Social and Role Functioning in the Psychosis Risk Syndrome: Moving Beyond Symptoms for Predicting Psychosis Onset

Adolescents and young adults at clinical high risk for developing psychosis (CHR) show persistent impairments in social and role functioning. Poor social functioning has been linked to greater risk of psychosis, but it remains unclear how functional trajectories differ across clinical outcomes.

Ninety-six healthy controls (HC), 70 CHR-Converters and 415 CHR individuals who did not develop psychosis classified into Remission, Symptomatic, and Progression subgroups were included as part of the third phase of the North American Prodrome Longitudinal Study. Social and role functioning were assessed at baseline, 2, 4, 6, and 8 months using the Global Functioning: Social and Role scales, alongside clinical symptoms and intellectual functioning.

Compared to HCs, all CHR subgroups showed significant social and role functioning impairments across time (Ps < .001). However, the pattern of impairment among the CHR subgroups differed by domain. For social functioning, converters had the lowest functioning compared to both HCs and the 3 non-converter subgroups. In contrast, for role functioning, converters were only significantly different from the progression subgroup. This pattern remained after adjusting for positive and depressive symptoms and intellectual functioning. In follow-up Cox regression analyses adjusting for positive symptoms, depressive symptoms, and intellectual functioning, lower baseline social functioning predicted shorter time to psychosis onset (HR = -0.168, 95%CI, 0.722-0.989; P = .036), but baseline role functioning did not emerge as a significant predictor (P = .057).

CHR individuals who transition to psychosis show enduring impairments in social and role functioning that are evident at baseline and stable across the short-term follow-up period. Poor baseline social, but not role functioning independently predicted time to psychosis onset, underscoring its importance as a prognostic marker in the early identification of psychosis risk.