K. Maurer’s research while affiliated with Central Institute of Mental Health and other places

Aim: Validation of Van Kampen's Schizotypic Syndrome Questionnaire (SSQ) model of schizophrenic pro-dromal unfolding. The SSQ model comprises 12 negative, asocial and psychotic-like symptoms that are hypothesized to determine each other in terms of cause and effect. Method: Use was made of the Interview for the Retrospective Assessment of the Onset of Schizo-phrenia (IRAOS)-dependent retrospective data assembled in the Mannheim Age-Beginning-Course Study sample of first-episode schizophrenic patients to measure the SSQ symptoms. Both the mean positions of the IRAOS-assessed symptoms on a continuum representing the proportion of total time of pre-psychotic disturbance and the outcome of a series of LISREL analyses conducted on the IRAOS-dependent data were addressed. Results: Both kinds of data supported the validity of the SSQ model; however, this was after introducing some (rela-tively minor or demonstrable ineffective) changes in the model as the 'translation' of the SSQ symptoms by means of the IRAOS was not always easy, or proved even impossible in the case of one symptom. Conclusions: The conclusion seems warranted that the present investigation supports the validity of the SSQ model as a model of pre-psychotic and prodromal unfolding in patients diagnosed as suffering from schizo-phrenia. From a theoretical perspective , arguments are presented to interpret the SSQ model as a model of the core or principal symptoms of schizophrenia, including their temporal unfolding.

Aim: Psychological interventions, such as cognitive behavioural therapy (CBT) and supportive counselling (SC), are used to treat people with schizophrenia and people at clinical high risk (CHR) of psychosis. However, little information is available on predictors of treatment response. This study aims to identify such predictors of psychological interventions in CHR. Methods: A total of 128 help-seeking CHR outpatients were randomized into two groups-integrated psychological intervention (IPI), including CBT, and SC-for 12 months. Multiple regression analysis was used to identify demographic, symptomatic and functional variables that predict improvement in positive (PANSS Positive), negative (PANSS Negative) and basic symptoms (Basic symptom total score) and improvement in functioning (GAF) at 1-year follow up. Results: In the merged group (IPI + SC), people who lived independently, were younger and presented with higher baseline functioning showed more improvement in symptomatic outcomes at follow up. Negative symptoms at baseline predicted less improvement in positive and basic symptoms. Being married or cohabiting and living in the primary family were found to correlate with good functioning at 1-year follow up. Conclusions: Younger CHR individuals and those who are functioning well may particularly benefit from early intervention. Treatment might need to be modified for low-functioning CHR and those who already display higher scores of negative symptoms. Registration number: NCT00204087.

Aim: Functional disability and social consequences frequently occur at the prodromal stage of schizophrenia. Efforts to recognize an increasing risk of psychosis onset have thus become a topical issue worldwide. This is to introduce the English version of the ERIraos early-recognition inventory. Methods: The ERIraos, developed in a systematic, empirical approach from the Instrument for the Retrospective Assessment of the Onset of Schizophrenia, incorporates basic symptoms from the Cologne Early Recognition Study. The research version also includes as further predictive items so-called brief limited intermittent psychotic symptoms and attenuated psychotic symptoms from the Comprehensive Assessment of At-Risk Mental States instrument. Results: The ERIraos with its 15-item screening Checklist and 50-item Symptom List permits early recognition of psychosis risk in three steps of decreasing sensitivity and increasing specificity. Step 1 relies on patients' self-perception of symptoms, which prompt them to contact a primary health service. There, in Step 2, at-risk individuals are identified using the Checklist, characterized by a low-risk threshold, and referred to further examination using the Symptom List (Step 3). Information on symptom accumulation and increasing symptom severity enhances the instrument's predictive power. In a validation test, psychotic transitions increased linearly up to 50% over 2 years. Compared with other instruments and on the prodromal stage of depressive disorder, the ERIraos has shown good predictive capacity. Conclusions: The ERIraos has been successfully employed as a two-step tool for the early recognition of psychosis risk in several German studies and translated into several foreign languages.

Investigate whether treatment response in people at clinical high risk of psychosis (CHR) is predicted by their cognitive performance. 128 CHR outpatients were randomized into two treatment groups, one receiving integrated psychological intervention (IPI), including psychoeducation, the other receiving supportive counselling (SC) for 12 months. Multiple regression analysis was used to identify neurocognitive predictors of treatment response in a subgroup of n = 105, measured by symptomatic and functional improvement at 1-year follow-up. In the IPI, treatment response was associated with performance of executive control and processing speed (R² = 0.27, p = 0.002). In both treatment groups, performance of working memory/attention was a significant predictor (IPI: R² = 0.15, p = 0.039, SC: R² = 0.19, p = 0.012). Cognitive performance is associated with treatment response in CHR people. The enhancement of cognitive performance is a useful target of early intervention. © Georg Thieme Verlag KG Stuttgart · New York.

The ERIraos Checklist (CL) is a screening instrument for assessing psychosis risk. Measuring CL data on a Rasch scale means that this scale locates individuals on a dimension of “proximity to psychosis onset” according to their current prodromal status. The probabilistic Rasch model leads to interval (difference) scales. The CL data from the German Research Network on Schizophrenia (GRNS) study were analyzed using the Rasch program Winsteps. All item measures based on data from different patient groups were consistent with the Rasch model. Examples demonstrate how item parameters were comparable in different subgroups and in patients in the early and late prodrome. The CL is a simple assessment tool fulfilling the requirements of a Rasch scale. This guarantees good psychometric properties, such as a high reliability and internal validity, and yields a measure of the construct “proximity to psychosis onset” on a difference scale.

Objectives: Screening questionnaires are often used at first-contact with psychiatric services to identify, among those displaying psychological distress, those who need more in-depth assessment. The Early Recognition Inventory for the retrospective assessment of the Onset of Schizophrenia Checklist (ERIraos-CL) may be a useful tool to prompt further screenings in young help-seekers, who are experiencing symptoms that are compatible with a prodromic state of psychosis. This study describes the psychometric proprieties of the Italian version of ERIraos-CL in high risk and early onset populations. Materials and methods: The study was carried out as part of Programma2000 in Milan (Italy). Participants were 113 individuals with a diagnosis of First Episode Psychosis (FEP) and 97 individuals with a diagnosis of high-risk psychosis (UHR). The ERIraos-CL reliability was measured by internal consistency (Cronbach alpha) and by test-retest stability after 6 months (intraclass correlation coefficient). The concurrent validity of ERIraos-CL was assessed by correlation with the Brief Psychiatric Rating Scale (BPRS) and with the Health of the Nation Outcome Scales (HoNOS). The discriminant validity of this tool was assessed by comparing scores between FEP and URP with threshold at 10, which is slightly less than the threshold that discriminates between at risk cases and non-cases (12). Results: Internal consistency was good for all the scales in both samples, with low values for ERIraos-CL. Retest stability after 6 months of ERIraos-CL was acceptable (> 0.70) in both diagnostic groups. In both groups, ERIraos-CL correlated positively with HoNOS and BPRS. ERIraos-CL discriminates effectively between FEP and UHR. The two groups differ statistically by symptoms that qualify for the presence of an active episode of psychosis: suspiciousness/distrust, ideas of self-reference, changes in perception, paranoid ideation and hallucinations. Conclusions: The Italian version of the ERIraos-CL has good psychometric properties that make it suitable for routine use as a scale for the identification of the cases that might benefit from a more in-depth assessment of the risk of psychosis.

The underlying structures of clinical caseness and need of care in prodromal (i.e., at-risk) and early phases of schizophrenia remain poorly characterized in their essential psycho-behavioral coherence. To identify the schizophrenia proneness-related subtypes within a population of young help-seekers referred to a dedicated, community-based early detection program (Programma 2000). A sample of consecutive referrals (n = 168) for suspected psychosis or first-episode schizophrenia spectrum psychosis received a detailed clinical assessment, including the early recognition inventory for the retrospective assessment of the onset of schizophrenia checklist. We used exploratory factor analysis (EFA) to determine the underlying dimensional structure and latent class analysis (LCA) to identify putative vulnerability subtypes. EFA identified four factors: dysphoria (irritability tension), paranoid autocentrism, introversive withdrawal, and disturbed subjective experience. LCA distinguished three classes, interpretable as carrying different degrees of "proneness to schizophrenia psychosis," which best captured the underlying continuum of clinical severity. The validity of the three classes was supported by distinct patterns of association with major clinical variables (i.e., diagnostic staging at referral). Vulnerability to schizophrenia psychosis in young help-seekers may manifest in three major clinical prototypes, presenting common levels of dysphoria and social withdrawal but different degrees of paranoid autocentrism and disturbed subjective experience. Overall, the results provide the empirical background to dissect shared features of clinical caseness from more schizophrenia-specific vulnerability components. This is of value for the refinement of the clinical staging model as well as for the pragmatic implementation of multiple-gate screening programs.

Background: The ABC schizophrenia study conducted by the same team over 25 years initially aimed at illuminating the onset, prodromal stage and sex differences in age at first hospitalization in schizophrenia. New hypotheses were systematically generated from the results achieved. Methods: A population-based sample of 276 first admission cases (232 first episodes, age 12-59 years), including a subsample of 130 first admissions (115 first episodes), were assessed to study prodromal stage, first illness episode, medium and long-term course and symptom dimensions in schizophrenia. The samples were compared with age and sex-matched healthy controls and with patients first admitted for unipolar depression. A total of 1,109 consecutive first admissions for schizophrenia spectrum disorders independent from the other study samples were assessed to study changes in symptomatology across the age range. Results: Before the onset of psychotic symptoms the prodromal stages of schizophrenia and severe and moderately severe depression are difficult to distinguish. The most frequent symptom in the course of schizophrenia, depressed mood, also represents the most frequent initial symptom in both disorders. Prodromal depression is a predictor of more depressive and positive symptoms in the first episode but not in the further course of the illness. Psychosis incidence for men, diagnosed according to ICD 9 (295, 297, 298.3/4), shows a pronounced peak at age 15-24 years, for women a lower peak at age 15-29 years and a second, still lower peak at the menopausal age of 45-49 years. The explanation, confirmed in animal experiments, lies in a protective effect of estrogen due to reduced D2 receptor sensitivity. The effect is antagonized by an elevated genetic risk. Functional and social impairment emerge even at the prodromal stage and the severity depends on sex and social status. Young men with schizophrenia show a less favorable social course because of the earlier age of onset and socially adverse illness behavior. Late onset is associated with a milder, primarily paranoid symptomatology and less severe social impairment. Schizophrenia is a disorder of all ages showing roughly equal life time incidence rates for men and women but considerable difference in certain periods of age. The symptom dimensions show a plateau-like course 2-5 years after the first episode. Hidden behind this picture are irregular symptom exacerbations which vary in duration. Schizophrenia conveys the picture of recurrent vulnerability to crisis and not of a stable residual state of disordered brain development or of a progressive neurodegenerative process.

Purpose The ABC Schizophrenia study, led by a single research team, investigated a schizophrenia sample systematically over quarter of a century. This paper summarises results from 1996 onwards. The initial goals were to explain the considerably higher age at first admission in women, and to obtain precise information on the onset and early course of schizophrenia as a prerequisite for early intervention. Method The study was hypothesis-driven. People with schizophrenia were compared in the prodrome and at first admission to those with unipolar depression and to healthy controls. We analysed the medium-term (5-year) and the long-term (12-year) course of schizophrenia, its symptom dimensions, social parameters and predictors. Samples: (1) 276 population-based first admissions (232 first episodes) of schizophrenia (age range 12–59 years); (2) a subsample of 130 first admissions for schizophrenia; (3) 130 first admissions for unipolar depression; (4) 130 healthy population controls and (5) 1,109 consecutive first admissions for schizophrenia spectrum disorder without an age limit. Results The prodromal stages of schizophrenia and depression were very similar until positive symptoms appeared. The most frequent symptom in schizophrenia was depressed mood. The course of psychosis from prodrome to 12 years following first admission was very variable. From 5 to 12 years after first admission the course was characterised by irregular exacerbations of the main symptom dimensions, with no overall deterioration or improvement. Conclusions Schizophrenic psychosis and severe affective disorder, rather than representing discrete illnesses, probably mark different stages in the manifestation of psychopathology produced by various degrees of brain dysfunction.