Flat affect is common following first-episode psychosis, fluctuates more than the literature suggests, and is associated with poorer functioning.
The findings, noted in a 10-year Scandinavian follow-up study of more than 180 patients, also show that enduring flat affect, though relatively rare, is particularly associated with poorer social functioning, Dr. Julie Evensen of Oslo University Hospital and her colleagues reported in Schizophrenia Research.
Of 301 patients enrolled between 1997 and 2000 in the Early Treatment and Intervention in First-Episode Psychosis (TIPS) trial, a longitudinal study of consecutively admitted patients, 184 completed a 10-year follow-up. Of these, 66% displayed flat affect and had either improvement (10%), deterioration (16%), or fluctuation (40%) of their flat affect. At 10 years, 41% had clinically significant flat affect, but only 5% had enduring flat affect across the entire follow-up period, the investigators reported (Schizophr. Res. 2012;139:99-104).
The group of patients who never displayed flat affect achieved the best scores on most clinical and functional variables, and the group with enduring flat affect had the poorest scores.
This trend was most pronounced for social function scores on the Premorbid Assessment of Functioning Scale, or PAS (scores of 1.12 and 3.17, respectively), and for negative symptoms assessed using the Positive and Negative Syndrome Scale, or PANSS (negative symptom scores of 16.0 and 30.4, respectively), they said, noting that the differences in these instances were statistically significant.
The strongest predictor of enduring flat affect was PAS social last score (odds ratio, 1.9).
As for differences between the groups at 10 years, PANSS symptom component scores showed that the group of patients who never displayed flat affect scored significantly lower than both the deteriorating and fluctuating groups on both positive and cognitive components.
"On the general negative component, the never-present and the improving groups scored statistically significantly lower than the remaining groups. No statistically significant differences were found on the depressive or excitative components. In the enduring group, all patients fulfilled criteria for schizophrenia spectrum disorders at 10-year follow-up," they noted.
In addition, the fluctuating, deteriorating, and enduring groups were psychotic for statistically significantly longer during the follow-up period, and fewer were in remission or recovery after 10 years, the investigators said, noting that these groups also had poorer function as determined based on employment status, reduced ability to live independently, and lower Global Assessment of Functioning general function (GAF-F) scores. Objective measures of social function during follow-up demonstrated statistically significant differences between the enduring group and the other groups at all assessments.
Even after all analyses were repeated on schizophrenia spectrum patients, little change was seen in group distribution, and only small differences were seen with respect to baseline variables and outcome measures at 10 years compared with analyses of the full sample, they noted.
"Social premorbid function remained the most important predictor of enduring flat affect, and social function from baseline to 10 years remained significantly poorer in the enduring flat affect group compared to the other groups," they wrote.
Study participants were adults aged 18-65 years from four Scandinavian catchment sites. First-episode psychosis was defined by a PANSS score of 4 or more on one or more positive subscale items 1, 3, 5, or 6, or on general subscale 9 for at least 7 days. They also met DSM-IV criteria for schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic episode, delusional disorder, affective psychosis with mood-incongruent psychotic features or psychotic disorder not otherwise specified, and an IQ of at least 70. Assessments were conducted at baseline, at 3 months, and at 1, 2, 5, and 10 years.
The findings contrast with those from prior, smaller studies, in that the current study shows greater instability with respect to flat affect, and the results underscore the importance of early identification of patients with flat affect as these patients appear particularly vulnerable, the investigators noted.
"We found that the enduring group was similar to the remaining patients on most baseline variables, but differed significantly in premorbid social functioning. Reduced display of affect has been found in the children who later developed schizophrenia compared to their siblings who did not develop schizophrenia. The combination of flat affect and poor social functioning could potentially be present from early stages in the life of a child vulnerable to psychotic illness," they explained.
Though limited by the use of a single-item measure of flat affect, the study is unique in that it "explores a large and representative group of first-episode psychosis patients 10 years after their first psychotic episode with a particular focus on different flat affect trajectories." Another strength of the TIPS study is its strict focus on reliability testing throughout the follow-up period, the investigators noted, concluding that the findings – particularly the finding that flat affect, especially when enduring, is related to poorer functioning and poorer social functioning – pose a challenge to clinicians to "target, track, and engage those particularly vulnerable groups within a first-episode psychosis sample."