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Psychosocial disability affects a number of individuals with psychosis and often begins years before the formal onset of disorder. This suggests that for many, their psychosocial disability is enduring, and targeted interventions are therefore needed earlier in their developmental trajectories to ensure that psychosocial disability does not become entrenched. Poor psychosocial functioning also affects individuals with a range of different emerging mental health problems, putting these young people at risk of long-term social marginalisation and economic disadvantage; all of which are known risk factors for the development of psychosis. Identification of the markers of poor psychosocial functioning will help to inform effective treatments. This editorial will discern the early trajectories and markers of poor psychosocial outcome in psychosis, and highlight which individuals are most at risk of having a poor outcome. This editorial will also discuss whether early interventions are currently being targeted appropriately and will propose how intervention and preventative strategies can be implemented, to restore psychosocial trajectories in a way that enables young people to maximise their life chances. [ABSTRACT FROM AUTHOR]

Objective The incidence and outcome of first-episode substance-induced psychotic disorder ( SIPD) are unclear. The study aimed to compare the 1-year outcomes of those given a SIPD diagnosis by clinicians compared to other psychosis diagnoses in a first-episode cohort. Method Data were from a large ( n = 1027) cohort of first-episode psychosis ( FEP) patients admitted to early intervention services in the UK (National EDEN). Diagnosis, including that of SIPD, was made by treating psychiatrists at baseline using ICD10 criteria. Details on symptoms, functioning, quality of life, relapse and recovery were available at baseline and 12 months. Results There were 67 cases of SIPD (6.5% of the cohort). At baseline, SIPD patients were no different to other psychoses on symptoms, functioning and quality of life. At 12 months, there was no difference in SIPD and other psychoses on functioning, quality of life or relapse and recovery rates. Levels of psychotic and general symptomatology were similar but depressive symptoms were higher in the SIPD group. Conclusions First-episode psychosis patients with a diagnosis of SIPD do not appear to have better outcomes than those with other primary psychotic diagnoses. The higher levels of depressive symptoms may be a specific marker in these patients. [ABSTRACT FROM AUTHOR]

BackgroundParanoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).MethodWe used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.ResultsOur sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.ConclusionsThis study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis. [ABSTRACT FROM AUTHOR]

Background Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses. Aims To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months. Method The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis. Results Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months. Conclusions Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the psychometric properties of the EQ-5D and the usefulness of this instrument in psychiatric practice as a measure of health-related quality of life (HRQoL) in a sample of young adults with first-episode psychosis. Methods: The validity of individual questionnaire items is studied using an Item Response/Latent Trait Theory modeling approach. Sensitivity of response patterns on EQ-5D items to particular diagnostic subtypes of psychosis is investigated using a finite mixture modeling approach through latent class analysis. Finally, a structural equation modeling framework is used to study differential item functioning via a multigroup approach. Results: Results suggest that the data closely correspond to the Rasch Rating Scale Model, and therefore that EQ-5D latent scores are equal interval measures. Despite comprising relatively few items, the instrument yields reliable measures of HRQoL for group comparisons and cost-effectiveness evaluation, but EQ-5D score is too imprecise for the assessment of HRQoL for clinical purposes at the individual level. A significant relationship was found between EQ-5D responses and type of psychosis due to inclusion of item anxiety/depression in EQ-5D. Two items ( anxiety/depression, functioning in usual activities) showed an ethnicity bias. Conclusions: Psychometric evidence confirmed the EQ-5D to be a valid, interval measure that is scalable according to Rasch principles. [ABSTRACT FROM AUTHOR]

BackgroundSocial anxiety disorder (SAD) is surprisingly prevalent among people with psychosis and exerts significant impact on social disability. The processes that underlie its development remain unclear. The aim of this study was to investigate the relationship between shame cognitions arising from a stigmatizing psychosis illness and perceived loss of social status in co-morbid SAD in psychosis.MethodThis was a cross-sectional study. A sample of individuals with SAD (with or without psychosis) was compared with a sample with psychosis only and healthy controls on shame proneness, shame cognitions linked to psychosis and perceived social status.ResultsShame proneness (p < 0.01) and loss of social status (p < 0.01) were significantly elevated in those with SAD (with or without psychosis) compared to those with psychosis only and healthy controls. Individuals with psychosis and social anxiety expressed significantly greater levels of shame (p < 0.05), rejection (p < 0.01) and appraisals of entrapment (p < 0.01) linked to their diagnosis and associated stigma, compared to those without social anxiety.ConclusionsThese findings suggest that shame cognitions arising from a stigmatizing illness play a significant role in social anxiety in psychosis. Psychological interventions could be enhanced by taking into consideration these idiosyncratic shame appraisals when addressing symptoms of social anxiety and associated distress in psychosis. Further investigation into the content of shame cognitions and their role in motivating concealment of the stigmatized identity of being ‘ill’ is needed. [ABSTRACT FROM PUBLISHER]

Objective: To investigate the predictive value of the Strauss and Carpenter Prognostic Scale (SCPS) for transition to a first psychotic episode in subjects clinically at high risk (CHR) of psychosis. Method: Two hundred and forty-four CHR subjects participating in the European Prediction of Psychosis Study were assessed with the SCPS, an instrument that has been shown to predict outcome in patients with schizophrenia reliably. Results: At 18-month follow-up, 37 participants had made the transition to psychosis. The SCPS total score was predictive of a first psychotic episode ( P < 0.0001). SCPS items that remained as independent predictors in the Cox proportional hazard model were as follows: most usual quality of useful work in the past year ( P = 0.006), quality of social relations ( P = 0.006), presence of thought disorder, delusions or hallucinations in the past year ( P = 0.001) and reported severity of subjective distress in past month ( P = 0.003). Conclusion: The SCPS could make a valuable contribution to a more accurate prediction of psychosis in CHR subjects as a second-step tool. SCPS items assessing quality of useful work and social relations, positive symptoms and subjective distress have predictive value for transition. Further research should focus on investigating whether targeted early interventions directed at the predictive domains may improve outcomes. [ABSTRACT FROM AUTHOR]

Upthegrove R, Birchwood M, Ross K, Brunett K, McCollum R, Jones L. The evolution of depression and suicidality in first episode psychosis. Objective: To have a clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, whether these events are predictable and how they relate to the early course of psychotic symptoms. Method: Ninety-two patients with first episode psychosis (FEP) completed measures of depression, including prodromal depression, self-harm and duration of untreated psychosis. Follow-up took place over 12 months. Results: Depression occurred in 80% of patients at one or more phases of FEP; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of self-harm. Conclusion: Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking. Efforts to predict and reduce depression and deliberate self-harm in psychosis may need to target this early phase to reduce later risk. [ABSTRACT FROM AUTHOR]

The article presents a study which discusses the use of evidence-based health care in the early intervention in psychosis. It mentions that the research focuses on the early stage of the disorder which identifies the two classes of patients which include those who have an essentially trivial problem and the other who have a hard time coping up with the disease despite treatments. It affirms that the creation of early psychosis models has been a significant factor in the treatment of the disease.

The consequences of psychotic relapse have been found to be damaging to both psychiatric clients and their families, as well as having a detrimental effect on the financial resources of mental health services. As a result of these findings, it is viewed that effective relapse prevention should form an integral component of standard psychiatric care. The prodromal phase of psychosis offers an important window of opportunity for such intervention, and also appears to contain a predictive feature in the progression of an individual's psychosis. The prodromal phase is perhaps best viewed as the emergence of early signs, and signifies the onset of psychotic relapse. A number of techniques have been developed to address the issue of relapse prevention, including pharmacological and cognitive-behavioral therapy (CBT) approaches. However, it is viewed that incorporating patient self-monitoring may result in more effective relapse prevention. The early intervention Back In The Saddle (BITS) approach is based on educating clients about early signs, and helping them to develop skills in self-monitoring. This collaborative therapeutic technique is aimed at constructing a relapse signature, developing a relapse drill, and helping the client to achieve a greater sense of understanding and control over their illness. It is concluded that relapse prevention is vitally important to the recovery process. By involving clients and educating them to use self-monitoring techniques, we can influence the progression of psychosis and the impact it makes upon peoples' lives. Ultimately, it is hoped that effective relapse prevention will reduce hospitalization, and consequentially decrease the financial demands upon mental health trusts. [ABSTRACT FROM AUTHOR]

Background: In paper I we reported that depression in the acute stage remitted in line with the psychosis and that 36% of patients developed post-psychotic depression (PPD).Aims: We apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.Method: Patients with ICD-10 schizophrenia (n=105) were followed up over 12 months following the acute episode, taking measures of depression, working self-concept, cognitive vulnerability, insight and appraisals of psychosis.Results: Before developing PPD, these patients felt greater loss, humiliation and entrapment by their illness than those who relapsed or did not become depressed, and were more likely to see their future selves in 'lower status' roles. Upon becoming depressed, participants developed greater insight, lower self-esteem and a worsening of their appraisals of psychosis.Conclusions: Depression in psychosis arises from the individual's appraisal of psychosis and its implications for his/her perceived social identity, position and 'group fit'. Patients developing PPD feel forced to accept a subordinate role without opportunity for escape. Implications for treatment are discussed. [ABSTRACT FROM AUTHOR]

Background: This paper describes the 5-year outcome of a cohort of patients who had received a cognitive therapy intervention during an acute episode of non-affective psychosis.Method: Thirty-four out of the original 40 patients who had taken part in a randomised controlled trial of a cognitive intervention were assessed, using standardised instruments completed at entry into the study. In the original trial, half the patients received a cognitive therapy programme (CT group) and the other half received recreational activities and support (ATY group).Results: At follow-up no significant differences in relapse rate, positive symptoms or insight between the groups were found, although the CT group did show significantly greater perceived 'Control over illness' than the ATY group. For individuals who had experienced a maximum of one relapse in the follow-up period, self-reported residual delusional beliefs and observer-rated hallucinations and delusions were significantly less in the CT than in the ATY group.Conclusion: Cognitive therapy applied in the acute phase of a psychotic disorder can produce enduring and significant clinical benefits if experience of relapse can be minimised. [ABSTRACT FROM AUTHOR]

The article proposes three key elements of an early therapeutic strategy for patients with schizophrenia. These elements include early detection of at-risk or prodromal mental states, early treatment of the first psychotic episode and interventions targeted during the early phase of psychosis. The following are the three elements of intervention of early psychosis: relapse prevention, psychosocial recovery and treatment resistance.

Background: A trial of CT in acute psychosis conducted by the authors has shown a significant impact on the rate and degree of recovery of positive symptoms, the focus of the intervention. This paper seeks to determine whether these effects generalise to other features of acute psychosis including dysphoria, insight and "low level' psychotic thinking which were not directly targeted.Method: Measures of dysphoria, insight and psychotic thinking were taken over a six-month period following presentation for acute psychosis. Using survival analysis, time to recovery from psychosis using three definitions of increasing stringency was compared between the CT and control group.Results: CT was associated with a 25-50% reduction in recovery time depending on the definition used.Conclusion: The impact of the CT intervention extended beyond positive symptoms to include insight, dysphoria and "low level' psychotic thinking. Nevertheless this kind of "clinical' recovery required a median of 20 weeks to complete. Implications for clinical models of acute care are discussed. [ABSTRACT FROM AUTHOR]

Background: The application of cognitive therapy (CT) to psychosis is currently being developed in the UK. This paper reports a trial of CT in acute psychosis with the objective of hastening the resolution of positive symptoms and reducing residual symptoms.Method: Of 117 patients with acute non-affective psychosis, 69 satisfied inclusion criteria and 40 proceeded to stratified randomisation. The experimental intervention involving individual and group CT was compared with a group receiving matched hours of therapist input providing structured activities and informal support; routine pharmacotherapy was provided by clinicians blind to group allocation. Patients were monitored weekly using self-report and mental state assessments during admission and over the subsequent nine months.Results: Both groups showed a decline in positive symptoms but this was more marked in the CT group (P < 0.001). At 9 months 5% of the CT group, v.56% of the control group, showed moderate or severe residual symptoms.Conclusion: CT appears to be a potent adjunct to pharmacotherapy and standard care for acute psychosis. Issues concerning internal and external validity of the study and opportunities for further research are discussed. [ABSTRACT FROM AUTHOR]

We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations. [ABSTRACT FROM AUTHOR]

"This paper reviews the recent empirical studies on psychosocial family intervention in schizophrenia. Six family educational intervention studies and five more intensive family work studies with 2-year follow-up have been included. A series of questions is asked relating to the effects of such interventions, the efficacy of the different educational models, the active ingredients of these multi-component treatment packages, and the contribution of this new generation of studies to our understanding of the mechanisms through which these interventions work. Suggestions for further research are made. Finally, from the published manuals, the common components of these diverse, multi-component treatment packages of different family-intervention studies are identified." [ABSTRACT FROM AUTHOR]

A response by M. Birchwood to the letter to the editor about his article on intervention in psychosis in the previous issue is presented.

A clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, and how this relates to other symptom dimensions, is essential for developing interventions to reduce risk. The studies presented here investigate whether depression and suicidal thinking are predictable, how they relate to the early course of psychotic symptoms and develop over time. 92 patients with first episode psychosis recruited from the Birmingham Early Intervention Service completed measures of depression, including an prodromal depression, psotove and negative symptoms, self-harm, duration of untreated psychosis, insight and illness appraisals. Follow up took place over 12 months. Depression occurred in 80% of patients at one or more phase of illness; a combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of selfharm. Post psychotic depression unheralded by previous depressive episodes was rare. Depression and suicidal thinking in the acute and post psychotic phases is associated with higher levels of loss and shame, and subordination to persecutors and malevolent voices. Depression early in the emergence of a psychosis is fundamental to the development of future depression and suicidal thinking, and related to the personal significance and impact of positive symptom dimensions. Efforts to predict and reduce depression and self-harm in psychosis may need to target this early phase to reduce later risk. [Copyright &y& Elsevier]

EPOS presented a unique opportunity to document all ''treatments as usual'' offered and received in the participating centres to help-seeking patients who fulfilled criteria for UHR status. The EPOS centres were drawn from very different healthcare systems, employing different treatment concepts and using different methods of ascertainment. EPOS ascertained n=245 UHR patients who were then followed up at 9 and 18 months, taking repeat measures of prodromal symptoms (SIPS), PANSS and depression. In this paper I will describe the different treatments offered in each EPOS centre and the impact of each treatment class on the course of symptoms over time, including ‘transition’ to psychosis. These data will have important bearing on the misnomer of the ‘false positive’ in high risk research and on the other risks and outcomes linked to the UHR/PACE paradigm and their treatment. [Copyright &y& Elsevier]

Aim: Evidence from long-term follow-up studies of schizophrenia and from the ‘new epidemiology’ of psychoses has forced us to rewrite the textbooks and challenge accepted wisdom. In this paper I aim to review the concept of my ‘Critical Period’ in the long-term trajectory of schizophrenia. Method: I will review long-term follow-up studies of first episode psychosis. Results: Studies suggest that: [a.] the course of the psychoses is very variable; [b.] much of this variability is laid down during the ‘prodromal’ and first 3 - 5 years following the first episode; [c.] the ‘disability’ plateaus quickly, much of it occuring before the positive symptoms develop (the ‘symptom-disability gap’) but [d.] the psychosocial and ecological risk factors that have now been uncovered, suggest a more protean, malleable process in the development of psychosis, as witnessed, for example by the considerable number of ‘at risk’ individuals with low-level, but disabling psychotic symptoms, who escape psychosis (the misnomer of the ‘false positive’). Conclusion: This picture presents a fresh take on my concept of the ‘critical period’ with implications for public health and prevention. [Copyright &y& Elsevier]

Using the lessons gained from implementing the St Vincent Declaration for Diabetes (1990), this declaration details general goals, 5 years targets, performance and outcome measures for the detection and management of early psychosis. Its successful implementation requires integrated partnerships working locally, nationally and internationally to: [ABSTRACT FROM AUTHOR]

Purpose In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment. Methods In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed. Results During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model. Conclusion A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Schizotypal features indicate proneness to psychosis in the general population. It is also possible that they increase transition to psychosis (TTP) among clinical high-risk patients (CHR). Our aim was to investigate whether schizotypal features predict TTP in CHR patients. Methods: In the EPOS (European Prediction of Psychosis Study) project, 245 young help-seeking CHR patients were prospectively followed for 18 months and their TTP was identified. At baseline, subjects were assessed with the Schizotypal Personality Questionnaire (SPQ). Associations between SPQ items and its subscales with the TTP were analysed in Cox regression analysis. Results: The SPQ subscales and items describing ideas of reference and lack of close interpersonal relationships were found to correlate significantly with TTP. The co-occurrence of these features doubled the risk of TTP. Conclusions: Presence of ideas of reference and lack of close interpersonal relations increase the risk of full-blown psychosis among CHR patients. This co-occurrence makes the risk of psychosis very high. [Copyright &y& Elsevier]

Background: Despite remission being the primary objective following the first episode of schizophrenia, clinically stabilised patients are rarely studied. Aims: To assess the extent and fluctuation of low-level positive symptoms in patients who are in remission following their first episode of schizophrenia, and consider whether symptoms displayed are similar to those exhibited in the prodromal population. Methods: Eleven patients who had recovered for at least six months following one episode of schizophrenia and subsequently fulfilled remission criteria were interviewed four times over the course of three months. Interviews were based on the Structured Interview of Prodromal Symptoms (SIPS), an in-depth assessment of low-level symptoms that is widely used in the prodromal group. Data was compared to equivalent results from the prodromal population (with data provided by the local ED:IT service). Results: Over the course of the interviews 73% of participants displayed attenuated positive symptoms, predominantly unusual thought content and suspiciousness. 18% experienced brief limited intermittent psychotic symptoms (BLIPS). Analysis with Friedman''s test revealed no significant fluctuation in positive symptoms, indicating that they are stable over time. Furthermore, the symptoms exhibited in the sample were closely comparable to those in the prodromal group in the ED:IT service. Conclusions: The majority of patients in remission are experiencing a form of ‘postdrome’, which appears to be an enduring state. The presence of these symptoms may put patients at an increased risk of relapse. Larger-scale research is required to follow-up this novel preliminary study. Declaration of interest: None. [Copyright &y& Elsevier]

Introduction The link between depression and paranoia has long been discussed in the psychiatric literature. Because this association is difficult to study in patients with full-blown psychosis, we investigated clinical high-risk (CHR) patients. Objective To clarify the causal connection between depression and paranoia. Aims To investigate how clinical depression relates to presence and new occurrence of paranoid symptoms in CHR patients. Methods Altogether, 245 young help-seeking CHR patients were assessed for suspiciousness/paranoid symptoms with the Structured Interview for Prodromal Syndromes at baseline, 9-month and 18-month follow-up. At baseline, clinical diagnoses were assessed by the Structured Clinical Interview for DSM-IV, childhood stressful experiences by the Trauma and Distress Scale, trait of suspiciousness by the Schizotypal Personality Questionnaire, and anxiety and depressive symptoms by the Positive and Negative Syndrome Scale. Results At baseline, 54.3 % of CHR patients reported at least moderate paranoid symptoms. At 9- and 18-month follow-ups, the corresponding figures were 28.3 % and 24.4 %. Depressive disorder, sexual abuse and anxiety symptoms associated with paranoid symptoms. Depressive, obsessive-compulsive and somatoform disorders, sexual abuse, and anxiety predicted occurrence of paranoid symptoms. Conclusion Depressive disorder is one of the major clinical factors associating with and predicting paranoid symptoms in CHR patients; also childhood sexual abuse and anxiety symptoms associate with paranoia. In addition, obsessive-compulsive and somatoform disorders seem to predict paranoid symptoms. Low self-esteem may be a common mediator between affective disorders and paranoia. Effective treatment of these disorders may alleviate paranoid symptoms and improve interpersonal functioning in CHR patients. [ABSTRACT FROM AUTHOR]

Introduction: Depressive and anxiety disorders are the most common clinical diagnoses in patients at clinical high-risk (CHR) of psychosis (1). Objectives: Clinical disorders and functioning in CHR patients. Aims: To study how depressive and anxiety disorders associate with patients’ functioning at baseline and follow-ups in CHR patients. Methods: In the EPOS project, 245 young help-seeking CHR patients were examined, and their baseline diagnoses were assessed by the SCID-I. The patients were interviewed with the SIPS/SOPS, including assessments of positive and negative symptoms and the Global Assessment of Function (GAF), at baseline and at 9 and 18 months follow-ups. Results: At baseline and follow-ups, the patients without depressive or anxiety disorders had highest GAF scores. At baseline, the patients with depressive disorders had lower GAF scores than the patients with anxiety disorders. At follow-ups, there were no differences in GAF scores between the patients with depressive or anxiety disorders. In modelling, negative symptoms associated with low GAF scores at baseline and follow-ups, positive symptoms only at baseline and anxiety disorders at 18 months follow-up. Conclusions: Depressive and anxiety disorders associate with poor functional outcome, and require thus special attention when intervention for the CHR patients is carried out. Positive symptoms predict transition to psychosis (2), but their role in predicting functional outcome is not as great. Instead, negative symptoms associate with poor functional outcome and require intensive intervention. [(1)] Salokangas RKR et al. Schizophr Res 2012, doi:10.1016/j.schres.2012.03.008. [(2)] Ruhrmann S et al. Arch Gen Psychiatry 2010;67:241-251. [Copyright &y& Elsevier]

The ultra-high risk state of developing a psychosis is mainly characterized by attenuated or transient full-blown psychotic symptoms. It can be assessed with the structured interview for prodromal symptoms (SIPS), comprising four domains: positive, negative, disorganization and general symptoms. As the scores of the SOPS sub-domains are regularly used to perform domain-related analyses the stability of the suggested domain structure and item composition is of major interest. Method: SIPS (version 3.0) data from n=243 participants of the European Prediction of Psychosis Study (EPOS) were used for the current analysis. Inclusion criteria comprised ultra-high risk criteria and the basic symptom criterion COGDIS. The EPOS investigators received extensive training by one of the scale''s authors (Tandy J. Miller, PhD). Pairwise interrater concordance for SIPS was 77%, which was determined acceptable by the training team. A principal component analysis was performed (Eigenvalues > 1, varimax rotation). Results: A five factor solution emerged. Factor 1 was primarily defined by a loss of intentionality, functioning and stress tolerance, factor 2 by anhedonia and affective blunting, factor 3 by cognitive and behavioural disorganization, factor 4 by delusions. Sleep disturbances and perceptual abnormalities/hallucinations have both been associated with dopaminergic disturbances, this may explain their common appearance on factor 5. Discussion: The originally suggested structure of the SIPS proofed not to be stable and was replaced by a five-factor solution. Our results suggest considering a different item and factor structure in future SIPS based data analyses. [Copyright &y& Elsevier]

Background: Ultra-high risk (UHR) criteria are defined by attenuated and/or transient full-blown psychotic symptoms and/or a combination of genetic risk factor and deterioration of functioning. To achieve a higher predictive specificity and a clear threshold of clinical importance, functional impairment has been considered as an obligate part of all UHR criteria. Method: In the European Prediction of Psychosis Study (EPOS)N=37 participants converted to psychosis, n=146 completed the whole 18-month follow-up period without conversion. Assessed by the Global Assessment of Functioning Scale, modified version (GAF-M), the following functional states were considered: Considered GAF-M: ≤30%/≤10% reduction of baseline scores related to highest scores in the previous year; scores ≤70/≤60. Results: The GAF reduction criteria led to a very unfavorable loss of sensitivity, even, if only 10% were demanded. This was accompanied by correspondingly unfavorable accuracy measures. Introducing functional impairment criteria defined by the current state reported to be predictive for psychiatric caseness (score ≤ 70) or to define serious impairment (score ≤ 60) (Kessler et al., 2002, 2003) kept sensitivity at a perfectly high level, yet did not produce any gain of specificity. Discussion: These results were certainly be caused by the fact that the whole group showed already low GAF-M scores in the previous year. Thus, a functional impairment criterion proved not to be useful to improve prediction. However, a combination of APS or BLIPS with a ‘clinical status’ criterion of GAF-M ≤ 70 may be considerable to demonstrate a strong need for intervention. [ABSTRACT FROM AUTHOR]

Introduction: A considerable number of patients at clinical high risk of psychosis (CHR) are found to meet criteria for co-morbid clinical psychiatric disorders. Objectives: It is not known how clinical diagnoses correspond to transitions to psychosis (TTP). Aims: We aimed to examine distributions of life-time and current Axis I diagnoses, and their association with TTP in CHR patients. Methods: In the European Prediction of Psychosis Study project, 245 young help-seeking CHR patients were examined, and their baseline and life-time diagnoses were assessed by the Structured Clinical Interview for DSM-IV (SCID-I). TTP was defined by continuation of BLIPS for more than seven days. Results: Altogether, 71 % of the CHR patients had one or more life-time and 62 % one or more current SCID-I diagnosis; about a half in each category received a diagnosis of life-time depressive and anxiety disorder. Currently, 34 % suffered from depressive, 39 % from anxiety disorder, 4 % from bipolar and 6.5 % from somatoform disorder. During follow-up, 37 (15.1 %) TTPs were identified. In multivariate Cox regression analyses, current bipolar disorder, somatoform and unipolar depressive disorders associated positively, and anxiety disorders negatively, with TTP. Conclusions: Both life-time and current mood and anxiety disorders are highly prevalent among help-seeking CHR patients and need to be carefully evaluated. Among them, occurrence of bipolar, somatoform and depressive disorders seem to predict TTP, while anxiety disorder may predict non-transition to psychosis. Treatment of bipolar, somatoform and depressive disorders may prevent CHR patients from developing full-blown psychotic disorders. [ABSTRACT FROM AUTHOR]

Introduction: Research on at-risk states of psychosis has mainly aimed to predict conversion. Yet as a considerable number of patients does not to progress to this outcome during the investigated observation periods, the course of these non-converters (NC) is of major interest, particularly with regard to preventive interventions and treatment. Aims: To analyze the psychopathological and functional in 18-month non-converters. Methods: Data were derived from the prospective multicenter European Prediction of Psychosis Study with an 18-month follow-up period. Participants had to fulfill ultra-high risk criteria and/or the COGDIS criterion, which is based on a set of cognitive basic symptoms. Psychopathology was assessed with the Structure Interview for Prodromal Syndromes (SIPS), including the Global Assessment of Functioning Scale (GAF) and a short version of the Schizophrenia Proneness Instrument (SPI-A). Results: All total and subscale scores improved significantly during follow-up. However, a more detailed analysis revealed that a considerable part of the patients showed no improvement or even a worsening of psychopathology and function. Conclusions: Our first analysis of course on non-converters shows that a high proportion of patients improved. In the light of results from retrospective studies, however, this improvement has to be interpreted with caution, as the observation period does not allow to determine the proportion of outpost syndromes, i.e. precursors of a later prodrome. Furthermore, a considerable portion of our sample worsened functionally and/or symptomatically. With regard to retrospective schizophrenia related results, very long observation periods may be needed to characterize the patterns of course in subpsychotic syndromes. [ABSTRACT FROM AUTHOR]