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Comprehensive Psychiatry xx (2013) xxx–xxxwww.elsevier.com/locate/comppsych

The Early Recognition Inventory ERIraos detects at risk mental states ofpsychosis with high sensitivity

Franziska Rausch, Sarah Eifler, Andrea Esser, Christine Esslinger, Frederike Schirmbeck,Andreas Meyer-Lindenberg, Mathias Zink⁎

Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany

Abstract

The identification of patients carrying an increased risk of psychosis is one of the most important demands in schizophrenia research.Currently used diagnostic instruments mainly focus on either attenuated psychotic symptoms and brief limited intermittent psychoticsymptoms or solely cognitive basic symptoms. The “Early Recognition Inventory based on IRAOS” (ERIraos) has been developed as acomprehensive assessment of both symptom groups within one scale. We compared the results obtained by ERIraos with an internationalstandard instrument, the “Comprehensive Assessment of At Risk Mental States” (CAARMS) and applied both scales in a sample of 121outpatients positively tested on a screening checklist for at risk mental states (ARMS). Subsamples were classified as first episode ofpsychosis, late ARMS with prevalent attenuated psychotic symptoms and/or brief limited intermittent psychotic symptoms, earlier stages ofARMS presenting cognitive basic symptoms as well as a vulnerability group, also differing regarding mean age and psychosocialfunctioning. Our results point to a higher sensitivity of ERIraos compared to scales that mainly focus on attenuated psychotic symptomsand brief limited intermittent psychotic symptoms. A detailed assessment of cognitive basic symptoms seems to be important in earlydetection, might be an important focus for therapeutic interventions in ARMS patients and might sustain attempts to alleviate cognitivedysfunction in schizophrenia.© 2013 Elsevier Inc. All rights reserved.

1. Introduction

Current diagnostic concepts on schizophrenia have beendeveloped at the beginning of the 19th century by EmilKraepelin, Eugen Bleuler and Kurt Schneider and stillinfluence the operationalized criteria of international classifi-cations. These pioneers have also been highly interested in theearly course of psychotic disorders and highlighted theimportance of affective and cognitive symptoms in theprodromal states of schizophrenia [1]. In light of currentlydiscussed classifications of psychiatric disorders the utmostearly and precise identification of at riskmental states (ARMS)is a core topic in clinical schizophrenia research and appearsnecessary in order to prevent pronounced functional deterio-

⁎ Corresponding author. Department of Psychiatry and Psychotherapy,Central Institute of Mental Health, Medical Faculty Mannheim/HeidelbergUniversity, P.O. Box 12 21 20, D-68072 Mannheim, Germany. Tel.: +49621 1703 2911; fax: +49 621 1703 1205.

E-mail address: mathias.zink@zi-mannheim.de (M. Zink).

0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.comppsych.2013.04.016

ration [2]. Careful epidemiological and retrospective assess-ments as well as longitudinal observations and treatment trialsin ARMS samples were performed [3,4]. These results wereentered into the definition of specific symptom groups, thedevelopment of diagnostic rating scales and the evaluation oftheir validity, mostly based on the prediction of transitions tofirst episode of psychosis (FEP) [5,6]. Patients meeting ultrahigh risk criteria for schizophrenia spectrum disorders (UHR)suffer from attenuated psychotic symptoms (APS) and/orbrief limited intermittent psychotic symptoms (BLIPS).These symptoms largely determine the diagnostic instruments“Comprehensive Assessment of At Risk Mental States”(CAARMS) [7,8] as well as the “Structured Interview forProdromal Syndromes” (SIPS) [9] including the “Criteria OfProdromal Syndromes” (COPS) [10]. In a German tradition,Huber, Gross and Klosterkötter defined cognitive basicsymptoms (BS) already occurring in early ARMS stages[11–14]. Later on, BS were grouped into the at-risk criterionCOPER (“cognitive-perceptive basic symptoms”) and thehigh-risk criterion COGDIS (“cognitive disturbances”) andintegrated into diagnostic instruments for children, youths and

2 F. Rausch et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

adults (Schizophrenia Proneness Instrument – Adult version:SPI-A, child and youth version: SPI-CY) [15]. In attempt tocombine a detailed assessment of APS, BLIPS andBS into onescale, the comprehensive instrument ERIraos (Early Recogni-tion Inventory based on IRAOS) has been established (seeFig. 1). Pioneer work by Häfner et al. elucidated the earlycourse of schizophrenia in a retrospective assessment (ABCinvestigation, IRAOS) [3]. These results were operationalizedwithin the German Research Network on Schizophrenia(GRNS) and contributed to the selection of items and theconceptualization of the ERIraos, that has been successfullyapplied in clinical samples [12,16–18]. ERIraos contains the10 COPER symptoms (“Thought perseveration of pastevents”, “Disturbance of receptive speech”, “Thought inter-ference”, “Pressing and racing thoughts”, “Thought block”,“Decreased ability to discriminate between ideas, perception,fantasy and true memories”, “Derealisation, Depersonalisa-tion”, “Unstable ideas of reference (subject-centrism)”,“Disturbances of optic perceptions”, “Disturbances of acousticperceptions”) and additionally the item “Disturbances ofolfactory, gustatory, sensible, somatic and tactile perceptions;Impaired bodily sensations (coenaesthesia)” that showedpredictive validity for a transition to psychosis in the GRNSstudy [19]. Another important difference relates to the itemizedsymptom definition in ERIraos allowing a more preciseevaluation of single cognitive symptoms compared to thesyndrome based approach (CAARMS).

On average, about 22% of the patients meeting ARMScriteria experience a transition to psychosis according tothe diagnostic criteria of DSM IV or ICD 10 [4,20–23]. The

Prepsychotic and psych

N = 232; (108 males,

Prodromal phase(Early ARMS)

Time period 5.0 years

first (negative or nonspecific)sign of mental disorder

2.42egA

Basic Symptoms

SPI A

ERIraos

Fig. 1. Attribution of symptom groups to diagnostic rating scales within the early codifferent ARMS-subgroups, the so-called pre-psychotic and psychotic prodromalsymptoms in different ways. Abbreviations: ABC-study (Age, Beginning and Courslimited intermittent psychotic symptoms), CAARMS (Comprehensive AssessmenIRAOS), SPI-A (Schizophrenia Proneness Instrument – Adult version).

prediction of transitions is still an important focus, but inaddition a clinically meaningful burden of disease should beattributed to the ARMS per se [2], even if a formal integrationof an ARMS category into revised diagnostic systems seemsunlikely at present (http://www.dsm5.org) [24]. Besides thediagnostic categorization of ARMS on a psychopathologicallevel, a careful description using neurobiological methodsmight be helpful in defining manifold aspects of impairmentduring ARMS and in evaluating therapeutic interventions[25]. Moreover, the neuropsychological profiles between theARMS subgroups were found to differ [18], further arguingfor a broad spectrum of symptom clusters including UHRcriteria and BS.

Differences in diagnosis and description of ARMSbetween research groups can most likely be explained by alack of comparative evaluations of alternative instruments.Ruhrmann et al. showed, that combining UHR criteria andCOGDIS provided modestly improved sensitivity for predict-ing a transition to psychosis [21] and Schultze-Lutter et al.pointed at a time sequence within the prodromal coursestarting with unspecific symptoms, followed by predictive BSand finally ending with APS and BLIPS [12]. The authorsconclude that BS might be a complementary approach tothe UHR criteria, which may allow an earlier or stepwisedetection of ARMS.

In a first comparative study we therefore evaluated andcompared ERIraos and CAARMS regarding their sensitivityto identify risk constellations for psychosis in an outpatientsample. In addition, we address questions of practicability inclinical routine.

otic prodromal states

124 females)

Psychotic prephase(Late ARMS)

1.1 years 0.2years

first positivesymptom

maximumof positivesymptoms

index-admission

positivesymptoms

negativesymptoms

3.031.030.92

ABC

SchizophreniaStudy

BLIPS / APS

CAARMS

urse of psychosis and to time windows. Results of the ABC-study suggestedstates. Accordingly, different diagnostic rating scales comprise the relatede Schizophrenia Study), APS (attenuated psychotic symptoms), BLIPS (brieft of At Risk Mental States), ERIraos (Early Recognition Inventory based on

3F. Rausch et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

2. Methods

2.1. Setting and patients

This cross-sectional investigation was performed in theoutpatient department “Early recognition of psychosis” of theCIMH (Central Institute of Mental Health). Patients werereferred by independent general practitioners, psychiatristsand psychotherapists or via an anonymous online self-rating(http://www.zi-mannheim.de/checkliste.html). Within theroutine diagnostic processes (see Fig. 2), in each patient theinstruments ERIraos and CAARMS were applied. In addition,patients were characterized according to family history,previous general and psychiatric history, preceding treatmentattempts using pharmacological and/or psychotherapeuticinterventions, educational levels, drug use and specific riskfactors for psychotic disorders, such as birth complications.

2.2. Diagnostic instruments

As presented in Fig. 2, all patients accessing the outpatientdepartment are examined with a 15-item screening checklistfor ARMS, which is also available online. Subjects are asked

Workflow of the outEarly Recognition

Instruments

ERIraos, SPQ, GAF, PSP, Family Risk

CAARMS (APS, BLIPS, Formal Thought Disorder)

Drug Consumption, Delinquency, Obstetric and Birth Complications, Delays in Childhood Development

+ Neuropsychological Test Battery+ Metacognitive Test Battery

CL negative

ERIraos negative

ERIraos negativebut-SPQ/ FR positive +-Drop of GAF-Score

ERIraos positiveNo APS/BLIPS

CL positive [N = 121]

ERIraos positive andAPS/BLIPS

Checklist: CL, RiskFactors

Fig. 2. Diagnostic work flow of the outpatient unit for early recognition of psychpsychotic symptoms), ARMS (at risk mental state), BLIPS (brief limited intermitteMental States), ERIraos (Early Recognition Inventory based on IRAOS), FEP (f(Personal and Social Performance Scale), SPQ (Schizotypal Personality Questionn

to refer if the evaluated symptoms occurred within the past12 months without any regard to frequency, duration orintensity. Symptoms can be grouped into (1) unspecificsymptoms (questions 1–5), (2) specific ARMS-symptoms(questions 6–10), and (3) specific symptoms occurring in lateARMS and/or FEP (e.g. BLIPS) (questions 11–15).Symptoms of the first section are very common and oftenoccur a long time before the onset of a psychosis, but theyhave no sufficient predictive power concerning an imminenttransition to psychosis. Therefore it is not possible to assessan increased risk of psychosis solely with these symptoms.Symptoms of the second section are specific for ARMSand give a distinct hint to an increased risk of psychosis.Symptoms of the third section can already provide someevidence for a psychotic syndrome and a diagnosticclarification and the decision whether an intervention isnecessary should happen immediately. Altogether thechecklist is considered to be very low-threshold and decisionsregarding the attribution to risk groups or therapeuticinterventions should never be met based on checklist results.Patients with at least one positive score in symptom group 2or 3 are considered positive and are further characterized by

patient unit for of Psychosis

No indication for ARMS [N = 191]

Vulnerability Group [ERIraos=3 (2,5%), CAARMS=4 (3,3%)]

FEP Group [ERIraos=22 (18,2%), CAARMS=18 (14,9%)]

Early ARMS [ERIraos=24 (19,8%), CAARMS=0]

CL false-positive, no ARMS [ERIraos=33 (27,3%), CAARMS=77(63,6%)]

Attribution

Late ARMS[ERIraos=39 (32,2%), CAARMS=22 (18,2%)]

osis at the CIMH in Mannheim, Germany. Abbreviations: APS (attenuatednt psychotic symptoms), CAARMS (Comprehensive Assessment of At Riskirst episode of psychosis), GAF (Global Assessment of Functioning), PSPaire – brief version).

4 F. Rausch et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

ERIraos. This scale consists of 50 symptoms, including BS,APS and BLIPS. For each of the 50 symptoms subjects areasked to refer (A) if this specific symptom was present in thepast four weeks, (B) if it already occurred within the last12 months, (C) if there was a deterioration during the last12 months and (D) if there is a current emotional strainregarding this symptom (score range 0–200, cut-off = 30).The absence of an increased risk of psychosis is assumed,when no BLIPS, no APS or less than two basic symptoms andno transgression of the cut-off score is presented. An earlyARMS is defined by a transgression of the cut-off or thepresence of at least two basic symptoms, while a late ARMSis defined by the presence of at least one BLIPS or APS,independent of the score achieved. In addition, theCAARMS, focusing on APS and BLIPS, is applied. Inorder to define the first onset of psychosis, the CAARMSrequires a symptom frequency of at least three to six times aweek for more than one hour or daily less than one hour,which is not demanded by ERIraos. The patients are furtherevaluated by the instruments GAF (Global Assessment ofFunctioning) to evaluate the psychological, social andoccupational functioning, PSP (Personal and Social Perfor-mance Scale), which focuses on socially useful activities,personal and social relationships, self-care and disturbing andaggressive behaviour, and SPQ-B (Schizotypal PersonalityQuestionnaire – B), which is a brief, self-report screeninginstrument for schizotypal personality features. Finally theassociated instruments of the ERIraos “Alcohol and drugconsumption”, and “Mental illness in the family” are applied.

2.3. Statistical evaluation

We used the Statistical Package for Social Sciences (IBMSPSS version 20.0, Chicago, IL, USA). Descriptive statisticsincluded calculations of means, medians, standard deviations

Table 1Sociodemographic and anamnestic data of the total sample, the early and late AR

Descriptive Statistics Total sample(N = 121)

Age 26.15 ± 7.64Sex 94 m; 27 fFamily history of psychosis (1st degree relatives) N = 17Years of education (school years) 11.23 ± 1.78Comorbidity with psychiatric disorders (according to DSM IV) 80 of 121Current psychotherapy no = 99, yes =

(18 CBT, 4 othCurrent medication antipsychotics

antidepressantsConsumption of legal and illegal drugs -

The table provides frequencies within the subsamples or means ± standard deviaunobtainable information. Most frequent comorbidity was major depressive episoddifferences are provided in Table 3. Abbreviations: ARMS (at risk mental statepsychosis), m (male).

and standard error of the means. Between-group compari-sons were performed with Student's t test and one-wayANOVAs (analysis of variance) including post hoc analysesusing LSD (Fisher's least significant difference). Correla-tions between rating scales were also analysed withparametric methods (Pearson's correlation coefficient r).Differences regarding the attributions to risk groups byERIraos and CAARMS and the representation of specific BSin the risk groups early ARMS and late ARMS wereanalysed with odds ratios.

3. Results

3.1. Sample description

Between April 2008 and September 2011 a number of 312patients were screened in the outpatient department. Anumber of 121 (94male, 27 female) patients scored positivelyon the screening checklist and were further evaluated withERIraos and CAARMS. Within these patients, 34% werereferred after first contact to a resident psychiatrists, 20% byindependent general practitioners, 4% by psychotherapists,about 23% by inpatient units of our clinic, 3% by otherpsychiatric hospitals and 16% by others (online-checklist,social psychiatric services). Sociodemographic and anam-nestic data of the complete sample, as well as of thesubgroups obtained by stratification according to ERIraos areprovided in Table 1.

Based on ERIraos group definition, about 50% (N = 63)were attributed to ARMS groups with 24 (19.8%) patientsshowing psychopathological properties of the early ARMS(mean age 23.0 years) and 39 (32.2%) patients of the lateARMS group (mean age 25.6 years). Finally, another 22(18.2%) patients were assigned to the first-episode-of-

MS groups and the FEP group.

Early ARMS group(N = 24)

Late ARMS group(N = 39)

FEP group(N = 22)

23.04 ± 3.92 25.62 ± 7.65 28.50 ± 9.4821 m; 3 f 29 m; 10 f 16 m; 6 fN = 4 N = 4 N = 011.23 ± 1.87 11.14 ± 1.74 11.10 ± 1.8016 of 24 21 of 39 10 of 22

22er)

no = 19, yes = 5(2 CBT, 3 other)

no = 33, yes = 6(6 CBT)

no = 18, yes = 4(4 CBT)

= 19= 35

antipsychotics = 1antidepressants = 6

antipsychotics = 4antidepressants = 11

antipsychotics = 7antidepressants = 4

(N = 10)nicotine current = 3cannabis:ever = 6regular = 2current = 0

(N = 17)nicotine current = 9cannabis:ever = 13regular = 3current = 2

(N = 6)nicotine current = 5cannabis:ever = 5regular = 4current = 2

tion. Sample size in consumption of legal and illegal drugs varies due toe, less frequent were personality disorders and alcohol abuse. Between groups), CBT (cognitive behavioural therapy), f (female), FEP (first episode of

Table 2Psychometric rating scales and ERIraos associated instruments.

Descriptive statistics Total sample (N = 121) Early ARMS group (N = 24) Late ARMS group (N = 39) FEP group (N = 22)

GAF score current 50.79 ± 11.11 51.67 ± 11.00 52.05 ± 11.85 42.95 ± 9.84GAF-criterion N = 53 N = 10 N = 22 N = 14GAF drop 13.47 ± 13.31 12.50 ± 15.95 13.97 ± 13.39 17.5 ± 12.89PSP 63.02 ± 15.05 (N = 43) 73.0 ± 6.75

(N = 10)62.0 ± 16.09 (N = 20) 52.86 ± 9.51 (N = 7)

SPQ-B 9.00 ± 4.45 (N = 47) 7.67 ± 3.45 (N = 12) 11.21 ± 3.98 (N = 19) 9.00 ± 4.69 (N = 8)

Data of the total sample, the early and late ARMS groups and the FEP group. Sample size in PSP and SPQ-B varies due to unobtainable information. GAF dropwas defined as the reduction of the GAF-score during the last 12 months. The “GAF-criterion” was defined as a 30%-drop in GAF score compared to thepremorbid level or a score of 50 or less during the last 12 months and scaled dichotomous (0 = not present; 1 = present). The table provides frequencies withinthe subsamples or means ± standard deviation. Abbreviations: ARMS (at risk mental states), FEP (first episode of psychosis), GAF (Global Assessment ofFunctioning), PSP (Personal and Social Performance Scale), SPQ-B (Schizotypal Personality Questionnaire – brief version).

Attributions to ARMS groups

0

10

20

30

40

50

60

70

80

90

[N]

ERIraos

CAARMS

No ARMS Vulnerability Group

33 3 24 39 2277 4 0 22 18

Early ARMS Late ARMS FEP

***

*

**

ig. 3. Attribution of patients to different risk constellations according to theiagnostic scales ERIraos and CAARMS. Within a sample of recentlyvestigated 121 patients superior sensitivity of the ERIraos for the earlyRMS became apparent. Abbreviations: ARMS (at risk mental states), FEPirst episode of psychosis). *p b .05, **p b .01, ***p b .001.

5F. Rausch et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

psychosis group (FEP, mean age 28.5 years). Regardingsociodemographic variables, males represented the majorityof 87.5% in the early ARMS and 74.4% in the late ARMSgroup. Both groups reported mean education levels of 11attended school years. For 16 (66.7%) patients in the earlyARMS and 21 (53.8%) patients in the late ARMS group,comorbidity with a second psychiatric illness was explored,leading to current pharmacological treatment with antide-pressants in six patients (25%) in the early ARMS and 11(28.2%) patients in the late ARMS group and psychotherapyin 5 (20.8%) early ARMS and 6 (15.4%) late ARMSpatients. In the early ARMS group most frequent comorbid-ities have been major depressive episode (33.3%), person-ality disorder (16.7%) and cannabis abuse (8.3%). In the lateARMS group most frequent comorbidities have beenpersonality disorder (20.5%), major depressive episode(15.4%) and cannabis abuse (10.3%). Antipsychotic treat-ment had been started by the referring psychiatrists beforesystematic diagnostic screening in 1 (4.2%) early ARMS and4 (10.3%) late ARMS patients. Respectively, in both groups,four patients had a positive family history with affected firstdegree relatives. Psychometric assessments (see Table 2)addressed general levels of psychosocial functioning andinstruments associated to the ERIraos. Every second ARMSpatient reported a 30% drop in the GAF-score compared tothe pre-morbid level or a score of 50 or less during the last12 months (N = 32 (50.8%)). None of the early ARMS and6 (15.4%) of the late ARMS patients met the criteria forschizotypal personality disorder assessed with SPQ-B. Basedon anamnestic data, 6 (25%) patients in the early ARMSgroup reported to ever have consumed cannabinoids, 2(8.3%) of them regularly, but none of them currently fulfilledthe criteria of abuse. In the late ARMS group 13 (33.3%)patients reported cannabinoid consumption, 3 (7.7%) ofthem on a regular basis and 2 (5.1%) with current abuse.

We observed significant between group differencesregarding age, current GAF-score and PSP. Post hocanalyses using LSD (Fisher's least significant difference)revealed significant differences between early ARMS andFEP (p = .014) regarding age. Further, current GAF-scoressignificantly differed between early ARMS and FEP (p =

.010) and late ARMS and FEP (p = .003). In parallel, PSPscores were higher in early ARMS compared to late ARMS(p = .038) and in early ARMS compared to FEP (p = .004).

3.2. Attribution toARMSsubgroupsbyERIraosversusCAARMS

Marked differences were observed regarding the attribu-tion to ARMS-subgroups when criteria of ERIraos versusCAARMS were applied. According to ERIraos, 33 (27.3%)subjects were assigned to “no ARMS”, representing falsepositive checklist and screening failure (see Fig. 3), whichexcludes the detection of an increased risk, whereas 77(63.6%) subjects were attributed to this group by CAARMS;3 (2.5%) (ERIraos) versus 4 (3.3%) (CAARMS) wereallocated to the “vulnerability group”. ERIraos referred 24(19.8%) subjects to the early ARMS, whereas CAARMSassigned no subjects to this group. By ERIraos 39 (32.2%)versus 22 (18.2%) (CAARMS) subjects were attributed tothe late ARMS and 22 (18.2%) (ERIraos) versus 18 (14.9%)(CAARMS) to FEP.

CAARMS was found unable to attribute patients to theearly ARMS group, neither are they attributed to the

FdinA(f

Table 3Correlations of the ERIraos sum score with GAF and PSP for the total sample versus the early and late ARMS group and the FEP group together.

Correlations (Pearson) All groups (N = 121) Early ARMS, late ARMS and FEP group (N = 85)

ERIraos sum score - current GAF score r = −.318; p ≤ .001 r = −.275; p = .011ERIraos sum score – GAF drop r = .159; p = .081 r = .113; p = .301ERIraos sum score - GAF-criterion r = .231; p = .011 n.s.ERIraos sum score – current PSP score r = −.296; p = .054

(N = 43)r = −.328; p = .047(N = 37)

Sample size in PSP varies due to unobtainable information. GAF drop was defined as the drop of GAF score during the last 12 months. GAF-criterion wasdefined as a 30%-drop in GAF score compared to the pre-morbid level or a score of 50 or less during the last 12 months and scaled dichotomous (0 = not present;1 = present). Abbreviations: ARMS (at risk mental states), FEP (first episode of psychosis), GAF (Global Assessment of Functioning), PSP (Personal and SocialPerformance Scale.

6 F. Rausch et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

Vulnerability Group. In consequence, some patients are notidentified by CAARMS at all, though they complain ofmeaningful symptoms. Importantly, rating with ERIraosdoes not miss any attributions to the late ARMS and FEP andcomprises the identical subjects defined by CAARMS. Thereason why ERIraos attributed slightly more subjects to lateARMS compared to the CAARMS, is, that CAARMSrequires a 30% drop in GAF-score compared to thepremorbid level or a score of 50 or less during the last12 months, which is not necessarily demanded by ERIraos.Regarding the FEP group, CAARMS requires a symptomfrequency of at least three to six times a week for more thanone hour or daily less than one hour, which is not demandedby ERIraos in that specific way. As shown in Table 3, theERIraos sum score correlated with the current total GAF-score in the complete sample (r = −.318; p ≤ .001), as wellas in the groups comprising psychosis-prone subjects (early

Specific BS in early and late ARMS

0

10

20

30

40

50

60

70

1 2 3 4 5 6 7 8 9 10 11Basic SymptomsP

erce

nta

ge

of

pat

ien

ts r

epo

rtin

g t

he

BS

Early ARMS (N = 24) Late ARMS (N = 39)

***

*

**

***

**

Fig. 4. Representation of specific BS in risk groups early ARMS and lateARMS. The numbers indicate the percentage of patients reporting specific BS:1 = Thought perseveration of past events, 2 = Disturbance of receptivespeech, 3 = Thought interference, 4 = Pressing and racing thoughts, 5 =Thought block, 6 = Decreased ability to discriminate between ideas,perception, fantasy and true memories, 7 = Derealisation, Depersonalisation,8 = Unstable ideas of reference (subject-centrism), 9 = Disturbances of opticperception, 10 = Disturbances of acoustic perceptions, 11 = Disturbances ofolfactory, gustatory, sensible, somatic and tactile perceptions; Impaired bodilysensations (coenaesthesia). Abbreviations: ARMS (at risk mental states), BS(basic symptoms). *p b .05, **p b .01, ***p b .001.

and late ARMS as well as FEP: r = −.275; p = .011). Incontrast, PSP only correlated with ERIraos scores of thelatter group, while the so-called GAF-criterion (definedas a 30% drop in GAF score compared to the pre-morbid level or a score of 50 or less during the last 12 monthsused as a categorical parameter: 0 = not present; 1 = present)correlated with ERIraos only in the total sample (r = −.231;p = 0.011).

3.3. Itemized analysis of symptoms

In our sample of 121 patients, positively selected by thechecklist instrument, 55 subjects (45.5%) reported BS, 52(43%) reported APS and 30 (24.8%) reported BLIPS. Withinthe early ARMS group, seven subjects (29.2%) wereattributed solely by transgression of the cut-off, 5 (20.8%)solely by BS and 12 (50%) exceeded the cut-off andadditionally reported BS.

Detailed analysis of BS in this early ARMS group,showed that the BS “Disturbance of perceptive speech”(58%) and “Thought block” (58%) were reported mostfrequently, while this was the case for “Disturbance ofperceptive speech” (41%), “Derealisation, Depersonalisa-tion” (36%) and “Unstable ideas of reference (subject-centrism)” (36%) in the late ARMS (see Fig. 4). “Thoughtinterference”, “Derealisation, Depersonalisation” and “Un-stable ideas of reference (subject-centrism)” were reportedmore often in late compared to early ARMS. We alsoevaluated the samples on an individualized basis and canexclude that the ERIraos might attribute individual patientsto lower ARMS groups than CAARMS.

4. Discussion

This cross-sectional investigation showed that the com-prehensive scale ERIraos is able to attribute patients toseveral stages of ARMS, potentially linked to differenttransition rates into psychosis, as has to be investigatedin forthcoming longitudinal studies. Compared to theinternational scale CAARMS no sensitivity is lost indetecting the late risk stages and the manifest psychosis,while ERIraos broadens the diagnostic spectrum, becausethe early ARMS is also detected due to the inclusion of

7F. Rausch et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

BS-addressed items into this scale. A detailed patient bypatient comparison showed that the groups identified byCAARMS are without exclusions subsets of ERIraos-relatedgroups. In consequence, ERIraos assessed all symptomsnecessary for group assignment as completely as CAARMSeven on an individualized basis.

In routine clinical practice, the application of ERIraosfollows a stringent and feasible process: It provides a 15-itemscreening checklist to run a pre-selection. Positively selectedpatients undergo further exploration with the 50-itemsymptom scale, which is feasible in about 30–60 minutes,and associated instruments. The time to be spent correspondsroughly to the demands of SPI-A or CAARMS, while thesescales comprise only subsets of the broad symptom clustersevaluated by ERIraos. Another advantage compared toCAARMS or SIPS is the itemized compared to a syndromalapproach, because it allows a more precise exploration of theparticular symptoms.

Previous literature shows that “Thought interference”,“Disturbance of receptive speech” and visual distortionswere highly predictive for a transition to psychosis [2]. Asreported above, Ruhrmann et al. were able to show, thatcombining UHR criteria and COGDIS provides modestlyimproved sensitivity for predicting a transition to psychosis[21]. In contrast to the suggested combination of UHR plusCOGDIS, the selection of specific BS in the ERIraos isslightly different and so far we cannot predict any transitionrates due to the lack of longitudinal data. But in constructingthe scale, only those BS were integrated which retrospec-tively predicted a transition to psychosis in the GRNSsample. This, however, was not the case for the complete setof COGDIS BS. We assume that the selected 11 BS might bean optimized compromise between completeness, predictivevalidity and practical feasibility.

Furthermore, the definitions of ARMS groups accordingto ERIraos do not necessarily require the GAF criterion, a30% drop in GAF-score compared to the pre-morbid level ora score of 50 or less during the last 12 months, which isdemanded to meet the UHR criteria. This is also aconsequence of results obtained in the GRNS sample,where most symptoms were found predictive for a transitionto psychosis even without a drop in GAF-score [19]. Thisview is supported by results obtained in this study: Due to thedescribed group distribution and significant correlationbetween the current GAF-score and the ERIraos total scorein our sample, we assume that ERIraos does not necessarilyneed the GAF to attribute to ARMS-groups.

Indeed, ARMS is associated with a pronounced func-tional deterioration [2] and significant negative correlationsof the ERIraos total score with the current GAF-score and asignificant correlation with the GAF-criterion corroboratethis fact (see Table 3). By indicating some significantdifferences between the ARMS groups and the FEP groupregarding age, current GAF-score and PSP we could partlyunderpin the findings of Schultze-Lutter et al. showing aprogress over time within the prodromal course [12]. In

contrast to the ERIraos, the CAARMS must be accompaniedby scales assessing psychosocial functioning as supported byrecent findings of Valmaggia et al. [26] and Velthorst et al.[27]. In both independent samples the criterion of functionaldecline or low functioning added sensitivity and discrimi-native power compared to the narrow characterization byUHR criteria. Within the large North American ProdromeLongitudinal Study (NAPLS) similar results underline theimportance of assessing the functional decline in addition tothe prodromal criteria alone [28,29].

The finding of a preponderance of schizotypal featuresin the late ARMS group (one in the early ARMS (4.2%) andsix (15.4%) in the late ARMS group) might be based on theoccurrence of APS in the late ARMS as they are known tobe symptoms of the schizotypal personality disorder.Furthermore there was a preponderance of cannabis usein the late ARMS group, as 6 (25%) patients in the earlyARMS group reported to ever have consumed cannabi-noids, but none of them currently fulfilled the criteria ofabuse. In contrast, in the late ARMS group 13 (33.3%)patients reported cannabinoid consumption and two (5.1%)fulfilled criteria of current abuse indicating the assumedimportance of cannabinoids in the pathogenesis ofpsychosis and disease progression.

Additionally our findings show that in our sample FEPpatients were significantly older than early ARMS patientsand that there was an increasing deterioration of functioningduring time, which supports the assumption that ARMSpatients suffer from affective and cognitive impairmentparticularly in later stages [22,18,30–32]. Therefore theidentification of utmost early stages is necessary in order toprevent disease progress by means of well tolerable earlyinterventions [33].

Diagnostic scales focusing on cognitive symptoms mightbe particularly helpful when interventions with cognitivebehavioral therapy (CBT) are designed, a method withrobust effects in preventing a first psychotic episode[33,34]. In order to provide data for differential treatmentdecisions, further randomized treatment trials are needed[4,25,35,36] and the secondary prevention of schizophreniastudy (PREVENT) [35] might significantly contribute tothis question.

Identifying the very early stages of psychosis is animportant step to prevent transitions to psychosis andhopefully will lead to less or shorter hospitalizations, lessfunctional decline, less stigma and less costs.

Limitations of this study are especially due to the cross-sectional design, the preponderance of male gender, themonocentric approach and the small number of cases. Ingeneral, longitudinal studies will have to define theproportion of false-positive attributions met by ERIraos.Currently, we try to validate the results of this study byfollow-up assessments of our patients in order to assurepredictive validity, but also to investigate the longitudinalchanges of subjective burden of disease associated withthe ARMS per se. At present, the ERIraos is only available

8 F. Rausch et al. / Comprehensive Psychiatry xx (2013) xxx–xxx

in German language, but English and Spanish translationsare planned.

In conclusion, the comprehensive scale ERIraos providesimproved sensitivity in detecting ARMS compared to UHR-related scales. Due to well tolerable treatment interventions,it will be increasingly important to minimize false negativeattributions while deciding on ARMS or non-ARMS. Puttingthe diagnostic and therapeutic focus on cognitive symptomsmight improve treatment of the so far insufficiently tackledcognitive dysfunctions in schizophrenia in general.

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