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Aims: Criteria for identifying people likely to develop a first psychotic episode are now used in many clinical services worldwide. In recent years within these services, there has been an increase in the practice of prescribing antipsychotic medication with the aim of reducing symptoms and preventing onset of full-blown disorder. This practice is based on clinical impression of an incipient psychosis, that is, a clinical judgment that a particular patient may soon progress to full-threshold disorder and may therefore benefit from antipsychotics. However, it is unclear how accurate this clinical impression is. If not accurate it could mean that individuals are receiving antipsychotics unnecessarily. In this study, we investigated the predictive validity of clinical impression of whether ultra high risk patients would develop frank psychosis. Methods: Experienced psychologists rated their clinical impression of incipient psychosis in 168 ultra high risk patients. Ratings were made upon entry to the PACE clinic, a clinical service for ultra high risk patients. Psychosis status over the subsequent 12-month period was established using the Comprehensive Assessment of At Risk Mental States or State medical records. Results: A total of 8.9% of the sample transitioned to psychosis over the 12-month follow-up period. There was a sensitivity of 0.80, specificity of 0.84, positive predictive value (PPV) of 0.32 and negative predictive value (NPV) of 0.98 for the prediction of psychosis using the clinical impression ratings. Conclusions: The results indicate that clinical impression is not sufficient for predicting psychosis outcome in ultra high risk cohorts and that ongoing rigorous research into predictors of outcome in such cohorts is required. The results also caution against the prescription of antipsychotic medication based on clinical impression of incipient psychosis. Future work should address the predictive validity of clinical impression with a larger sample and over a longer follow-up period. [ABSTRACT FROM AUTHOR]

The current paper examines a neglected function of ‘ultra high risk’ (UHR) clinics: to detect first-episode psychosis (FEP) mistakenly identified as a prodrome. A clinical audit was conducted of referrals to a UHR service, the Personal Assessment and Crisis Evaluation Clinic, over a 12-month period (April 2005–March 2006). In this audit, 11.4% of the total number of referrals ( n= 149) and 11.9% of those who attended a first appointment were psychotic on referral. These figures indicate that a substantial proportion of individuals thought to be prodromal are in fact suffering FEP. UHR clinics minimize duration of untreated psychosis for FEP patients mistaken as prodromal. [ABSTRACT FROM AUTHOR]

Objective: Recognizing the prodrome of a first psychotic episode prospectively creates the opportunity of intervention, which could delay, ameliorate or even prevent onset. Valid criteria and a reliable methodology for identifying possible prodromes are needed. This paper describes an instrument, the Comprehensive Assessment of At-Risk Mental States (CAARMS), which has been designed for such a purpose. It has two functions: (i) to assess psychopathology thought to indicate imminent development of a first-episode psychotic disorder; and (ii) to determine if an individual meets criteria for being at ultra high risk (UHR) for onset of first psychotic disorder. This paper describes the pilot evaluation of the CAARMS. Method: Several methodologies were used to test the CAARMS. First, CAARMS scores in a group of UHR young people and the association between CAARMS scores and the risk of transition to psychotic disorder, were analysed. Second, CAARMS scores in a UHR group were compared to a control group. To assess concurrent validity, CAARMS-defined UHR criteria were compared to the existing criteria for identifying the UHR cohort. To assess predictive validity, the CAARMS-defined UHR criteria were applied to a sample of 150 non-psychotic help-seekers and rates of onset of psychotic disorder at 6-month follow-up determined for the CAARMS-positive (i.e. met UHR criteria) group and the CAARMS-negative (i.e. did not meet UHR criteria) group. The inter-rater reliability of the CAARMS was assessed by using pairs of raters. Results: High CAARMS score in the UHR group was significantly associated with onset of psychotic disorder. The control group had significantly lower CAARMS scores than the UHR group. The UHR criteria assessed by the CAARMS identified a similar group to the criteria measured by existing methodology. In the sample of non-psychotic help-seekers those who were CAARMS-positive were at significantly increased risk of onset of psychotic disorder compared to those who were CAARMS-negative (relative risk of 12.44 (95% CI = 1.5–103.41, p = 0.0025)). The CAARMS had good to excellent reliability. Conclusions: In these preliminary investigations, the CAARMS displayed good to excellent concurrent, discriminant and predictive validity and excellent inter-rater reliability. The CAARMS instrument provides a useful platform for monitoring subthreshold psychotic symptoms for worsening into full-threshold psychotic disorder. [ABSTRACT FROM AUTHOR]

The identification of individuals at high risk of developing a psychotic disorder has long been a goal of clinicians because it is thought that early treatment of this group may prevent onset of the disorder. However, little is known of predictive factors of psychosis, even within a high-risk group. This study followed up 104 young people thought to be at ‘ultra high risk’ for schizophrenia and other psychotic disorders by virtue of having a family history of psychotic disorder combined with some functional decline or the presence of subthreshold or self-limiting psychotic symptoms. All subjects were therefore symptomatic, but not psychotic, at intake. Thirty-six subjects (34.6%) developed frank psychotic symptoms within 12 months.Measures of symptom duration, functioning, disability and psychopathology were made at intake, 6 and 12 months. Poor functioning, long duration of symptoms, high levels of depression and reduced attention were all predictors of psychosis. A combination of family history of psychosis, a recent significant decrease in functioning and recent experience of subthreshold psychotic symptoms was also predictive of psychosis. Combining highly predictive variables yielded a method of psychosis prediction at 12 months with good positive predictive value (80.8%), negative predictive value (81.8%) and specificity (92.6%) and moderate sensitivity (60.0%).Within our symptomatic high-risk group, therefore, it appears possible to identify those individuals who are at particularly high risk of developing a psychotic disorder such as schizophrenia. Given the very high PPV and low false positive rate with this two-step process, it may be justifiable to target these individuals for intensive monitoring of mental state and even low-dose neuroleptic medication or other biological and psychosocial treatments depending on clinical condition. This indicated prevention approach could be further developed and preventive strategies in the psychoses refined. [Copyright &y& Elsevier]

Abstract: Objective: Studies conducted in community samples indicate that psychotic-like experiences (PLEs) are common in the general population; it has been suggested that such experiences are either variations in normal personality or different expressions of vulnerability to psychotic disorders. The aim of this study was to determine whether different subtypes of PLEs could be identified in a community sample of adolescents and young adults, and to investigate whether particular subtypes of PLEs were more likely to be associated with psychosocial difficulties, i.e. distress, depression and poor functioning, than other subtypes. Method: 1882 students from high schools and universities participated in a cross-sectional multisite survey that measured i) PLEs using the Positive Scale of the Community Assessment of Psychic Experiences (CAPE), ii) depression and distress using the CAPE Depression and Distress Subscales, and iii) functioning using the General Health Questionnaire-12. Factor analysis was conducted to identify any subtypes of PLEs. Results: Four subtypes of PLEs were identified: bizarre experiences (BE), perceptual abnormalities (PA), persecutory ideas (PI) and grandiosity (GR). Intermittent, infrequent psychotic experiences were common, whereas frequent experiences were not. BE and PI were strongly associated with distress, depression and poor functioning. PA and GR were associated with these variables to a lesser degree. Conclusions: Different subtypes of PLEs were identified in this large sample, confirming the findings of our previous studies. These subtypes seem to have different psychopathological meaning and may therefore indicate different levels of risk of severe psychiatric disorders, which suggests it is misleading to define PLEs as a homogenous entity. [Copyright &y& Elsevier]

Objective: Recent years have witnessed widespread interest in the early phase of psychotic disorders. The most widely used approach to identify individuals in the prodromal phase is the ultra-high risk (UHR) approach, which combines known trait and state risk factors for psychotic disorder. The Personal Assessment and Crisis Evaluvation Clinic introduced the Comprehensive Assessment of At Risk Mental States (CAARMS) in order to assess UHR status. A training DVD and manual in the use of the CAARMS was recently developed in order to assist with UHR identification. The current paper reports the outcome of a series of training workshops with mental health professionals based around this DVD. The research aim was to investigate whether the training workshops assisted mental health professionals in their confidence and ability to accurately identify UHR cases and distinguish these from non-UHR and first-episode psychosis (FEP) cases. Method: A total of 137 mental health workers participated in the training sessions across eight training sites. The training sessions consisted of four modules: theoretical background; rating written vignettes for UHR, non-UHR or FEP status; viewing and discussing the CAARMS Training DVD; and re-rating matched written vignettes for UHR, non-UHR or FEP status. Results: Participants' confidence in identifying UHR cases and in using the CAARMS increased as a result of the workshop. Participants' ability to correctly identify UHR-positive cases did not improve as a result of the workshop. This may have been the result of a ceiling effect due to the baseline ability to identify UHR-positive cases being high. But there was a trend for participants' ability to correctly identify UHR-negative cases to improve as a result of the workshop. Conclusions: UHR training workshops are a valuable means of increasing mental health workers' confidence in identifying UHR patients. Future UHR training programmes with experienced mental health professionals should pay particular attention to the correct identification of UHR-negative cases. [ABSTRACT FROM AUTHOR]

Introduction: Two thirds of individuals identified as ultra-high risk (UHR) for psychosis do not transition to psychosis over the medium to long-term (non-transition; UHR-NT). Nevertheless, many of these individuals have persistent attenuated psychotic symptoms (APS). The current study examined whether there were differences in baseline grey matter volume (i.e. at initial identification as UHR) in UHR-NT individuals whom had APS compared to those without APS (No-APS) at medium to long-term follow-up.Methods: Participants were help-seeking individuals who were identified as being at UHR for psychosis between 2 and 12years previously (mean=7.5). The sample consisted of 109 participants who underwent a Magnetic Resonance Imaging scan at baseline and who had not been observed to develop a psychotic disorder over the follow-up period (UHR-NT). Using voxel-based morphometry, baseline grey matter volume (GMV) was compared between participants with (N=30) and without (N=79) APS at follow-up.Results: At baseline, the APS and No-APS groups were clinically indistinguishable. At follow-up, the APS group had significantly worse symptoms and impaired functioning. Individuals with APS had reduced baseline GMV in frontal, temporal, posterior and cingulate regions compared to those without APS at follow-up. Reduced GMV was associated with more severe positive, negative and depressive symptoms and lower global functioning in the combined UHR-NT cohort. These associations were independent of later APS outcome.Discussion: This study found that differences in regional GMV are discernible at an early stage of UHR and may be specific to individuals who have APS and psychopathology at follow-up. Our findings suggest that lower GMV at baseline may confer neurobiological risk for later APS and/or increased psychopathology while the absence of these structural abnormalities might be protective. [ABSTRACT FROM AUTHOR]

Aim: Although the different approaches to psychosis research have made significant advances in their own fields, integration between the approaches is often lacking. This paper attempts to integrate a strand of cognitive research in psychotic disorders (specifically, social cognition research) with phenomenological accounts of schizophrenia and other psychotic disorders. Method: The paper is a critical investigation of phenomenological models of disturbed selfhood in schizophrenia in relation to cognitive theories of social cognition in psychotic disorders. Results: We argue that disturbance of the basic sense of self, as articulated in the phenomenological literature, may underlie the social cognition difficulties present in psychotic disorders. This argument is based on phenomenological thinking about self-presence (‘ipseity’) being the primary or most basic ground for the intentionality of consciousness – that is, the directedness of consciousness towards others and the world. A disruption in this basic ground of conscious life has a reverberating effect through other areas of cognitive and social functioning. We propose three routes whereby self-disturbance may compromise social cognition, including dissimilarity, disruption of lived body and disturbed mental coherence. Conclusions: If this model is supported, then social cognition difficulties may be thought of as a secondary index or marker of the more primary disturbance of self in psychotic disorders. Further empirical work examining the relationship between cognitive and phenomenological variables may be of value in identifying risk markers for psychosis onset, thus contributing to early intervention efforts, as well as in clarifying the essential psychopathological features of schizophrenia and other psychotic disorders. [ABSTRACT FROM AUTHOR]

Abstract: Valid criteria to identify young people who are believed to be at ultra high risk (UHR) of developing a psychotic episode were developed over the last decade. The first randomized controlled trial of treatment in a UHR cohort indicated that specific pharmacotherapy and psychotherapy delayed onset of disorder, and possibly reduced incidence. This paper reports results of follow-up of that trial. 41 of the 59 (69.5%) participants in the original study agreed to follow-up. No differences were found in transition rate, level of symptomatology or functioning between participants who received a combination of psychological treatment and anti-psychotic medication compared to those who received supportive therapy alone. A significant proportion of both treatment groups reported moderate levels of psychiatric morbidity and a continuing need and desire for care at this follow-up. Low levels of hospitalisation were noted for those who did progress to psychosis. Conclusions that can be drawn from this exploratory study are limited by the relatively small number of participants in the original study and the failure to follow-up the entire cohort. Although participants may have been treated too briefly to result in enduring positive effects, there appear to have been some cost savings in inpatient mental health treatment required after the end of the trial for individuals in both treatment groups who developed psychosis. [Copyright &y& Elsevier]

Abstract: Early detection of imminent psychosis allows for the possibility of interventions to prevent onset, or to minimise severity and disability. It also has potential to enhance knowledge of the factors important in the etiology of psychotic illnesses. Neurocognitive deficits are well documented in psychotic illnesses and there is evidence to suggest that such deficits are present in individuals long before they develop the illness. Further, it has been proposed that such impairments may indicate an underlying predisposition to develop psychosis and may thus be described as ‘vulnerability indicators’. This study aimed to investigate the proposed vulnerability indicator of impaired sustained attention in young people thought to be at ultra high-risk of developing psychosis imminently to see whether it would improve the prediction of psychosis in this group. The Continuous Performance Test – Identical Pairs (CPT-IP) version performance of an ultra high-risk group (UHR, N =70) was compared with that of a healthy comparison group (NC, N =51) and a first-episode psychosis group (FEP, N =32). The UHR group exhibited performance deficits compared to the NC group and performed at a level similar to that of the FEP group. However, within the UHR group, those who developed psychosis within the timeframe of the study did not differ from those who did not develop psychosis on their CPT-IP performance. These results support sustained attention as an indicator of vulnerability to psychosis, but suggest that CPT-IP performance does not help to predict transition to psychosis in an ultra high-risk group. [Copyright &y& Elsevier]

Objective : An association between birth and pregnancy complications and the later development of schizophrenia has been described for decades and obstetric complications (OCs) have been proposed as a vulnerability marker for psychosis in line with the neurodevelopmental hypothesis of psychotic disorders. Previous studies of OCs have focused on established schizophrenia. In this study, the association between OCs and the development of psychotic disorder was studied in a group of 74 young people identified as being at very high risk for the first onset of psychosis. Method : The‘ultra’ high risk (UHR) cohort was identified by the presence of subthreshold psychotic symptoms, or a combination of first-degree relative with a psychotic disorder and recent functional decline. Thirty-eight per cent of the cohort developed an acute psychotic episode over the 12-month period after recruitment. As a component of a larger research study, the level of OCs experienced by the UHR cohort was assessed at intake. Results : Obstetric complications were not associated with the later development of psychosis in the UHR group included in this study. Conclusions : This study does not support a role for OCs as a risk factor for the later development of psychosis; however, we cannot conclude that they should be completely ignored as a candidate risk factor for onset of psychosis. A number of weaknesses of the study suggest that it may be premature to dismiss OCs as a risk factor for the development of psychosis and further research is urged in this area. Australian and New Zealand Journal of Psychiatry 2005; 39:460–466 [ABSTRACT FROM AUTHOR]