Emotional and personality dysfunctions are common and clinically important in early psychosis and even in clinical‑high‑risk states, often shaping long‑term social functioning more than positive symptoms do.
 
Core Emotional Dysfunctions
In first‑episode psychosis (FEP), negative‑valence disturbances such as anhedonia (especially anticipatory), avolition, and blunted affect are prominent and can appear already in the prodrome. Anhedonia in FEP spans social, physical, anticipatory, and consummatory domains, with anticipatory deficits particularly linked to reduced role functioning and poorer quality of life. Deficits in emotion processing are thought to underlie classic negative symptoms like flat affect and anhedonia, affecting both subjective experience and outward emotional expression. Longitudinal work shows that baseline negative symptom severity in early psychosis strongly predicts 2–5‑year functional outcomes, often more robustly than positive symptoms or cognitive deficits.
 
Alexithymia and Affect Regulation
Alexithymia, difficulty identifying and describing feelings, with externally oriented thinking, is consistently elevated in schizophrenia and psychosis‑vulnerability samples. Meta‑analytic data indicate large‑effect associations between schizophrenia and difficulties in identifying feelings, and moderate effects for difficulties describing feelings and externally oriented thinking. In community samples, subclinical negative symptoms correlate moderately with alexithymic difficulties in identifying and describing feelings, suggesting a dimensional link between early negative symptoms and impaired emotional awareness. Independently of psychosis, alexithymia predicts poorer emotion recognition, empathy, and emotion regulation, highlighting its role as a contributor to broader social cognitive dysfunction.
 
Social Cognition and Interpersonal Emotion
Early psychosis and at‑risk states are frequently accompanied by deficits in social cognition, including recognizing others’ emotions, empathic responding, and theory of mind. Alexithymia appears to mediate some of these impairments: higher alexithymia scores predict worse emotion recognition and empathy even after controlling for anxiety and depression. Such social‑emotional deficits interact with negative symptoms (e.g., social anhedonia, avolition) to erode social networks, heighten loneliness, and reduce access to support, which in turn impacts prognosis and functional recovery. Clinically, this combination often presents as emotional disconnection: the person reports feeling numb or confused about emotions and appears interpersonally distant or flattened.
 
Personality Traits and Personality Disorders Around Onset
Adolescents and young adults at clinical high risk (CHR) for psychosis show elevated rates of clinically significant personality traits and disorders compared to other clinical groups. In CHR samples, schizoid, schizotypal, borderline, and avoidant traits are especially prevalent and associated with poorer adaptive functioning and greater distress. One study found that roughly three‑quarters of high‑risk individuals met criteria for a personality disorder, with depressive, borderline, and masochistic traits particularly frequent. Although findings on which personality disorders predict transition are mixed, schizoid and borderline diagnoses may carry some additional risk or at least mark more severe clinical complexity.
 
Interaction of Emotional and Personality Dysfunction
Personality pathology in CHR and early psychosis often co‑occurs with mood and anxiety disorders, major depression and social anxiety are especially common, and with basic symptoms of subtle self and perception disturbance. Borderline traits (affective instability, abandonment fears, self‑harm) can overlap phenomenologically with early psychotic experiences (e.g., transient paranoia, dissociation), complicating differential diagnosis. Schizotypal and schizoid traits (social withdrawal, odd beliefs, restricted affect) overlap with negative symptoms and social anhedonia, blurring the boundary between premorbid personality and emergent psychosis. Clinically, personality diagnoses may help explain severe distress, disability, and treatment challenges in CHR patients, even when they do not clearly increase conversion risk on their own.
 
Clinical Implications
Assessment in early psychosis benefits from structured evaluation of negative symptoms, anhedonia subtypes (anticipatory vs consummatory), and alexithymia alongside standard positive‑symptom scales. Structured personality assessment is important in CHR services, given the high prevalence of schizoid, schizotypal, borderline, and avoidant traits and their contribution to distress and care complexity. Psychosocial interventions that target emotion identification and labelling, social cognition, and reward‑based behavioral activation are promising adjuncts to pharmacotherapy in addressing these early emotional and personality dysfunctions.
 
References
Boldrini, T., Tanzilli, A., Di Cicilia, G., Gualco, I., Lingiardi, V., et al. (2020, December 8). Personality Traits and Disorders in Adolescents at Clinical High Risk for Psychosis: Toward a Clinically Meaningful Diagnosis. Frontiers in Psychiatry.

Di Tella, M., Adenzato, M., Catmur,C., Miti, F., Castelli, L. & Ardito, R.B. (2020, August 1). 273: 482-492. The role of alexithymia in social cognition: Evidence from a non-clinical population. Journal of Affective Disorders.
 
​Di Tella, M., Benfante, A., Castelli, L., Adenzato, M. & Ardito, R.B. (2024, August). 21(4):236-265. On the Relationship Between Alexithymia and Social Cognition: A Systematic Review. Clinical Neuropsychiatry.
 
Martin, J.C., Clark, S.R., Hartmann, S. & Schubert, K.O. (2024, July 24). A Tale of Three Spectra: Basic Symptoms in Clinical-High-Risk of Psychosis Vary Across Autism Spectrum Disorder, Schizotypal Personality Disorder, and Borderline Personality Disorder. Schizophrenia Bulletin.
 
Merchant, J. (2021 October 1). Social and Non-Social Pleasure in Schizophrenia: Associations with Negative Symptoms and Depression. Washington University . 
 
Oorschot, M., Lataster, T., Thewissen, V., Lardinois, M., Wichers,M., et al. (2011, October 20). 39(1):217-225. Emotional Experience in Negative Symptoms of Schizophrenia—No Evidence for a Generalized Hedonic Deficit. Schizophrenia Bulletin.
 
Ozdemir, E., Xiao, Z., Griffiths, H. & MacBeth, A. (2025, March 19). 81(6):410-424. Di Tella, M., Adenzato, M., Catmur,C., Miti, F., Castelli, L. & Ardito, R.B. (2020, August 1). 273: 482-492. The role of alexithymia in social cognition: Evidence from a non-clinical population. Journal of Affective Disorders.
 
Di Tella, M., Benfante, A., Castelli, L., Adenzato, M. & Ardito, R.B. (2024, August). 21(4):236-265. Alexithymia in Schizophrenia and Psychosis Vulnerability: A Systematic Review and Meta‐Analysis. Journal of Clinical Psychology.
Ricci, V., Sarni, A., Barresi, M., Remondino, L. & Maina, G. (2025, July 24). 13(15): 1796. Anhedonia and Negative Symptoms in First-Episode Psychosis: A Systematic Review and Meta-Analysis of Prevalence, Mechanisms, and Clinical Implications. Healthcare (Basel).
 
Sevilla-Llewellyn-Joes, J., Camino,G., Russo, D.A., Painter, M., Montejo, A.L., et al. (2018, March). 261:498-503. Clinically significant personality traits in individuals at high risk of developing psychosis. Psychiatry Research.

​Substance misuse is extremely common in first episode psychosis (FEP), worsens virtually every important outcome, and needs fully integrated management rather than being treated as an optional add‑on. The substance most consistently linked to poorer outcomes is cannabis, but alcohol and stimulants are also major contributors.
 
Around 40–50% of people with FEP meet criteria for a current or recent substance use disorder, most often cannabis and alcohol. In one prospective FEP cohort, over half (53%) met criteria for substance misuse during 15‑month follow‑up; cannabis misuse was present in 42% and alcohol in 30%. Young age, male sex, and being single are typical correlates; for cannabis, about 46% of FEP patients in a large London cohort had documented use at presentation.
 
Substance misuse in FEP is associated with more inpatient admissions, longer time in hospital, and higher rates of compulsory admission. Misuse is linked with increased risk and earlier onset of relapse, even after controlling for diagnosis, duration of untreated psychosis, and adherence. Persistent misusers show more positive symptoms, more depressive symptoms, and poorer functional outcomes than those who stop or never misuse, whereas stopping cannabis after FEP clearly improves long‑term outcome.
 
Cannabis use in FEP is associated with higher frequency of hospital admissions, more days in hospital, and a higher likelihood of compulsory detention. Part of this effect appears mediated by antipsychotic treatment failure, indexed by a greater number of different antipsychotics prescribed over time. Continued cannabis use after onset of psychosis increases relapse risk in a dose‑like manner, while discontinuation is associated with better symptom and functional trajectories.
 
Substance misuse can obscure the boundary between primary psychotic disorders and substance‑induced psychosis; longitudinal observation and careful temporal mapping of symptoms vs use are crucial. Comorbid misuse is associated with more aggression, legal problems, poor engagement, and higher rates of non‑adherence to medication and follow‑up. At the same time, a proportion of FEP patients stop substances spontaneously after the episode, underscoring the importance of early psychoeducation and motivational work.
 
Guidelines for early psychosis emphasise that psychosis and substance use must be treated in an integrated fashion within the same team rather than in parallel, fragmented services. Routine, structured assessment of all substances (including tobacco), with collateral history and toxicology where indicated. Psychoeducation for the young person and family about links between substances, relapse, and medication response, delivered early and repeatedly. Motivational interviewing and cognitive–behavioural strategies targeting both psychotic symptoms and substance use, with harm‑reduction goals where abstinence is initially unrealistic. 
 
Careful antipsychotic management (“start low, go slow”), with attention to side‑effect burden that might otherwise drive the person back to substances. Second‑generation antipsychotics are preferred in FEP; long‑acting injectables can be considered to support adherence where substance misuse destabilises oral treatment. For alcohol or other drugs, evidence‑based substance-induced psychosis treatments (e.g., relapse‑prevention medications, structured psychosocial programmes) should be embedded in early psychosis services rather than referred out. Tobacco treatment should be offered proactively; smoking is highly prevalent in FEP and interacts with antipsychotic metabolism (especially clozapine and olanzapine).
 
Overall, comorbid substance misuse is one of the most important modifiable determinants of prognosis in FEP, shaping relapse risk, service use, and functional recovery. The trajectory is not fixed: patients who reduce or stop substances after a first episode move towards outcomes approaching those of non‑users, especially over the long term. For any individual with emerging psychosis, early, assertive, integrated work on substance use should be considered core treatment rather than secondary adjunctive care.
 
References
 
Archie, S., Rush, B.R., Akhtar-Danesh, N., Norman, R., Malla, A., Roy, P. & Zipursky, R.B. (2007, March 3). 33(6):1354-1363. Substance Use and Abuse in First-Episode Psychosis: Prevalence Before and After Early Intervention.Schizophrenia Bulletin.
 
Gonzalez-Pinto, A., Alberich, S., Barbeito, S., Gutierrez, M., Vega, P. et al. (2009, November 13). 37(3):631-639. Cannabis and First-Episode Psychosis: Different Long-Term Outcomes Depending on Continued or Discontinued Use. Schizophrenia Bulletin.
 
NICE Clinical Guidelines, No. 20. (2011). Psychosis with Coexisting Substance Misuse: Assessment and Management in Adults and Young People. Psychosis with Coexisting Substance Misuse. British Psychological Society (UK). 
 
Patel, R., Wilson, R., Jackson, R., Ball, M., Shetty, H., et al. (2016, March). Association of Cannabis Use with Hospital Admission and Antipsychotic Treatment Failure in First Episode Psychosis: An Observational Study. British Medical Journal.
 
Rege. S. (2020, December 16). First Episode Psychosis/Early Psychosis – Key Principles from the Australian Clinical Guidelines for Early Psychosis. Psych Hub Scene. 
 
Schoeler, T., Petros, N. & Di Forti, M. (2016, November). Association Between Continued Cannabis Use and Risk of Relapse in First-Episode Psychosis: A Quasi-Experimental Investigation Within an Observational Study. JAMA Psychiatry.
 
Wisdom, J.P., Manuel, J. I. & Drake, R.E. (2011, September). 62(9):1007-1012. Substance Use Disorder Among People with First-Episode Psychosis: A Systematic Review of Course and Treatment. Psychiatric Services. 

Suicide risk is markedly elevated around the time of first episode psychosis (FEP), but intensive, early, integrated intervention can reduce deaths and attempts by roughly one‑third. Prevention hinges on systematic risk assessment, assertive engagement, treatment of psychosis and comorbid depression, and sustained psychosocial support in the early years.
 
Individuals with FEP have high rates of suicidal ideation (around one quarter) and attempts in the early phase of treatment. The key risk factors include prior self‑harm, current or past suicidal ideation, depressive symptoms, hopelessness, longer duration of untreated psychosis (DUP), and substance misuse. The risk tends to peak around acute onset and during early recovery/transition points (e.g. discharge, change of team, return to study/work), when insight and demoralisation often increase.
 
The core elements of suicide risk assessment in FEP are:
Conduct comprehensive, face‑to‑face assessment as early as possible at first presentation, covering suicidal thoughts, intent, plans, means, past attempts, and non‑suicidal self‑injury.
 
Evaluate dynamic factors: severity of positive symptoms, command hallucinations, depression, anxiety, substance use, insight, hopelessness, agitation, and support/resources.
 
Reassess at high‑risk junctures such as symptom exacerbations, disengagement, medication changes, or major psychosocial stressors, as risk can change rapidly over weeks to months.
 
At the acute stage, safety management would include:
Prioritising immediate safety: remove or restrict access to means, ensure continuous supervision if indicated, and consider urgent hospitalisation when there is persistent intent, plans, or psychosis with poor control.
 
Implement a collaboratively developed safety plan (warning signs, internal coping strategies, people/places for distraction, crisis contacts, steps to make the environment safer) rather than relying only on no‑harm contracts.
 
Include crisis support includes 24‑hour hotline, text/chat services and emergency evaluation at general hospitals with psychiatric services.
 
Preventive treatment strategies in early psychosis care:
Early Intervention for Psychosis (EIP) programmes that combine antipsychotic treatment, psychotherapy, psycho-education, case management, and family work are associated with about a one‑third reduction in suicide deaths and attempts compared with usual care.
 
Optimizing antipsychotic treatment (minimising DUP, treating persistent positive symptoms, considering clozapine where indicated) and aggressively treating comorbid depression and anxiety reduce suicidal behaviour.
 
Family psychoeducation and involvement improve adherence, detect early warning signs, and buffer hopelessness and isolation, all of which are linked with lower suicidality.
 
Psychosocial and cognitive interventions:
Structured CBT‑informed suicide‑focused therapy during FEP targets hopelessness, problem‑solving, meaning‑making, and barriers to help‑seeking, and is recommended as an adjunct to standard early psychosis care.
 
Ongoing support for social recovery (education/vocational rehabilitation, supported employment, social skills work) helps restore roles and quality of life, which correlate with reduced suicidal ideation.
 
System‑level strategies (proactive outreach to disengaging patients, assertive follow‑up after self‑harm, clear crisis pathways) are emphasised as central to suicide prevention in early psychosis services.
 
References
Bornheimer, L.A. (2018, February 14). 49(2):423-431. Suicidal Ideation in First-Episode Psychosis: Examination of Symptoms of Depression and Psychosis Among Individuals in an Early Phase of Treatment. Suicide Life Threat Behaviour.
 
Moro, L., Sicotte, R., Joober, R., Malla, A., Lepage, M. & Orri, M. (2024, October). Trajectories of Suicidality During a 2-Year Early-Inrervention Program for First-Episode Psychosis: A Longitudinal Study. Psychiatry Research.
 
Pompili, M., Serafini, G., Innamorati, M., Lester, D., Shrivastava, A., Giradi, P. & Nordentoft,M. (2011, June). 129(1):1-11. Suicide Risk in First Episode Psychosis: A Selective Review of the Current Literature. Schizophrenia Research.
 
Power, P. & McGowan, S. (2011). Suicide Risk Management in Early Intervention. Yorkshire & Humber Improvement Partnership. 
 
Sarkhel, S., Vijayakumar, V. & Vijayakuma, L. (2023, January 30). 65(2):124-130. Clinical Practice Guidelines for Management of Suicidal Behaviour. Indian Journal of Psychiatry.
 
Tahmazov, E., Bosse, J., Glemain, B., Nabbe, P., Guillou, M., et al. (2024, November 27). 15192):127-141. Impact of Early Intervention for Early Psychosis on Suicidal Behavior – A Meta-Analysis. Acta Psychiatrica Scandinavica. 

The at-risk mental state (ARMS) for psychosis is a clinical construct used to identify help‑seeking individuals who have a substantially elevated short‑to-medium‑term risk of developing a first episode of psychosis, but who have not yet crossed the threshold into full psychotic disorder. It is closely related to, and often used interchangeably with, the ultra‑high risk (UHR) or clinical high risk (CHR) concepts used in early psychosis services.
 
Most ARMS/UHR frameworks (e.g. CAARMS, SIPS/SOPS) converge on three main inclusion pathways:
Attenuated psychotic symptoms (APS):

Subthreshold positive symptoms (e.g. suspiciousness, unusual thought content, perceptual disturbances) that are below psychotic intensity or frequency, but clearly abnormal and distressing/impairing; typically present in the recent period (e.g. past year).
 
Brief, limited, intermittent psychotic symptoms (BLIPS/BIPS):
Fully psychotic‑level symptoms (e.g. clear hallucinations or delusions) that emerge but resolve spontaneously within a short duration (often defined as less than 1 week) without sustained antipsychotic treatment and recur intermittently.
 
Genetic risk plus functional decline:

Either a family history of psychotic disorder in a first‑degree relative or a schizotypal personality disorder, combined with a significant recent decline in psychosocial or occupational functioning.
 
Individuals meeting any of these pathways, and who are help‑seeking, are considered to have an ARMS and are candidates for specialized monitoring and indicated preventive interventions in early psychosis services.
 
ARMS criteria aim to enrich for imminent risk of psychosis compared with the general help‑seeking or community population. Transition rates in ARMS cohorts are typically:
Approximately 10–15% within the first year.
Around 20–30% by 2–3 years of follow‑up.
 
Thus, the construct is prognostically meaningful, but most ARMS individuals do not transition within these time frames, highlighting both the utility and the limitation of ARMS as a prediction tool. Within the ARMS population, certain baseline features consistently increase transition risk and are used to refine prediction beyond the categorical ARMS label:
 
Greater severity/frequency of subthreshold positive symptoms (unusual thought content, suspiciousness, perceptual abnormalities, disorganized speech).
 
Longer duration of attenuated/BLIPS symptoms before presentation.
 
Poor social and role functioning and functional decline.
 
Negative symptoms and cognitive problems (e.g. poor attention, subtle cognitive deficits).
 
Older age within the typical ARMS range (often late vs early adolescence), which may index longer duration of prodromal phenomena.
 
These variables underpin multivariate risk calculators that attempt individualized risk estimates within the ARMS group, rather than treating ARMS as a homogeneous category. Beyond the canonical ARMS criteria, several related constructs and markers have been investigated to improve early prediction:
 
Basic symptoms:
Very subtle, self‑experienced disturbances in thinking, perception, and self‑experience that are subjectively recognized as abnormal, sometimes preceding APS/BLIPS; certain basic‑symptom profiles are associated with higher long‑term risk of schizophrenia.
 
Neurocognitive and neurobiological markers:

Impairments in tasks such as verbal learning, social cognition, and electrophysiological indices (e.g. mismatch negativity) have shown added predictive value in some cohorts.

 
Structural and functional neuroimaging–based pattern‑recognition approaches have reached proof‑of‑concept accuracy for predicting transition in ARMS samples, although these are not yet routine clinical tools. Overall, the ARMS concept is a pragmatic clinical gateway: it identifies a small, enriched group at substantially elevated risk, within which more fine‑grained clinical, cognitive, and biological predictors can be used to estimate individual transition risk and to guide indicated preventive interventions.
 
 
References
Bonnett, L.J., Hunt, A., Flores, A., Smith, C. T., Varese, F., et al. (2025, February 27). Clinical Prediction Model for Transition to Psychosis in Individuals Meeting At Risk Mental State Criteria. Schizophrenia. 
 
McGorry, P.D., Hartmann, J.A., Spooner, R. & Nelson, B. (2018, May 24). Beyond the “At-Risk Mental State” Concept: Transitioning Transdiagnostic Psychiatry.World Psychiatry.
 
Radez, J., Waite, F., Izon, E. & Johns, L. (2023, January 11). Identifying Individuals At Risk of Developing Psychosis: A Systematic Review of the Literature in Primary Care Services. Early Intervention in Psychiatry.
 
Tavares, V., Vassos, E., Marquand, A., Stone, J., Valli, I., et al. (2023, January 19). Prediction of Transition to Psychosis From an At-Risk Mental State Using Structural Neuroimaging, Genetic, and Environmental Data. Frontiers in Psychiatry.
 
Thompson, A., Marwaha, S. & Broome, M.R. (2018, January 2). At-Risk Mental State for Psychosis: Identification in Current Treatment Approaches. BJPsych Advances. Cambridge University Press.
 
Zarogianni, E., Storkey, A.J., Borgwardt, S., Smieskova, R., Studerus, E., Riecher-Rossler, A. & Lawrie, S.M. (2019, December). Individualized Prediction of Psychosis in Subjects with an At-Risk Mental State. Schizophrenia Research.
 
Yung, A.R., Wood, S.J., Malla, A., Nelson, B., McGorry, P. & Shah, J. (2019, October 28). The Reality of At-Risk Mental State Services: A Response to Recent Criticisms. Psychological Medicine.