Attachment styles are used to describe patterns of attachment in relationships. Adults with a secure attachment style tend to have good self-esteem, they share their feelings with partners and friends, and have trusting, lasting relationships. Insecure attachment styles include anxious attachment style (also known as ambivalent or preoccupied), which involves reluctance to become close to others, worry about the security of relationships, a reduced sense of autonomy, and increased dependence on others. Avoidant attachment style is another insecure style. It involves problems with intimacy, over-regulation of emotions, and unwillingness to share thoughts and feelings. Fearful attachment style is represented by an inconsistent sense of self and an inability to regulate one’s emotions.

While attachment style in adulthood is thought to be based on early experiences with primary care givers, life’s experiences can also impact on attachment style in adults. Children described as ambivalent or avoidant can become securely attached as adults, while those with a secure attachment in childhood can show insecure attachment patterns in adulthood.

What is the evidence for attachment styles in people with schizophrenia?

Moderate to high quality evidence found the prevalence of insecure attachment styles is higher in people with schizophrenia than in people without a mental illness (76% vs. 38%), with fearful attachment style being the most prevalent in patients (38%) followed by avoidant (23%), then anxious (17%) attachment style. This large effect of more insecure attachment styles in people with schizophrenia compared to controls was similar to that seen in people with depression or bipolar disorder. It was also similar across all three disorders for anxious attachment style. However, for avoidant attachment style, it was small for schizophrenia, medium-sized for bipolar disorder, and large for depression.

Small to medium-sized associations were found between increased general and positive symptoms and increased anxious and avoidant attachment styles. There was a weak association between increased negative symptoms and increased avoidant attachment style, and no significant association between negative symptoms and anxious attachment style. There were also medium-sized associations between decreased social and personal recovery and increased anxious and avoidant attachment styles in patients.

February 2022

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Dermatoglyphics, also referred to as epidermal ridges, are the distinct patterns and lines on the hands and fingers. These ridges appear on the hands between weeks 6 and 15 during foetal development, and remain largely unchanged after this period. Alterations in the patterns and counts of dermatoglyphics may be an indication of disruption to foetal development in the early- to mid-gestation period. A triradius occurs where three ridge systems meet at a point, and occurs four times on the palm, at the base of each of the four digits (a, b, c, and d). Dermatoglyphic indices include: fingertip patterns; finger ridge counts, which are the number of ridges between the center of the fingertip patterns and their corresponding triradius; palmar ridge counts, which are the number of ridges on the palm connecting two triradii; fluctuating asymmetries, which are the differences in ridge counts or pattern types between parallel structures on the left and right hands; and the ATD angle, which is the angle formed by lines drawn from the most remote triradius near the base of the palm, to triradii a and d, located close to the index and little fingers respectively.

What is the evidence for dermatoglyphics?

Moderate to high quality evidence found a medium-sized effect of reduced total ridge count and a-b palmar ridge count in people with schizophrenia compared to controls, with no differences in ATD angle, fingertip pattern asymmetry or ridge count asymmetry.

February 2022

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Key features of the symptoms of disorganisation include disorganised speech and behaviour, as well as inappropriate affect. Severely disorganised speech is difficult to follow, being incoherent, irrelevant and/or illogical. These symptoms are sometimes referred to as positive formal thought disorder. Disorganised speech may also be deprived of content, which is sometimes referred to as negative formal thought disorder symptoms. Disorganised behaviour includes bizarre or inappropriate behaviour, actions or gestures. Inappropriate (incongruous) affect involves exhibiting incorrect emotional responses for a given context.

Symptoms of disorganisation have been identified as risk factors for poor illness outcome, and have a significant negative effect on a person’s day-to-day functioning and quality of life. There is evidence to suggest that disorganisation symptoms may be associated with impaired cognitive performance.

What is the evidence regarding disorganised symptoms?

Moderate to high quality evidence found small to medium-sized associations between positive and negative formal thought disorder and poor cognition in the areas of memory, attention, processing speed, planning, semantic processing, social cognition, and social functioning. Positive formal thought disorder was particularly associated with poor inhibition and syntactic comprehension, while negative formal thought disorder was particularly associated with poor fluency. There was also a medium-sized association between poor insight (overall unawareness of having a mental disorder) and increased disorganised symptoms.

There was a small to medium-sized effect of more formal thought disorder symptoms in people with schizophrenia than in people with bipolar disorder. This effect was significant only in non-acute, stable patients.

High quality evidence shows significant concordance of disorganisation symptoms in siblings with schizophrenia. Low quality evidence suggests unclear concordance in twins with schizophrenia.

February 2022

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Dissociation is described as disruption or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, or behaviour. Common dissociative experiences include mild forms of absorption, such as daydreaming. Less common and more severe dissociative experiences include amnesia, derealisation, depersonalisation, and fragmentation of identity. Dissociative features may play a role in the pathology of schizophrenia.

What is the evidence for dissociation?

Moderate to high quality evidence found more dissociation in people with schizophrenia than controls without schizophrenia. In those with schizophrenia, there was a medium-sized association between exposure to childhood adversity and more dissociation. There were also medium to strong associations between increased dissociation and increased psychotic symptoms.

Moderate to low quality evidence found less dissociation in people with schizophrenia than in people with dissociative disorders, post-traumatic stress disorder, borderline personality disorder, or conversion disorder.

February 2022

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Early detection refers to the correct identification of individuals who are at high risk of developing schizophrenia, with an emphasis on the development of frank psychosis. Generally, there are two approaches that dictate the characteristics used as markers for detection. The first is the ultra-high risk approach which focuses on a triad of at-risk mental states defined as having a family history of psychosis plus non-specific symptoms and recent decline in functioning, recent onset of attenuated psychotic symptoms with decline in functioning, and brief, intermittent and limited psychotic symptoms. The other approach is based on Huber’s Basic Symptoms, which focuses on a detailed way of describing subjective disturbances, and may be an earlier indicator of risk.

What is the evidence for early detection of psychosis?

Moderate to high quality evidence found the mean rate of transition to psychosis in those assessed as being at clinical high risk is around 16% by 2 years and 29% by 3 years. In adolescents and young adults (16-24 years) who were diagnosed with attenuated psychotic syndrome, transition rates were 11% by 6 months, 15% by 12 months, 20% by 2 years months, and 23% by 3 years. In children (<18 years) assessed as being at clinical high risk, transition rates were between 17% and 20% by 1 year follow-up and between 7% and 21% by 2 year follow-up. 36% of children and adolescents recovered from their clinical high risk status by 6-year follow-up, and 40% continued to meet clinical high risk criteria without transition to psychosis.

People assessed as being at clinical high risk of obsessive-compulsive disorder were at higher risk of psychosis transition than people assessed as being at clinical high risk of bipolar disorder, which in turn had higher risk of psychosis than people assessed as being at high risk of depression. The rate of transition to psychosis was one third the rate of transition to non-psychotic disorders in people at assessed as being at clinical high risk for any non-psychotic disorder.

Studies with older samples reported higher transition rates than studies with younger samples, and more recent publications reported lower transition rates than older publications. Studies using the basic symptoms approach reported higher transition rates than studies using the ultra-high risk approach. Studies of people receiving psychosocial treatments for high risk groups (e.g., cognitive behavioural therapy) reported lower transition rates than studies of people receiving standard care (e.g., case management). Studies of people on antipsychotics also reported lower transition rates than studies of people not on antipsychotics.

Moderate to high quality evidence suggests instruments based on ultra-high risk criteria have good sensitivity and moderate specificity. Moderate to low quality evidence found the Assessment of Basic Symptoms Scale has good sensitivity and moderate specificity. This indicates validated tools are generally good at correctly identifying individuals who do develop psychosis, but not as good at identifying individuals who do not develop psychosis.

Moderate quality evidence suggests the model with the best predictive value (86%) for transition to psychosis was a clinical model including odd beliefs, marked impairment in role functioning, blunted affect, auditory hallucinations, and anhedonia/asociality. A biological model using grey matter volume, and a neurocognitive model using IQ, verbal memory, executive functioning, attention, processing speed, and speech perception, both had positive predictive values of ~83%. An environmental model with a positive predictive value of 63% involved urbanicity, social-sexual aspects, and social-personal adjustment. The best combination model had a positive predictive value of 82% and involved disorganised communication, suspiciousness, verbal memory deficit, and decline in social functioning.

February 2022

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Functional laterality refers to a natural asymmetry in left or right-side dominance, for example in terms of handedness, or brain function. Handedness refers to the preference for using one hand over the other for certain tasks. Right-handed people show increased dexterity in their right hand, left-handed people show increased ability the left hand. People may also be ‘mixed’ handed and show different hand preference for different tasks. Listening tasks can be used to assess language lateralisation. People with schizophrenia may show differences in handedness or footedness, as well as altered visual and auditory dominance that may reflect abnormalities in brain laterality and dominance.

What is the evidence for altered functional laterality?

High quality evidence shows that people with schizophrenia are more likely to be left or mixed-handed than people without schizophrenia, including people with other psychiatric disorders. Moderate to high quality evidence suggests this finding is similar for males and females. Moderate to high quality evidence suggests people with schizophrenia have less right-ear dominance, which may be most apparent in people who experience auditory hallucinations. Moderate to low quality evidence suggest people with schizophrenia show an absence of normal leftward asymmetry in the planum temporale and Sylvian fissure brain regions, and an excess rightward asymmetry in the superior temporal gyrus (particularly posterior). There is also a higher frequency of abnormal (reversed) asymmetry in the frontal and occipital lobes.

February 2022

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Minor physical anomalies (MPAs) are subtle anatomical deviations that have little functional or aesthetic impact. They may be traced to events occurring prenatally and may represent risk markers for underlying illness susceptibility. MPAs may be important risk indicators when an individual is already at high risk of developing psychosis, for example, having a first-degree relative with psychosis, and when multiple MPAs occur together in one individual.

What is the evidence for minor physical anomalies in people with schizophrenia?

Moderate to high quality evidence found a large increase in overall MPA scores in people with schizophrenia compared to controls without schizophrenia. There were also increased MPA scores in people with schizophrenia compared to their relatives, with no differences between relatives and controls.

Moderate quality evidence suggests MPA frequency is increased in six regions: head, eyes, ears, mouth, hands and feet. Specific MPAs include tongue with irregular smooth-rough spots, single transverse palmar crease (one crease extending across the palm of the hand), syndactyly (wholly or partially united) 2nd and 3rd toes, malformed ears, low set ears, smaller head circumference, and curved fifth finger.

Moderate to high quality found no differences between people with schizophrenia and controls in second-to-fourth digit ratio, apart from the right hand of males with schizophrenia which showed increased second-to-fourth digit ratio than controls. Second-to-fourth digit ratio is constant throughout life and is the ratio of the length of the index finger (second digit) to the length of the ring finger (fourth digit) of the same hand. Higher 2D:4D ratio is suggested to be the result of lower levels of fetal testosterone.

February 2022

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Morphometrics is the measurement of the variation in the structure or form of organisms. In the mid-1900s, William Herbert Sheldon introduced the notion that there were three components that determine the morphology of a human individual: mesomorphy (musculoskeletal robustness relative to height); endomorphy (relative fatness); and ectomorphy (relative erectness or slenderness). The study of body shapes and their prevalence in both physical and mental disorders may provide insight into the biology of, and risk for, schizophrenia.

What is the evidence for morphometrics?

High quality evidence shows people with schizophrenia are often slighter shorter in height than people without schizophrenia. Moderate to low quality evidence also finds people with schizophrenia are often be more erect and slender, and have a lower body mass compared to both people without schizophrenia and people with other mental disorders.

February 2022

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Catatonia was originally categorised as a subtype of schizophrenia, but it is found in people with other medical, neurological, and psychiatric disorders. Catatonia is characterised by repetitive non-goal-directed movements or goal-directed movements that are executed in an idiosyncratic way. Other forms of catatonia include immobility, mutism, staring, and rigidity. Tardive dyskinesia is a ‘hyper-kinetic’ (excessive movement) disorder, characterised by jerky, involuntary movements, usually of the face and/or limbs. Parkinsonism is another common movement disorder associated with schizophrenia and is a ‘hypo-kinetic’ (reduced movement) disorder, characterised by slowness of movement and rigidity. These movement disorders are associated with antipsychotic medications but can arise independent of medication status.

What is the evidence for movement disorders in schizophrenia?

Moderate quality evidence finds the overall prevalence of extrapyramidal symptoms in people with schizophrenia taking antipsychotics is around 37%. Parkinsonism prevalence is 20%, akathisia prevalence is 11%, catatonia prevalence is 10%, and tardive dyskinesia prevalence is 7%. Non-white ethnicity and the presence of early extrapyramidal symptoms is associated with a small to medium-sized increase in the risk of tardive dyskinesia in patients treated with antipsychotics. There were no moderating effects of age, sex, or medication dose.

Moderate to high quality evidence finds around 17% of people with schizophrenia who are antipsychotic-naïve show symptoms of parkinsonism, and 9% show symptoms of dyskinesia. This corresponds to a large increase in the risk of dyskinesia and parkinsonism when compared to controls. There was also a small increase in these symptoms in first-degree relatives of people with schizophrenia.

February 2022

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Negative symptoms of schizophrenia refer to an absence of normal functions. These include a scarcity of facial expressions of emotion, reduced frequency and range of gestures and voice modulation, restricted eye contact, poverty of speech (alogia), reduced social interaction, reduced motivation (avolition), poor hygiene, and reduced experience of pleasure (anhedonia) which is often manifested as scarcity of recreation, inability to experience closeness, and reduced interest in any sexual activity. Deficit schizophrenia is a subtype of schizophrenia with persisting negative symptoms that is described by specifically defined assessments used primarily in research.

What is the evidence for negative symptoms?

Moderate to low quality evidence indicates negative symptoms occur in 50-90% of people with first-episode psychosis. This estimate decreases to 35-70% with treatment, but 20-40% of first-episode patients have persisting negative symptoms. There were more severe negative symptoms in patients with a family history of psychosis than in patients without a family history of psychosis.

Moderate to high quality evidence shows people with chronic schizophrenia report more anhedonia, and less consummatory and anticipatory pleasure than controls. There were small to medium-sized associations between more overall negative symptoms and more episodic memory deficits, more depression symptoms, less insight, and less motivation.

Moderate to high quality evidence finds deficit syndrome is apparent in around one-third of people with chronic schizophrenia. Deficit syndrome is associated with greater severity of negative and disorganised symptoms and less severity of mood symptoms. Deficit schizophrenia is more likely to occur in males than in females.

Moderate quality evidence finds large effects of longer pauses and less spoken time in people with schizophrenia compared to controls. There were medium-sized effects of lower speech rate and less pitch variability. No differences were found for pitch, intensity variability, duration of utterance and number of pauses. Significant associations were found between more negative symptoms and less pitch variability, greater flat affect, less time spoken, more alogia, and more duration of pauses.

Moderate to high quality evidence found no differences in negative symptoms between people with schizophrenia and current cannabis and/or nicotine use and people with schizophrenia with no cannabis and/or nicotine use. However, there was a small to medium-sized effect of less severe negative symptoms in people with schizophrenia who recently abstained from cannabis use.

March 2022

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