Clinical assessment of personality and attachment patterns in adolescents at ultra high risk for psychosis

Introduction: “Ultra-high risk” (UHR) diagnostic criteria (Miller et al., 2003) pinpoint a combination of state (attenuated or brief intermittent positive psychotic symptoms) and trait (genetic risk with a deterioration in functioning) risk factors that identify youth and young adults at heightened and imminent risk of developing a first episode of psychosis. Identifying UHR individuals can help guide mental health practitioners in their treatment decision-making and adapt their interventions to the individual characteristics of patients in order to prevent the onset of psychosis. Nevertheless, UHR population is highly heterogeneous, displaying varying clinical conditions, including anxiety, depression and substance disorders. As this heterogeneity undermines both clinical research and the evaluation and treatment of patients, many mental health care providers ex- press concern with the current diagnostic practice, which does not enable efficacious therapeutic planning. In particular, according to epidemiological data, has been shown that about 40% of UHR patients receive at least one diagnosis of personality disorder. Although some common genetic and environmental diatheses underlie both schizotypal personality disorders and schizophrenia, some studies have shown the rates of schizotypal UHR patients to be relatively modest. In contrast, other studies have found a considerable prevalence of schizoid, borderline and avoidant personality traits/disorders among UHR patients (Shurze-Lutter et al., 2012). So far, only few studies have thus evaluated personality features in the UHR population, suggesting that the personality characteristics of such patients vary considerably. To our knowledge, these personality differences have never been systematically evaluated. Furthermore, there are evidences linking attachment adversity to psychosis, from the premorbid stages of the disorder to its clinical forms. To date, very little research has evaluated attachment patterns in UHR individuals. In each case, the researchers used exclusively self-report instruments and detected a high rate of insecure patterns (e.g., 93% in Quijada et al., 2015; and 95% in Russo et al., 2018). We consider a systematic investigation of the UHR population critical for improving our understanding of the different symptom patterns of UHR individuals and achieving more accurate diagnoses. We aim to conduct such an investigation by: (1) examining the full spectrum of person-specific psychopathology and its manifestation in patient personality structures, under the assumption that symptoms take different meanings and roles according to the larger context of patient personality functioning. (2) investigating attachment patterns using the gold standard measure for attachment. Methods: 40 adolescent UHR outpatients were compared to 40 individuals who didn’t meet the ultra-high risk criteria. The recruited patients’ treating clinicians were also involved and asked to provide basic demo- graphic and diagnostic data, and to complete clinician-report assessment tools. Each patient received a DSM personality diagnosis and was assessed using the Brief Psychiatric Rating Scale (BPRS). The Structured Interview for Prodromal Syndromes (SIPS/SOPS) has been administered to assess prodromal symptoms. According to the SIPS, UHR participants must meet one of three criteria: (1) increasing but attenuated positive symptoms; (2) a recent, brief psychotic episode that is too short in duration to meet diagnostic criteria for a psychosis disorder; or (3) a first-degree relative with psychosis, and recent functional decline. The Adult Attachment Interview (AAI), a semi-structured interview used to assess individuals’ “state of mind” or internal working models with respect to attachment relationships, was administered to each patient. The AAI interviews have been audio recorded, transcribed verbatim, and coded by two independent certified coders who were blind to all other study conditions. Childhood trauma has been coded from the verbatim transcripts of the AAI by two independent raters, according to the clinical version of the Complex-TQ, a questionnaire aimed to assess multi-dimensional features of childhood trauma. Finally, treating clinicians were supervised by the researchers for evaluate patients’ personality trait and disorders, according to the SWAP-200, a well- established and widely used psychometric procedure that provides a comprehensive assessment of personality and personality pathology. Results: No differences between groups have been found when personality disorders were measured according to the DSM-IV-TR categories. However, UHR patients showed more impaired personality functioning and higher scores on two Q-factors of the SWAP- 200: “inhibited/self-critical” and “emotionally dysregulated”. Finally, a higher degree of “cannot classify low-coherence” attachment pat- terns was found in UHR patients’ group. Conclusions: These primary findings seem to suggest the importance of taking into account the emotional dysregulation, social inhibition and disorganized attachment in treatment planning of UHR patients. To date, the intervention strategies available to significantly change the clinical course of UHR conditions have proven to be poorly effective in follow-ups longer than 12 months (Davies et al., 2018). Preliminary results this study seem to suggest that attachment-informed psychotherapy, tailored to the personality characteristics of patients, may be an effective preventive treatment for UHR patients.