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 asses...

Mapping the onset of psychosis: the Comprehensive Assessment of At-Risk Mental States

As the number of studies related to the early identification of and intervention in the schizophrenia prodrome continues to grow, it becomes increasingly critical to develop methods to diagnose this new clinical entity with validity. Furthermore, given the low incidence of patients and the need for multisite collaboration, diagnostic and symptom severity reliability is also crucial. This article provides further data on these psychometric parameters for the prodromal assessment instruments developed by the Prevention through Risk Identification, Management, and Education (PRIME) prodromal research team at Yale University: the Structured Interview for Prodromal Syndromes and the Scale of Prodromal Symptoms. It also presents data suggesting that excellent interrater reliability can be established for diagnosis in a day-and-a-half-long training workshop.

https://cdr.lib.unc.edu/downloads/b5644t84j

Prodromal Assessment With the Structured Interview for Prodromal Syndromes and the Scale of Prodromal Symptoms: Predictive Validity, Interrater Reliability, and Training to Reliability

Context Early detection and prospective evaluation of individuals who will develop schizophrenia or other psychotic disorders are critical to efforts to isolate mechanisms underlying psychosis onset and to the testing of preventive interventions, but existing risk prediction approaches have achieved only modest predictive accuracy. Objectives To determine the risk of conversion to psychosis and to evaluate a set of prediction algorithms maximizing positive predictive power in a clinical high-risk sample. Design, Setting, and Participants Longitudinal study with a 2½-year follow-up of 291 prospectively identified treatment-seeking patients meeting Structured Interview for Prodromal Syndromes criteria. The patients were recruited and underwent evaluation across 8 clinical research centers as part of the North American Prodrome Longitudinal Study. Main Outcome Measure Time to conversion to a fully psychotic form of mental illness. Results The risk of conversion to psychosis was 35%, with a decelerating rate of transition during the 2½-year follow-up. Five features assessed at baseline contributed uniquely to the prediction of psychosis: a genetic risk for schizophrenia with recent deterioration in functioning, higher levels of unusual thought content, higher levels of suspicion/paranoia, greater social impairment, and a history of substance abuse. Prediction algorithms combining 2 or 3 of these variables resulted in dramatic increases in positive predictive power (ie, 68%-80%) compared with the prodromal criteria alone. Conclusions These findings demonstrate that prospective ascertainment of individuals at risk for psychosis is feasible, with a level of predictive accuracy comparable to that in other areas of preventive medicine. They provide a benchmark for the rate and shape of the psychosis risk function against which standardized preventive intervention programs can be compared.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/482556/yoa70062_28_37.pdf

Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America.

Context During the past 2 decades, a major transition in the clinical characterization of psychotic disorders has occurred. The construct of a clinical high-risk (HR) state for psychosis has evolved to capture the prepsychotic phase, describing people presenting with potentially prodromal symptoms. The importance of this HR state has been increasingly recognized to such an extent that a new syndrome is being considered as a diagnostic category in the DSM-5. Objective To reframe the HR state in a comprehensive state-of-the-art review on the progress that has been made while also recognizing the challenges that remain. Data Sources Available HR research of the past 20 years from PubMed, books, meetings, abstracts, and international conferences. Study Selection and Data Extraction Critical review of HR studies addressing historical development, inclusion criteria, epidemiologic research, transition criteria, outcomes, clinical and functional characteristics, neurocognition, neuroimaging, predictors of psychosis development, treatment trials, socioeconomic aspects, nosography, and future challenges in the field. Data Synthesis Relevant articles retrieved in the literature search were discussed by a large group of leading worldwide experts in the field. The core results are presented after consensus and are summarized in illustrative tables and figures. Conclusions The relatively new field of HR research in psychosis is exciting. It has the potential to shed light on the development of major psychotic disorders and to alter their course. It also provides a rationale for service provision to those in need of help who could not previously access it and the possibility of changing trajectories for those with vulnerability to psychotic illnesses.

The Psychosis High-Risk State: A Comprehensive State-of-the-Art Review

Objectives The Brief Pain Inventory (BPI) is a short, self-administered questionnaire that was developed for use in cancer patients. While most empirical research with the BPI has been in pain of that etiology, the questionnaire is increasingly evident in published studies of patients with non-cancer pain. The current research addresses the need for formal evaluation of the reliability and validity of the BPI for use in non-cancer pain patients. Methods Approximately 250 patients with arthritis or low back pain (LBP) self-administered a number of generic and condition-specific health status measures (including the BPI) in the clinic of their primary care provider at 2 time points: the initial clinic visit and the first visit following treatment. Results The reliability of BPI data collected from non-cancer pain patients was comparable to that reported in the literature for cancer patients and sufficient for group-level analyses (coefficient alphas were greater than 0.70). The factor structure of the BPI was replicated in this sample and the relationship of the BPI to generic measures of pain was strong. The BPI exhibited similar relationships to general and condition-specific measures of health as did a generic pain scale (SF-36 Bodily Pain). Finally, the BPI discriminated among levels of condition severity and was sensitive to change in condition over time in arthritis and LBP patients. Discussion Results support the validity of the BPI as a measure of pain in patients without cancer and, in particular, as a measure of pain for arthritis and LBP patients.

Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain.

OBJECTIVE: This study was conducted to determine the interrater reliability and predictive validity of a set of diagnostic criteria for the prodrome of the first episode of schizophrenic psychosis when based on the Structured Interview for Prodromal Syndromes. METHOD: The subjects were patients referred for evaluation because of a suspected schizophrenia prodromal syndrome. For the reliability study, two to four raters independently diagnosed 18 patients on the basis of face-to-face or videotaped interviews. For the validity study, 6- and 12-month outcome data were collected for 29 patients. RESULTS: Agreement in differentiating prodromal from nonprodromal patients was 93%. The prodromal features had converted to schizophrenic psychosis for 46% of the prodromal patients at 6 months and for 54% at 12 months. CONCLUSIONS: In small groups of subjects, these diagnostic criteria for the schizophrenic prodrome and the Structured Interview for Prodromal Syndromes showed promising interrater reliability and predi...

/pdf/prospective-diagnosis-of-the-initial-prodrome-for-1xzws4drpg.pdf

Prospective Diagnosis of the Initial Prodrome for Schizophrenia Based on the Structured Interview for Prodromal Syndromes: Preliminary Evidence of Interrater Reliability and Predictive Validity

Individuals who develop schizophrenia often suffer long standing deficits All too often available treatments remain palliative and do not improve the long-term course of illness The neurobiological deficits associated with the onset of schizophrenia may be most active and damaging in the early stages of this life long illness, a fact which has shifted the focus of research and clinical work toward the early or prodromal stages of this disorder Results from limited studies suggest that early intervention may lead to a better prognosis Early interventions that could delay or prevent the onset of psychotic illnesses have obvious public health implications and rely on being able to identify true prodromal patients The Structured Interview for Prodromal Symptoms and the Scale of Prodromal Symptoms are assessment instruments developed for operationally defining diagnosis and for quantitatively rating symptom severity for patients prodromal for psychosis

Symptom assessment in schizophrenic prodromal states.

Objective: As physician-assisted suicide is debated, a need for standardized measurement of desire for death among medically ill individuals has emerged. The authors present preliminary validation data for a new self-report instrument, the Schedule of Attitudes Toward Hastened Death. Method: The participants were 195 patients with HIV/AIDS from two sites: 148 ambulatory patients and 47 patients who had been recently admitted to a facility for end-of-life care. The ambulatory participants completed the 20-item Schedule of Attitudes Toward Hastened Death and several other instruments, including the Beck Depression Inventory and Brief Symptom Inventory. The terminally ill patients also completed the Schedule of Attitudes Toward Hastened Death, along with other measures, and were assessed by clinicians with the Hamilton Depression Rating Scale and the Desire for Death Rating Scale, a global clinician rating of the patient’s desire for death. Results: The Schedule of Attitudes Toward Hastened Death demonstrated high reliability. The total score significantly correlated with the clinician rating on the Desire for Death Rating Scale and with ratings of depression and psychological distress. In addition, the Schedule of Attitudes Toward Hastened Death score significantly correlated with pain intensity and physical symptom distress. Factor analysis supported a single factor structure for the instrument. Conclusions: These results indicate that the Schedule of Attitudes Toward Hastened Death is a reliable, valid measure of desire for death among patients with HIV/AIDS. Further research with this measure may help address many of the unanswered questions emerging from the ongoing debates regarding legalization of assisted suicide. (Am J Psychiatry 1999; 156:94‐100)

https://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.156.1.94

Measuring desire for death among patients with HIV/AIDS: the schedule of attitudes toward hastened death

Concerns are often raised regarding the credibility of patients' report of pain and this concern is heightened among individuals with AIDS, where many patients have a history of injection drug use This study compared the pain experience, adequacy of pain management and psychological well-being among patients with AIDS who reported a history of injection drug use (IDU) as their HIV transmission risk factor and patients with other HIV transmission risk factors Five hundred and sixteen ambulatory AIDS patients participating in a quality of life study completed a series of self-report instruments including the Brief Pain Inventory, the Beck Depression Inventory, the Brief Symptom Inventory, the Functional Living Inventory and the Social Support Questionnaire Results demonstrated that IDU and non-IDU subjects did not differ significantly in their report of pain prevalence, pain intensity or pain-related functional interference However, IDU patients were significantly more likely to receive inadequate analgesic medications, reported lower levels of pain relief and a greater degree of psychological distress There was also no difference in report of pain intensity, pain relief or functional interference among patients who acknowledged continued drug use, those who denied any recent drug use and patients participating in a methadone maintenance program These data support the validity of AIDS patients' report of pain, at least in research settings, and suggest that undertreatment of pain is not restricted to patients who actively abuse drugs

Kelly Stein

Papers

Prospective Diagnosis of the Initial Prodrome for Schizophrenia Based on the Structured Interview for Prodromal Syndromes: Preliminary Evidence of Interrater Reliability and Predictive Validity

Symptom assessment in schizophrenic prodromal states.

Measuring desire for death among patients with HIV/AIDS: the schedule of attitudes toward hastened death

A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse

Structured Interview for Prodromal Symptoms