Motivations The growing interest in the investigation of longitudinal course and outcome of psychotic disorders grew from the Kraepelinian view of schizophrenia, which was considered a disease with progressive downhill course. With emerging evidence-based findings suggesting outcome heterogeneity, prospective studies have strived to identify factors influencing the course and outcome. The paucity of prospective long-term studies has prevented us from knowing the enduring impacts of predictors. Using a prospective cohort of 153 psychosis patients, the study aimed to determine the outcome of global functioning, remission, functional recovery, and recovery at 13 years following the first-episode psychosis. Prognostic values of a range of baseline and early outcome predictors were examined. Specific research interests included the explorations of the enduring impact of duration of untreated psychosis (DUP), the longitudinal relationship between neurocognition and functional outcome, and the added predictive ability of early outcome predictors. Methods This study attempted to follow up the 153 patients at 13 years following their first episode onset of psychosis. Prior investigations collected a comprehensive profile of demographics, premorbid adjustment, clinical symptoms, and neurcognition at baseline. Early outcomes at 3 years including remission, relapse, primary negative symptoms, and unemployment were also ascertained. In this current investigation, living subjects were invited to an interview in order to assess their outcomes of global functioning, remission, functional recovery, and recovery at 13 years. Appropriate regression models were applied to identify predictors of long-term outcomes. Standardized mortality ratios (SMRs) for all-cause mortality and suicide were also determined. Results Ninety-six patients were successfully interviewed. Their mean (s.d.) score of global functioning was 64.3 (16.5). Considerable proportions of patients fulfilled criteria for remission (47%), functional recovery (33%), and recovery (16%) at 13 years. Higher level of global functioning was predicted by a married status at study entry and being in remission and employed at 3 years. Remission was predicted by a shorter DUP and better premorbid social adjustment. Functional recovery was predicted by better premorbid social adjustment, better baseline visual memory, and being employed at 3 years. No baseline and early outcome predictors of recovery could be identified. Addition of early outcome predictors significantly increased the variance explained for global functioning and improved model discrimination between patients who had functional recovery and those who had not. SMRs for all-cause mortality and suicide were 6.07 and 24.80, respectively. Discussion A prolonged DUP may intensify the progression of negative symptoms and lead to less likelihood of remission. The study has confirmed the enduring adverse impact of DUP but its reversibility is still in doubt. As the significance of visual memory in functional outcome has not received consistent support from literature, more prospective long-term studies are in need to re-examine the relationship. Early outcome predictors appear to be more relevant to functional outcome than clinical outcome. Discussion A prolonged DUP may intensify the progression of negative symptoms and lead to less likelihood of remission. The study has confirmed the enduring adverse impact of DUP but its reversibility is still in doubt. As the significance of visual memory in functional outcome has not received consistent support from literature, more prospective long-term studies are in need to re-examine the relationship. Early outcome predictors appear to be more relevant to functional outcome than clinical outcome. / published_or_final_version / Psychiatry / Doctoral / Doctor of Philosophy

Insight impairment is commonly reported in psychosis patients and such impairment leads to poor outcome and it also causes burden to the family and caregivers. It is as yet unclear what causes unawareness of illness therefore it is essential to find out the key element to form this fundamental correlation. Wiffen and David proposed that self-reflective processing may have similar cognitive mechanisms as theory of mind processing, but this does not imply that the processes cannot be affected independently. Lysaker et al. demonstrated that better meta-cognitive skills, such as the ability to think about one’s own thoughts were related to better insight in schizophrenia patients. An increasing number of studies suggest that patients lacking insight into their own illness, were fully capable of recognizing the illness and symptoms in other patients. This indicated that insight impairment only happened at the self-recognition level. The ability of integrating information from outside world to the self is seen as a factor in gaining insight, therefore self-reflection ability are commonly seen as key features of awareness of mental illness. Previous studies of chronic schizophrenia patients show that their ability to accept the biological model of their own psychotic symptoms, assessed with Guided Illness Model Questionnaire (GIM) questionnaire, has a positive association with their neuropsychological function and awareness of illness However, it has not been common to use GIM questionnaire in early stage psychosis patients. This study aims are (1) use Guided Illness Model Questionnaire (GIM) to assess the self-reflection ability of early stage psychosis patients (2) explore the relationship between self-reflection and insight (3) Cognitive functions, particular executive functions, will be evaluated with self-reflection ability and insight. Insight will be measured by scale to assess unawareness of mental disorder (SUMD). Results show self-reflection ability is related with insight impairment and executive function, especially processing speed and attention contributes to self-reflection ability and poor insight. Further investigation reveals that self-reflection ability acts as a mediator for poor insight. This study concludes that executive functioning is the basic-order process for gaining insight and self-reflection could act as higher-order process as mediator for provoking insight for psychosis patients. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

Empirical studies had demonstrated inconsistencies between duration of untreated psychosis (DUP) and outcome measures including negative symptoms severity and functional outcome. Therefore, this study aimed to investigate how either the construct of duration of untreated psychosis (DUP) or duration of untreated illness (DUI) acted on associating and predicting negative symptoms, its sub-domains and functional outcome among psychotic population in Hong Kong. Totally three hundred and forty five subjects were recruited from in-patient and out-patient setting in hospitals under hospital authority. DUP and DUI were assessed by semi-interviewed with subjects, their family members and other significant others. And the Scale of Assessment of Negative Symptoms (SANS) and Social and Occupational Functioning Assessment Scale (SOFAS) were adopted as assessment tools to measure negative symptoms severity and functioning of individual respectively. Regression models were used to analyse how DUI and DUP differed in associating and predicting different variables. Results showed that DUI took a more significant role in associating and predicting negative symptoms and functional outcome in which it demonstrated stronger positive correlation with negative symptoms and stronger negative correlation with functional outcome. DUI was also found to act as a potential predictor for both negative symptom severity and functional outcome. At the same time, among all sub-domains, anhedonia showed mild positive correlation with both DUI and DUP while other four didn’t show similar association. The results provided increased insight that DUI might play a more significant role in determining the development of negative symptoms and functional outcome than DUP. Yet, limitations on various aspects had been addressed in this study such as the high level of heterogeneity of our sample and potential confounders which partially correlated with the outcome parameter. Also, no causal relationship had been yield between DUI / DUP and outcome variables. Further investigation was suggested on dividing the sample into sub-group to draw information regarding the characteristics of associations. Meanwhile, better control on potential confounding variables might help generating clearer picture on how independent variables associated with each other. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

Aims: Psychosis is associated with serious stigma, impacting a person's psychosocial functioning. Religious group membership may provide social support for patients recovering from psychosis, while there may also be additional clinically beneficial effects of religiosity. We test the primary hypothesis that patients with religious group membership have better social support and functioning, compared with patients who are not attached to any religious group, with or without other group activities. The qualities that may contribute to clinical and social improvements in patients with religion are explored. Methods: This study uses a cross-sectional design with semi-structured interviews and questionnaires. A total of 63 participants were recruited from out-patient clinics: (1) 12 patients with religious group background (Catholic or Protestant); (2) 16 patients with no religious background participating in other community groups; (3) 15 patients with no religious background and other community activities; and (4) 20 healthy controls without religious background for comparison of social support and social functioning. Results: ANOVA analyses show that religious group was significantly better than community-activity group, followed by non-religious group in interpersonal functioning and social support. Healthy controls, though, had advantages in social functioning over the community-activity and non-religious groups, they were not significantly better than the religious group in interpersonal functioning, perceived social functioning or social support. This study discovers that the internal qualities, namely private practice, intrinsic experience, and subjective importance of religion, predict the clinical outcomes and social functioning, instead of the collective features of religion. Discussion: The findings confirm that the religious group had better social functioning and social support than the community-activity group, suggesting that apart from the emphasis on community activities, religion is also valuable in building up social functioning and support. Among different areas of religion, frequency of private practice, intrinsic experience and subjective importance significantly correlated with clinical outcome, medication compliance, social functioning, social support, perceived stigma and experienced stigma. It may imply that the internal qualities have a greater impact on functioning and outcomes than the communal activities. The semi-structured interviews revealed that patients obtained positive aspects of religion, namely, comfort, support, sense of control, and meanings of illness. Ways of dealing with mental illness through religion were mentioned in the interviews. Significance: The study shows that religion and religiosity also play an important role in social functioning and mental health even more so than community activities. The ways of living with symptoms may also be helpful to patients with psychotic symptoms. The spiritual interventions in treatment of psychosis could be considered in case management. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

Objective: To develop and validate a standardized self-stigma scale to capture the self-stigma level of early psychosis patients with lack of insight of their own mental condition. This bridges the research gap for existing scales measuring self-stigma in early psychosis patients. Method: We used qualitative data from focus groups and individual interviews with early psychosis patients to develop a pilot scale with15 concern issues and 48 items. We recruited 40 early psychosis patients in order to validate the scale. Of these, 15 were invited to complete the questionnaire twice within two to three weeks’ time for measuring the test-retest reliability for the scale. Results: The final self-stigma scale with 15concern issues and 32 items was produced. The self-stigma scale scores were positively correlated with depression, medication side-effects, positive and negative symptoms, insight, social withdrawal, perceived devaluation and discrimination, as well as experienced stigma. While the self-stigma scores were negatively correlated with social functioning and self-disclosure. However, their correlation with the self-stigma scale all served as discriminant validity. Discussion: The self-report questionnaire, which could be completed within ten to fifteen minutes, might help us understand more about the role of self-stigma in early psychosis patients in both research and clinical settings, also, its future applications were discussed. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

Background Many researches have studied stigma among people with mental illness, mainly focusing on its relationship with insight, psychological well-being and clinical outcomes. Psychotic disorder is described as a condition that influences one’s affect, thoughts and behaviors, with psychiatric symptoms including disorganized speech and bizarre behaviors, which frighten the general population. Common scales used in literatures to study stigma target the general population’s attitude towards mental illness instead of self-stigma, the internalized stereotypes of people suffering from psychotic disorders. Insight is likely to be different at different stages of schizophrenic spectrum disorder, but current evidence was mostly done in chronic schizophrenia patients. Aim This study explored the correlational association between self-stigma, insight and social functioning among people with first episode psychotic disorder and if self-stigma and insight were predictors of social functioning. Method Self-stigma, insight and social functioning were assessed among using structured interviews and questionnaires. Thirty-three out patients from the Early Intervention Team at Queen Mary Hospital in Hong Kong diagnosed with schizophrenic spectrum disorder participated in the study. The internalized stigma of mental illness scale was used to assess self-stigma; the unawareness of mental disorder scale was used to assess level of insight; and the social and occupational functioning assessment scale was used to assess level of social functioning. Results The linear regression analysis showed that self-stigma and insight were not significant predictors of social functioning (r = 0.67, β= -0.289, p < 0.05; adjusted R² = 0.39). However the regression analysis showed the subscale stereotype endorsement was a significant predictor of social functioning (r = 0.690, β= -0.333, p < 0.05; adjusted R² = 0.420) and accounted for 47.6% of the variance in social functioning levels. Moreover, the bivariate correlational analysis showed significant negative correlational relationships between self-stigma and social functioning, and insight and social functioning. There was no correlational relationship between self-stigma and level of insight. Conclusion Results showed that self-stigma and insight play different roles towards social and role functioning. Although analysis did not show a significant outcome indicating self-stigma and insight being the predictors of functioning, data showed that the values were close to being significant. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

Medication adherence is a well-known barrier in hindering successful pharmacological treatment, particularly in early psychosis patients. The aims of promotion and implementation of early intervention service not only change patient’s trajectory of long-term outcome positively but also broaden a therapeutic window by detecting patient’s medication non-adherence attitudes and behaviors in the very early stage of illness. Needless to say, the rate of non-adherent to medication in early psychosis is high due to a variety of potential risk factors. The consequences of medication non-adherence are devastating. In adherence research, the researchers devote their life to investigate in this aspect. As suggested by previous studies, a basket of consistent and inconsistent as well as strong or weak predictors are relevant to medication adherence. However, they tend to examine the medication adherence attitudes and behaviors together. Since someone behavior is not the same as his/her attitude toward medication adherence, the current study thus explores them separately. Given very scanty studies addressing the issue, this study focuses on asking whether different sets of baselines predictors contribute to medication adherence attitudes and behaviors differently are true. Within a six-month period of follow-up, 340 first episode psychosis patients have been included in the sample. We assessed various patient-related, medication-related, and environmental-related constructs (age, gender, martial status, education level, occupation, living condition, family history of mental illness, mode of onset, premorbid functioning, DUP, hospitalization, symptoms severity, level of insight, type of medication, medication side effects, and therapeutic alliance) at baseline as well as measured their medication adherence attitude and behaviors at six-month follow-up period. The result of the study are in accord with our hypothesis that different groups of risk factors contribute to medication adherence attitude and behaviors differently in the first six months of treatment of early psychosis patients. After putting the same set of variables into analyses on medication adherence attitudes and behaviors separately, findings reveal that DUP, insight, side effect on psychic aspect, and patients’ rating on communication effectiveness with clinicians are the significant predictors for medication adherence attitudes while gender, experienced hospitalization, and psychopathology severity are the influential indicators in predicting medication adherence behaviors. Our data indeed fills in the adherence research gap to address what predictors affect medication adherence attitude and behavior differently. The implication is that if we just put medication adherence attitude and behavior together into the discussion, it would oversimplify the medication adherence phenomenon. Our study serves as a cornerstone to obtain a better understanding in the dynamic process of medication treatment decision-making in terms of patients’ medication adherence attitudes and behaviors separately. We hope our findings as the stimuli to move on to next step by exploring whether a wider context of speculation, the structural barriers in our mental healthcare services delivery system and family involvement, influences medication adherence in early psychosis. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

Humor recognition and appreciation are important aspects to enhance psychological well-being and enrich social relationships and interactions. The present study hypothesized that first-episode psychosis (FEP) patients with adult onset in the Chinese society have deficits in humor recognition and appreciation compared with healthy controls. It also predicted FEP patients with a diminished ability in recalling humorous stimuli. Moreover, this study sought to explore the potential associations of humor recognition and appreciation deficits with measures of clinical symptoms, psychosocial and neurocognitive functioning, and self-perception towards hope and recovery among FEP patients. Thirty FEP patients with a DSM-IV diagnosis of schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder or delusional disorder were compared with 30 healthy controls matched for gender, age and education years on a humor task comprising six comedy video clips. Humor recognition was measured by the detection of total ‘standard humorous moments’ in the comedy clips. Humor appreciation was measured by self-report Visual Analogue Scale (VAS) funniness ratings. Percentage of recalled ‘standard humorous moments’ was also measured. Changes in positive and negative mood states were measured using Positive and Negative Affect Schedule (PANAS). Patients were assessed for clinical symptoms, psychosocial functioning, self-perception towards recovery and hope, and a battery of neuropsychological tests measuring executive function, working memory, intelligence quotient, semantic and visuospatial memory, and selective attention. FEP patients had a lower number in detection of total ‘standard humorous moments’, in total VAS funniness rating, and in percentage of recalled ‘standard humorous moments’ compared with healthy controls. Patients and healthy controls did not differ in positive and negative mood changes induced by the comedy clips. In patients, humor recognition had significant negative correlation with negative symptoms and significant positive correlation with self-perception towards hope. Recall of ‘standard humorous moments’ had significant negative correlation with negative symptoms and significant positive correlation with immediate and delayed recall using working memory. Both humor recognition and appreciation had no correlation with psychosocial and neurocognitive functioning. FEP patients had impaired humor recognition, appreciation and recall compared with healthy controls. The degree of humor recognition and recall deficits may be, respectively, associated with the extent of negative symptoms and attributed to impairments in the neurocognitive domain of working memory. Potentials of humorous stimuli in inducing a positive impact on mood for the patient population were found, providing insight for the introduction of humor therapy as a new form of intervention that could further improve psychological well-being. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

The current study analysed baseline data from the Jockey Club Early Psychosis (JCEP) 4-year RCT study (still underway). The aims were to (1) examine whether the correlations between premorbid functioning and the outcome variables of social functioning and clinical symptoms were significant in baseline measurements of the JCEP study, and (2) pave the way for the examination of the persistence of these correlations at 4 year follow-up, after the completion of the JCEP study. 360 first-episode adult-onset psychosis patients with schizophrenia-spectrum disorders were recruited from all inpatient and outpatient psychiatric units in Hong Kong since 2009. Premorbid functioning was measured by the Premorbid Adjustment Scale (PAS). Social functioning was measured by the Role Functioning Scale (RFS) and Social and Occupational Functioning Assessment Scale (SOFAS). Clinical symptoms were measured using the Positive and Negative Syndrome Scale (PANSS), Scale for Assessment of Negative Symptoms (SANS), and Scale for Assessment of Positive Symptoms (SAPS). Premorbid adjustment was significantly correlated with social functioning and negative symptoms; patients with poorer premorbid adjustment had worse social functioning and more severe negative symptoms. Positive symptoms were not significantly correlated with premorbid adjustment. There were no gender differences in premorbid adjustment. The majority of patients had a pattern of good premorbid adjustment (adequate to good levels of premorbid adjustment across all age-specific time periods). There were no significant differences in the outcome variables between the premorbid adjustment patterns. The current study findings have important clinical implications, in terms of advising the use of more effective and personalized interventions and treatment regimens on patients. In addition, the examination of premorbid adjustment facilitates early detection and identification of high risk psychosis individuals, which may help to reduce the duration of untreated psychosis. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

Motivations Ideas and delusions of reference (I/DOR) are common psychotic symptoms and can be defined as self-referential experiences in excess of the amount of evidence available in the immediate environment. A putative neurocognitive mechanism is increased automatic attention capture by self-referential (SR) information. This study was carried out to test the hypotheses that 1) compared with patients with no I/DOR, those who have the symptom have increased attentional shift to SR information and 2) there is a positive correlation between the severity of I/DOR and the extent of attentional shift to SR information. Clinical and cognitive correlates of I/DOR were also explored. Methods Patients with I/DOR (n=20, mean age 25.2±7.9 years, 4 men) and without I/DOR (n=17, mean age 28.6±8.2 years, 10 men) matched for age and education were assessed for positive symptoms, negative symptoms, mood symptoms and basic neurocognition. I/DOR were phenomenologically assessed using the Ideas of Reference Interview Scale (IRIS). In an interference task, patients were instructed to respond to computerized Stroop tasks while ignoring a voice clip presented binaurally with the subject’s own name (SON) embedded in certain trials. Within-subject differences in reaction time and accuracy between Stroop trials with and without SON were used as parameters to measure the degree of attentional shift to SR information. Between-group and within-subject differences in the reaction time and accuracy in the interference task were analysed using 2×2 mixed-ANOVA. Bivariate correlation was used to explore the relationship between IRIS scores and performance in the interference task. Stepwise linear regression analysis was used to explore the correlates of I/DOR. Results There was statistically significant interaction between conditions with and without SON and patient groups on the reaction time of the interference task (p=0.048). Simple main effects showed the mean difference of reaction time between conditions with and without SON was statistically significant in patients with I/DOR (p=0.001) but not in patients without I/DOR (p=0.862). Parameters used in the interference task correlated highly with IRIS global score and subscores on pervasiveness, self-referential discrepancy, conviction and frequency (r=0.328-0.517, range; p<0.05), unaltered by other clinical and cognitive variables except depressive symptoms and social anxiety. Regression analysis showed that I/DOR were related to depressive symptoms, social anxiety and attentional shift to SON. Discussion The significant interaction and simple main effect suggest that I/DOR are associated with a heightened attentional shift to SR information. The robust correlations between IRIS scores and attentional shift to SON provide some evidence to support the continuum hypothesis of I/DOR. The possible roles of emotions in the pathogenesis of I/DOR are discussed. Significance With the use of well-matched patient samples and an ecologically valid paradigm based on known human cognitive functions, the present study provided first empirical evidence for a theoretical link between cognitive anomaly and a key psychotic symptom. The SON paradigm provides a promising tool for further research and can potentially be developed into a neurocognitive parameter of I/DOR. The present study also shed light on the complexity of I/DOR in relation to other symptoms to inform future studies. / published_or_final_version / Psychiatry / Master / Master of Research in Medicine