Moreover, strategies to improve encoding may be of benefit to persons living with HIV-associated memory deficits; for example, requiring self-generation of stimulus pairing has shown to greatly improve immediate and delayed verbal recall in HIV disease . Translated to a clinical setting, asking a patient to generate their own plan for remembering their medications may deepen encoding processes and facilitate later recall thereby improving adherence. Other neurorehabilitation techniques that target encoding and retrieval processes in order to deepen the memory trace may be additionally fruitful in enhancing adherence, such as visual imagery , spaced-learning , and/or pairing medication behaviors with other daily habits that might trigger recall . Additionally, the prominence of a primary retrieval deficit profile strengthens the sub-cortical dementia explanation of HAND. Because sub-cortical dementias are often coupled with slowed mental processes and apathy additional techniques, such as providing information at a slower rate or enhancing patient buy-in and decreasing apathy by focusing on the rationale of proper adherence, could prove helpful. Moving forward, future studies that begin to examine the utility of these techniques to improve antiretroviral adherence are certainly warranted and long overdue as the field begins to translate observations into interventions.While diagnosis of the schizophrenia prodrome has been a target of the psychiatry field for over a century,drying weed it is only in the last decade or so that reliable clinical assessment instruments were developed to identify these “psychosis risk syndromes”.
A flurry of research ensued, with an increasing number of specialty clinics worldwide using a variety of assessment and screening tools, and a growing awareness of psychosis risk syndromes in community mental health settings. Most recently, this area of work resulted in an ongoing debate over the inclusion of an attenuated psychosis syndrome diagnosis in the upcoming 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders. Despite the strong reliability of instruments, data only partially support their validity in identifying true “prodromal” cases; therefore, these instruments identify “risk syndromes,” often focused on the presence of attenuated positive psychotic symptoms that are not expected to confer 100% risk for later developing a formal psychotic disorder. The assessment of prodromal psychosis can be complicated by the often non-specific nature of symptoms, and because symptoms typically present in adolescence or young adulthood, when changes in functioning and emotional well-being are common. Furthermore, the assessment process does not end with diagnosis; once the presence of attenuated psychotic symptoms is established, educating clients and their families and addressing anxiety surrounding symptoms and their implications can be challenging. In this paper, we will review psychosis risk syndrome assessment and screening instruments, describe the assessment and feedback process with youth and families and use a case example to illustrate some common issues that arise during psychosis risk assessment. We will primarily focus on the most common risk syndrome based on the presence of attenuated psychotic symptoms but will briefly discuss other syndromes and assessment approaches.Within the last two decades, three well-validated semi-structured interviews sensitive to sub-threshold psychotic symptoms were developed to assess the putative prodromal or clinical high risk syndrome for psychosis. These instruments fall into two categories: instruments aimed at diagnosing CHR syndromes through the presence of attenuated psychotic symptoms , the presence of psychotic symptoms transient in nature, or a combination of trait and state vulnerability markers and instruments aimed at detecting psychosis risk through the presence of subjective neuropsychological and cognitive deficits, or basic symptoms .
Mean transition time to psychosis was longer when BS were used to assess psychosis risk than when CHR criteria were used , therefore BS could possibly allow for an earlier assessment of psychosis risk than APS. However, there is a lack of prospective studies investigating the sequence with which symptoms emerge in the course of the prodromal period of psychosis, and therefore this needs further exploration. The set of at-risk criteria based on attenuated psychotic symptoms was initially developed by Yung and colleagues through literature reviews and retrospective assessment of first episode psychosis cases. They first used DSM-III criteria, later turning to a combination of the Brief Psychiatric Rating Scale and the Comprehensive Assessment of Symptoms and History . Attenuated psychotic symptoms were defined by the presence of BPRS symptoms of attenuated level intensity held with a reasonable degree of conviction, as assessed by the CASH . The Comprehensive Assessment of at Risk Mental States was then developed to allow for more sensitivity and breadth in assessing attenuated level psychotic symptoms by defining sub-threshold symptoms across a wider range of scores, with concrete anchors. The Structured Interview for Prodromal Syndromes was based on the criteria outlined by Yung and colleagues and modeled after the Positive and Negative Syndrome Scale . Both instruments assess the presence/absence of CHR syndromes and allow for longitudinal assessment of attenuated psychotic symptom severity. Symptoms ratings are based on onset, frequency, impairment, distress, and degree of conviction. The SIPS includes the Scale of Prodromal Syndromes , a 19 item scale which allows clinicians to rate symptoms on four sub-scales that assess: positive symptoms , negative symptoms , disorganized symptoms and general symptoms . Symptoms are rated from 0 to 6 , with considerations of frequency and intensity/degree of conviction included in the individual symptom rating.
A rating from 0-2 is considered sub-threshold and a rating from 3-5 is in the attenuated range, whereas a rating of 6 is considered fully psychotic. All symptoms are rated on the SOPS based on the last month. In addition to the SOPS, the SIPS contains the Criteria of Psychotic Syndromes , a modified version of the Global Assessment of Functioning Scale , a schizotypal personality disorder criteria checklist, and an assessment of family history of mentalillness. Similar to the CAARMS, the SIPS identifies 3 CHR syndromes and 1 psychotic syndrome; see Table 1 for a detailed overview of syndrome definitions. The SIPS shows good predictive validity,pruning cannabis with 40% of CHR patients converting to full psychosis at 2.5 year follow-up . The inter-rater reliability is excellent, with interclass correlation coefficients above 0.75 on all sub-scales , based on ratings of four videotapes by trained clinician . Basic symptoms are subtle subjective neuropsychological and cognitive deficits believed to indicate risk for future psychosis. The Bonn Scale for the Assessment of Basic Symptoms is a clinician-led semi-structured interview that assesses BS, developed in Germany based on the work of Huber . The original interview has 92 items , although shorter versions of the BSABS are commonly used. The version used by Klosterkotter and colleagues in the Cologne Early Recognition Project assesses for the presence of 66 Basic symptoms, divided into 5 clusters; thought, language, perception, and motor disturbances, impaired body sensations, impaired tolerance to stress, disorders of emotion and affect, and increased emotional reactivity, impaired ability to maintain or initiate social contacts and disturbances of normal nonverbal expression . Each symptom is rated as present, questionably present, or absent. The BSABS shows good diagnostic validity, with the presence of at least one basic symptom predicting schizophrenia with a probability of 70% over an average follow up period of 9.6 years . Inter-rater reliability of the BSABS items ranged from fair to very good based on ratings gathered during 18 joint interviews by a trained clinician pair . There is growing consensus that the SIPS/CAARMS and BSABS approaches can be complementary in the detection of psychosis risk, and can be used to guide treatment specific to each type of syndrome . The European Prediction of Psychosis study in Germany combines the SIPS and BSABS to determine psychosis risk, and found transition rates to psychosis of 19% at 18 month follow up, with the combined approach achieving the highest sensitivity . Given the intensive time and staff training required to use the structured psychosis risk interviews, several self-report -screening measures have been developed to identify those individuals who are most likely to benefit from the interviews.
All measures were developed for use in a two-stage screening process with clinical interview and not to be used alone for diagnosis .The Prodromal Questionnaire has long and short versions, with the latter focused on positive symptoms only, along with related distress and impairment.The PQ showed moderate agreement with SIPS diagnoses in an early psychosis clinic-referred sample with 90% sensitivity and 49% specificity, while the PQ-B showed stronger specificity in a similar sample, with 89% sensitivity and 68% specificity . The PROD-SCREEN has 29 items and showed moderate agreement with SIPS diagnoses in a sample of first-degree relatives of schizophrenia patients, and in a general population sample, with less accurate performance among psychiatric outpatients . Preliminary data for the PRIME SCREEN, developed by the authors of the SIPS, was promising , and a revised 12-item Japanese version showed perfect sensitivity and good specificity against SIPS diagnoses in an outpatient psychiatric sample, with predictive validity at 6-month follow-up of 11% . Three other self-report screens with published data include the Self-Screen –Prodrome , the Youth Psychosis At Risk Questionnaire , and the Adolescent Psychotic-Like Symptom Screener , although all calculated concordant validity using full psychosis/schizophrenia interviews or rating scales that were not psychosis risk measures per se. In sum, screening measures have shown moderate to good concordant validity against risk syndrome diagnosis, with less data available on validity of predicting conversion to full psychosis. They may be most useful in screening mental health patients, with less evidence at this point for use with the general public, which carries a high false positive rate. The percentages of CHR individuals who develop full psychosis range from 16% by 24 month follow-up to 70% by 9.6 years , with average transition rates across studies of 36.7% . Transition to psychosis was more likely in individuals with impaired role and social functioning, prodromal psychotic symptoms of longer duration, a family history of psychosis and more severe levels of prodromal symptoms at baseline . Transition rates are highest in the 6-month period after CHR diagnosis, with decreasing rates over time . Similar to risk assessment across all areas of medicine, transition rates also depend upon the selection process for the sample, with higher rates in “enriched” samples such as those seeking help specifically for potential CHR syndromes . Of note, transition rates to psychosis have declined over time in the published literature , indicating an increased proportion of people falsely identified as being “at-risk” for developing psychosis. Yung and colleagues suggest that individuals are being identified earlier in the course of their illness, pointing out that the duration of untreated attenuated psychotic symptoms in research samples has progressively decreased over time. As mentioned earlier, a longer period of untreated symptoms is associated with increased risk of transition to psychosis. Alternatively, previously employed follow-up times might not be sufficient in length to see these individuals ultimately transition to full psychosis. Outcomes may also possibly be more varied in the early course of CHR syndromes than later on. Finally, widely available interventions may further contribute to a decrease in transition rates, as treatment is never withheld from patients in “naturalistic” longitudinal studies. In addition to tracking psychotic transition rates, two recent studies attempted to characterize the functional and symptomatic outcomes of CHR “false-positives”. A significant percentage of “false-positives” continued to experience attenuated level psychotic symptoms, functional impairment, or both at follow up . Similarly, ongoing longitudinal studies are focusing on functional outcomes independent of conversion status, with a recent study showing that poor verbal learning and memory at baseline predicted worse functional outcome up to 13 years later . It is still unclear how to best conceptualize the symptoms and impairment seen in this group; although Schlosser and colleagues speculate that the stable attenuated level psychotic symptoms and functional impairment seen in these individuals might align more closely with a diagnosis of Schizotypal Personality Disorder than a CHR syndrome. The following vignette illustrates the assessment of attenuated positive symptoms in an adolescent, using the SIPS. This represents a typical case seen at the Prodrome Assessment, Research and Treatment clinic in the Department of Psychiatry at The University of California, San Francisco. Along with obtaining a description of the adolescent’s symptoms in her own words, a key goal of the assessment is to evaluate presenting symptoms across dimensions of onset, duration, frequency, degree of distress, degree of conviction or meaning attached to the experience and degree of interference in life areas.