Social and role functioning in people at ultra-high risk for psychosis

  • Jack Cotter

Student thesis: Phd


Criteria have been developed to identify individuals at ultra-high risk (UHR) of developing a psychotic disorder. Many UHR young people exhibit marked and persistent impairments in social and occupational functioning, regardless of symptomatic remission or transition to full-threshold psychotic disorder. In this thesis, I sought to identify factors that drive and sustain functional impairment in this group. The aim was to identify risk factors for poor functional outcome in this population. This in turn could potentially help to inform interventions. In Paper 1, I conducted a systematic review of factors associated with functional deficits in the UHR population. This was the first systematic review examining this issue. The review identified negative symptoms, disorganisation and neurocognitive deficits as robust predictors of poor outcome. I also identified areas that had been little studied, including the effect of childhood trauma, social cognitive dysfunction and the drivers of poor “real world” outcomes such as long term unemployment. Exposure to childhood trauma is common among the UHR group. I provided an extended rationale for examining its association with functioning in Paper 2, citing a range of literature linking exposure to trauma to functional deficits in people with severe mental illnesses. I then analysed which of a range of clinical and sociodemographic variables at baseline, including trauma, were the strongest predictors of long-term functioning in a large UHR cohort (Paper 3). Only childhood trauma and transition to psychosis were significant independent predictors of poor long-term functioning in the multivariate analyses. Paper 4 is the first study to investigate the long-term unemployment rate and baseline predictors of employment status at follow-up in an UHR cohort. After 2-13 years (mean = 7), 23% of the sample was not in employment, education or training. Childhood trauma and the duration of untreated illness at baseline were significant independent predictors of employment status at follow-up. Paper 5 identified a cross-sectional association between performance on a theory of mind task and a measure of global functioning that remained significant after controlling for negative symptoms and stress in multivariate analyses. Finally, in Paper 6 I reported the findings of a qualitative study that I conducted with twenty UHR service-users. Participants reported a range of impairments in their social and occupational functioning which they attributed to a combination of clinical, cognitive and psychological factors. This included negative symptoms, cognitive deficits and adverse childhood experiences, as well as variables which had been largely unexplored previously, such as self-stigmatising attitudes and dysfunctional metacognitive beliefs, providing new targets for future research. Based on these findings, the quantitative analyses and my literature review, I propose a model that attempts to explain how these variables interact to drive and sustain functional impairment in the UHR group. This thesis provides new insights into factors that underlie functional deficits in the UHR group. I end the thesis with a discussion of these findings and their clinical implications, consider the strengths and limitations of this work and identify areas for future research.
Date of Award1 Aug 2018
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorRichard Drake (Supervisor), Dawn Edge (Supervisor), Sandra Bucci (Supervisor) & Alison Yung (Supervisor)


  • Ultra-high risk
  • Functioning
  • Psychosis

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