investigated. Correlation analyzes revealed some weak but statistically significant relationships between social cognitive tests and negative symptoms, prodromal psychotic symptoms, and thought disorder. In addition, it has been shown that both the premorbid functionality and current functionality of the group with 'Psychosis High-Risk Syndrome in Bipolar Disorder' are more impaired than the other group. Correlation analysis results indicate that this impairment in functionality can have significant associations with negative symptoms, prodromal psychotic symptoms, and thought disorders. Conclusion: Our results indicate that the group with 'Psychosis High-Risk Syndrome in Bipolar Disorder' differs from the other group in terms of some clinical features, Schneiderian symptoms, functionality, apathy,mand impulsivity. The fact that no significant differences were observed between groups in formal thought disorder, neurocognitive tests, and social cognitive tests suggests that different types of underlying mechanisms other than forms of cognitive impairment should be investigated. Elucidating these mechanisms will be clinically valuable. The fact that the groups did not show any differences in terms of thought disorder, neurocognition, and social cognition indicates that the impairments in these areas are not limited to a certain diagnostic group, but are found in varying degrees of severity on a spectrum. This is an expected finding. In our dimensional evaluations, we found that there is a relationship between the severity of negative symptoms, prodromal psychotic symptoms, thought disorder and schizotypy, and social cognition and functionality, supporting the idea that we are faced with syndromes of varying severity across the spectrum. Our results highlight the multidimensional nature of the diseases. Considering the cognitively heterogeneous structure of bipolar disorder, subgroups should be defined so that specific and personalized interventions can be made. If euthymic period findings that pose a risk for psychosis are noticed in the early stages of bipolar disorder, early intervention strategies can be developed, just like in the period before the first episode of psychosis. It is important to recognize the risk of psychosis and the predictors of clinical course in order to develop correct intervention strategies. The data we obtained will contribute to future studies that will prospectively examine the transformation from bipolar disorder to a disorder at the psychotic end of the spectrum. Additionally, this study will lead to risk calculator studies that will be developed using factors that predict conversion to psychotic disorder.