[Questionnaire on Treatment Satisfaction in Inpatient Child and Adolescent Psychiatry (FBZ-KJP) - Results of a Swiss Pilot Study]. / Fragebogen zur Behandlungszufriedenheit in der stationären Kinder- und Jugendpsychiatrie (FBZ-KJP).

Questionnaire on Treatment Satisfaction in Inpatient Child and Adolescent Psychiatry (FBZ-KJP) - Results of a Swiss Pilot Study Abstract: Objectives: Patient satisfaction is an established indicator for medical interventions. Existing questionnaires for the assessment of patient satisfaction in child and adolescent psychiatry are too global to target quality improvement in child and adolescent psychiatric hospitals. The assessment of patient satisfaction in child and adolescent psychiatry is very challenging because specific demands (development status, role of parents in treatment) have been taken into account. Therefore, an expert team leaded by the Swiss Society of Child and Adolescent Psychiatry developed a targeted instrument to assess patient satisfaction in both language regions (i. e., German and French). Methods: The article reviews the development of a new child and adolescent psychiatric questionnaire for the assessment of patient satisfaction as well as the findings of a survey conducted in a representative sample of 174 patients and 145 parents in six hospitals. Results: The internal consistency (Cronbach's α = .93) is excellent. The questionnaire has high levels of both convergence and face validity, and the correlation with the Client Satisfaction Questionnaire (CSQ-8) is ρ = .80 (patient-report) and .83 (parent-report). Furthermore, this questionnaire reveals the relative strengths and weaknesses of individual hospitals. The correlation between patient and parent assessment is, as expected, moderate (ρ = .29, for the total score and ρ = .39 for the CSQ-8). Conclusions: The Patient Satisfaction Questionnaire can be recommended to professionals as a standard for collecting data on client satisfaction within child and adolescent psychiatry.

The Important Role of Stereotypes in the relation between Mental Health Literacy and Stigmatization of Depression and Psychosis in the Community.

Increased mental health literacy (MHL) has not reduced stigmatization of people with mental disorder. Thus, we examined the role of stereotypes in the interplay of MHL (correct labelling, causal explanations) and the wish for social distance (WSD) from people with depressive and psychotic symptoms in a community sample of 1526 German-speaking participants in the Swiss 'Bern Epidemiological At-Risk' study (age 16-40 years; response rate: 60.1%). Following the presentation of an unlabelled case vignette of depression or psychosis, MHL, stereotypes and WSD were assessed in a questionnaire survey. Their interrelations were studied using structural equation modelling. MHL was not directly linked to WSD, only the psychosocial causal model was directly negatively associated with WSD. Perceived dangerousness particularly increased WSD, this was increased by a biogenetic causal model and decreased by a psychosocial causal model. Awareness-campaigns that, next to biological causes, emphasize psychosocial causes of mental disorders might better reduce stigmatization.

Basic symptoms and gray matter volumes of patients at clinical high risk for psychosis.

BACKGROUND: Clinical high-risk (CHR) for psychosis is indicated by ultra-high risk (UHR) and basic symptom (BS) criteria; however, conversion rates are highest when both UHR and BS criteria are fulfilled (UHR&BS). While BSs are considered the most immediate expression of neurobiological aberrations underlying the development of psychosis, research on neurobiological correlates of BS is scarce. METHODS: We investigated gray matter volumes (GMV) of 20 regions of interest (ROI) previously associated with UHR criteria in 90 patients from the Bern early detection service: clinical controls (CC), first-episode psychosis (FEP), UHR, BS and UHR&BS. We expected lowest GMV in FEP and UHR&BS, and highest volume in CC with UHR and BS in-between. RESULTS: Significantly, lower GMV was detected in FEP and UHR&BS patients relative to CC with no other significant between-group differences. When ROIs were analyzed separately, seven showed a significant group effect (FDR corrected), with five (inferior parietal, medial orbitofrontal, lateral occipital, middle temporal, precuneus) showing significantly lower GM volume in the FEP and/or UHR&BS groups than in the CC group (Bonferroni corrected). In the CHR group, only COGDIS scores correlated negatively with cortical volumes. CONCLUSIONS: This is the first study to demonstrate that patients who fulfill both UHR and BS criteria - a population that has been associated with higher conversion rates - exhibit more severe GMV reductions relative to those who satisfy BS or UHR criteria alone. This result was mediated by the BS in the UHR&BS group, as only the severity of BS was linked to GMV reductions.

Predictors of help-seeking behaviour in people with mental health problems: a 3-year prospective community study.

BACKGROUND: The majority of people with mental illness do not seek help at all or only with significant delay. To reduce help-seeking barriers for people with mental illness, it is therefore important to understand factors predicting help-seeking. Thus, we prospectively examined potential predictors of help-seeking behaviour among people with mental health problems (N = 307) over 3 years. METHODS: Of the participants of a 3-year follow-up of a larger community study (response rate: 66.4%), data of 307 (56.6%) persons with any mental health problems (age-at-baseline: 16-40 years) entered a structural equation model of the influence of help-seeking, stigma, help-seeking attitudes, functional impairments, age and sex at baseline on subsequent help-seeking for mental health problems. RESULTS: Functional impairment at baseline was the strongest predictor of follow-up help-seeking in the model. Help-seeking at baseline was the second-strongest predictor of subsequent help-seeking, which was less likely when help-seeking for mental health problems was assumed to be embarrassing. Personal and perceived stigma, and help-seeking intentions had no direct effect on help-seeking. CONCLUSIONS: With only 22.5% of persons with mental health problems seeking any help for these, there was a clear treatment gap. Functional deficits were the strongest mediator of help-seeking, indicating that help is only sought when mental health problems have become more severe. Earlier help-seeking seemed to be mostly impeded by anticipated stigma towards help-seeking for mental health problems. Thus, factors or beliefs conveying such anticipated stigma should be studied longitudinally in more detail to be able to establish low-threshold services in future.

Age effects on basic symptoms in the community: A route to gain new insight into the neurodevelopment of psychosis?

Reports of limited clinical significance of attenuated psychotic symptoms before age 15/16 indicate an important role of neurodevelopment in the early detection of psychoses. Therefore, we examined if age also exerts an influence on the prevalence and clinical significance of the 14 cognitive and perceptive basic symptoms (BS) used in psychosis-risk criteria and conceptualized as the most direct self-experienced expression of neurobiological aberrations. A random representative general population sample of the Swiss canton Bern (N = 689, age 8-40 years, 06/2011-05/2014) was interviewed for BS, psychosocial functioning, and current mental disorder. BS were reported by 18% of participants, mainly cognitive BS (15%). In regression analyses, age affected perceptive and cognitive BS differently, indicating an age threshold for perceptive BS in late adolescence (around age 18) and for cognitive BS in young adulthood (early twenties)-with higher prevalence, but a lesser association with functional deficits and the presence of mental disorder in the below-threshold groups. Thereby, interaction effects between age and BS on functioning and mental disorder were commonly stronger than individual effects of age and BS. Indicating support of the proposed "substrate-closeness" of BS, differential age effects of perceptual and cognitive BS seem to follow normal brain maturation processes, in which they might occur as infrequent and temporary non-pathological disturbances. Their persistence or occurrence after conclusion of main brain maturation processes, however, might signify aberrant maturation or neurodegenerative processes. Thus, BS might provide important insight into the pathogenesis of psychosis and into differential neuroprotective or anti-inflammatory targets.

Prevalence and clinical relevance of interview-assessed psychosis-risk symptoms in the young adult community.

BACKGROUND: An efficient indicated prevention of psychotic disorders requires valid risk criteria that work in both clinical and community samples. Yet, ultra-high risk and basic symptom criteria were recently recommended for use in clinical samples only. Their use in the community was discouraged for lack of knowledge about their prevalence, clinical relevance and risk factors in non-clinical, community settings when validly assessed with the same instruments used in the clinic. METHODS: Using semi-structured telephone interviews with established psychosis-risk instruments, we studied the prevalence of psychosis-risk symptoms and criteria, their clinical relevance (using presence of a non-psychotic mental disorder or of functional deficits as proxy measures) and their risk factors in a random, representative young adult community sample (N=2683; age 16-40 years; response rate: 63.4%). RESULTS: The point-prevalence of psychosis-risk symptoms was 13.8%. As these mostly occurred too infrequent to meet frequency requirements of psychosis-risk criteria, only 2.4% of participants met psychosis-risk criteria. A stepwise relationship underlay the association of ultra-high risk and basic symptoms with proxy measures of clinical relevance, this being most significant when both occurred together. In line with models of their formation, basic symptoms were selectively associated with age, ultra-high risk symptoms with traumatic events and lifetime substance misuse. CONCLUSIONS: Psychosis-risk criteria were uncommon, indicating little risk of falsely labelling individuals from the community at-risk for psychosis. Besides, both psychosis-risk symptoms and criteria seem to possess sufficient clinical relevance to warrant their broader attention in clinical practice, especially if ultra-high risk and basic symptoms occur together.

Course of clinical high-risk states for psychosis beyond conversion.

BACKGROUND: The main focus of research on clinical high-risk states for psychosis (CHR) has been the development of algorithms to predict psychosis. Consequently, other outcomes have been neglected, and little is known about the long-term diagnostic and functional outcome among those not converting to psychosis. METHODS: In a naturalistic study, incidence, persistence, and remission rates of CHR states according to symptomatic ultra-high risk or cognitive disturbances criteria were investigated in 160 of 246 outpatients of an early detection of psychoses service (21.1% CHR negative and 78.9% CHR positive at baseline) who had not converted to psychosis within follow-up (median 53.7 months, range 13.9-123.7 months). RESULTS: Remission rate of CHR status was 43.3% of all 194 CHR-positive cases, including converters, or 72.4% if only the 116 non-converters were considered, persistence rate was 27.6%, and new occurrence rate in initially CHR-negative patients was 9.1%. At follow-up, 54.5% of the non-converters met criteria of at least one Axis-I diagnosis, mainly affective and anxiety disorders, and had functional problems. The severity of risk at baseline was not associated with a higher presence of Axis-I diagnosis at follow-up. CONCLUSIONS: During follow-up, CHR symptoms remitted in one-third of initially CHR-positive patients, while almost 10% met CHR criteria newly in CHR-negative adults presenting at early detection services. The presence of CHR criteria seems to maintain the risk for lower functioning and mental disorders, particularly for affective disorders. Thus, therapeutic efforts targeting CHR patients should also focus on the current mental disorders as well as social and role functions to improve the long-term outcome.

Negative symptoms, anxiety, and depression as mechanisms of change of a 12-month trial of assertive community treatment as part of integrated care in patients with first- and multi-episode schizophrenia spectrum disorders (ACCESS I trial).

Assertive community treatment (ACT) has shown to be effective in improving both functional deficits and quality of life (QoL) in patients with severe mental illness. However, the mechanisms of this beneficial effect remained unclear. We examined mechanisms of change by testing potential mediators including two subdomains of negative symptoms, i.e. social amotivation as well as expressive negative symptoms, anxiety, and depression within a therapeutic ACT model (ACCESS I trial) in a sample of 120 first- and multi-episode patients with a schizophrenia spectrum disorder (DSM-IV). Path modelling served to test the postulated relationship between the respective treatment condition, i.e. 12-month ACT as part of integrated care versus standard care, and changes in functioning and QoL. The final path model resulted in 3 differential pathways that were all significant. Treatment-induced changes in social amotivation served as a starting point for all pathways, and had a direct beneficial effect on functioning and an additional indirect effect on it through changes in anxiety. Expressive negative symptoms were not related to functioning but served as a mediator between changes in social amotivation and depressive symptoms, which subsequently resulted in improvements in QoL. Our results suggest that social amotivation, expressive negative symptoms, depression, and anxiety functioned as mechanisms of change of ACCESS. An integrated and sequential treatment focusing on these mediators may optimise the generalisation effects on functioning as well as on QoL by targeting the most powerful mechanism of change that fits best to the individual patient.

The association of psychopathology with concurrent level of functioning and subjective well-being in persons with schizophrenia spectrum disorders.

The objective is to investigate the relationship between psychopathology measured by the positive and negative syndrome scale (PANSS) and concurrent global assessment of functioning (GAF) and subjective well-being under neuroleptics (SWN) in patients with schizophrenia spectrum disorder (SSD) regarding severity of illness and disease phase. We analyzed a sample of 202 SSD patients consisting of first episode psychosis (FEP) and multiple episode psychosis (MEP) patients followed up to 12 months using linear mixed models. All PANSS syndromes except excitement were associated with GAF scores (positive syndrome: p < 0.001, d = 1.21; negative syndrome: p = 0.029, d = 0.015; disorganized syndrome: p < 0.001, d = 0.37; anxiety/depression syndrome: p < 0.001, d = 0.49), and positive symptoms had an increasing impact on global functioning with higher severity of illness (mildly ill: p = 0.039, d = 0.22; moderately ill: p < 0.001, d = 0.28; severely ill: p < 0.001, d = 0.69). SWN was associated with positive (p = 0.002, d = 0.22) and anxiety/depression (p < 0.001, d = 0.38) syndromes. Subgroup analyses showed differing patterns depending on illness severity and phase. Over all our results show different patterns of associations of psychopathology and concurrent functioning and subjective well-being. These findings contribute knowledge on the possible role of specific psychopathological syndromes for the functioning and well-being of our patients and may enable tailored treatments depending on severity and phase of illness.

Suicide in adolescents: findings from the Swiss National cohort.

Suicide in adolescents is the second most common cause of death in this age group and an important public health problem. We examined sociodemographic factors associated with suicide in Swiss adolescents and analysed time trends in youth suicide in the Swiss National Cohort (SNC). The SNC is a longitudinal study of the whole Swiss resident population, based on linkage of census and mortality records. We identified suicides in adolescents aged 10-18 years from 1991 to 2013. A total of 2.396 million adolescents were included and 592 suicides were recorded, corresponding to a rate of 3.7 per 100,000 [95% confidence interval (CI) 3.4-4.0]. Rates increased with age from 0.0 per 100,000 at age 10 years to 14.8 per 100,000 (95% CI 12.6-17.5) at 18 years in boys, and from 0.0 to 5.4 per 100,000 (4.1-7.2) in girls. Being a boy, living in a single parent household, being an only or middle-born child, and living in rural regions were factors associated with a higher rate of suicide. Hanging was the most common method in boys, and railway suicides were most frequent in girls. There was no clear evidence for an increase or decrease over calendar time. We conclude that familial and socioeconomic factors including type of household, birth order and urbanity are associated with youth suicide in Switzerland. These factors should be considered when designing prevention programmes for youth suicide.

Rates and predictors of 18-months remission in an epidemiological cohort of 661 patients with first-episode psychosis.

OBJECTIVES: Most first episode psychosis (FEP) outcome studies are based on patient samples enrolled through an informed consent procedure, which may induce important biases. Our aim was to study the 18-month outcome of FEP in an epidemiological sample of patients treated at the Early Psychosis Prevention and Intervention Centre (EPPIC). METHODS: The files of 661 FEP patients treated for up to 18 months between 1998 and 2000 were assessed. Symptomatic remission was defined as receiving a score ≤3 on the Clinical Global Impressions (CGI) scales, and functional remission as concurrent fulfillment of occupation/employment and independent living. Predictors were analyzed using stepwise logistic regression models. RESULTS: At endpoint, 63% of FEP patients had reached symptomatic remission and 44% functional remission. Duration of untreated psychosis, baseline symptom intensity, time in service and decrease or remission of substance use, predicted both symptomatic and functional outcome. A history of suicide attempt or non-adherence to medication was linked to lower likelihood to reach symptomatic remission while pre-morbid GAF and employment at baseline were linked to functional outcome. CONCLUSIONS: The development of early intervention strategies should be pursued, in order both to provide treatment before symptoms reach a high intensity and to maintain social integration. Specific strategies need to promote engagement, facilitate adherence to medication and to create a framework where key issues such as substance abuse co-morbidity can be addressed.

Age effect on prevalence of ultra-high risk for psychosis symptoms: replication in a clinical sample of an early detection of psychosis service.

Higher frequencies of perceptual and lesser clinical significance of non-perceptual attenuated psychotic symptoms (APS) have been reported by 8- to 15-year-old of the general population compared to 16- to 40-year-old. We examined if such an age-effect can also be detected in a clinical never-psychotic sample (N = 133) referred to a specialized service for clinical suspicion of developing psychosis. APS and brief intermittent psychotic symptoms (BIPS) were assessed using items P1-P3 and P5 (non-perceptual), and P4 (perceptual) of the Structured Interview for Psychosis-Risk Syndromes, current axis-I disorders with the Mini-International Neuropsychiatric Interview, and psychosocial functioning with the Social and Occupational Functioning Assessment Scale. In the sample, 64% reported APS (61%) or BIPS (7%); any perceptual APS/BIPS was reported by 43% and any non-perceptual APS/BIPS by 44%. In correspondence to the results in the general population sample, perceptual but not non-perceptual APS/BIPS were significantly more frequent in younger age groups below the age of 16 (8-12 years: odds ratio (OR) = 4.7 (1.1-19.5); 13-15 years: OR = 2.7 (0.9-7.7); 20-24-year-old as reference group). An age-effect of APS/BIPS on the presence of any current axis-I disorder (59%) or functional difficulties (67%) was not detected. However, when onset requirements of APS criteria (onset/worsening in past year) were met, the likelihood of a psychiatric diagnosis increased significantly with advancing age. Overall, the replicated age-effect on perceptual APS/BIPS in this clinical sample highlights the need to examine ways to distinguish clinically relevant perceptual APS/BIPS from perceptual aberrations likely remitting over the course of adolescence.

[Developmental Aspects in the Early Detection and Intervention in Clinical High Risk States for Psychosis]. / Entwicklungsspezifische Aspekte in der Früherkennung und Frühbehandlung eines erhöhten Psychoserisikos.

Developmental Aspects in the Early Detection and Intervention in Clinical High Risk States for Psychosis The early detection and intervention in psychoses, which are a main source of disability-adjusted life years already in children and adolescents, have made good progress within the past years. In particular the attenuated and transient positive symptoms of the ultra-high risk criteria and the basic symptom criterion "Cognitive Disturbances" open promising routes to an indicated prevention and have recently been considered as diagnostic criteria of a psychosis-risk syndrome by the European Psychiatric Association (EPA). However, because their association with a development of psychosis has been weaker in children and adolescents than in adults, only the assessment and monitoring of these risk symptoms was recommended for children and adolescents, while interventions aiming at the prevention of psychoses were discouraged. Furthermore, treatment of comorbid current mental disorders and psychosocial problems over the prevention of a potential future disorder also characterizes the intervention recommendations of the EPA. Furthermore, these give primacy to psychological, in particular cognitive-behavioral interventions over psychopharmacological treatments. Yet, also with regard to an early intervention, current evidence indicates that children and adolescents might benefit less than adults. Overall, age-related or developmental peculiarities in the early detection and intervention in psychoses become more and more apparent and should be more focused in future research in this field.

Attenuated psychotic and basic symptom characteristics in adolescents with ultra-high risk criteria for psychosis, other non-psychotic psychiatric disorders and early-onset psychosis.

While attenuated psychotic symptoms (APS) and basic symptoms (BS) are the main current predictors of psychosis in adults, studies in adolescents are scarce. Thus, we (1) described the prevalence and severity of positive, negative, disorganization, general, and basic symptoms in adolescent patients at ultra-high risk for psychosis (UHR), with other non-psychotic psychiatric disorders (PC) and with early-onset psychosis (EOP); and (2) investigated BS criteria in relation to UHR criteria. Sixty-nine 12-18-year-old adolescents (15.3 ± 1.7 years, female = 58.0 %, UHR = 22, PC = 27, EOP = 20) were assessed with the structured interview for prodromal syndromes (SIPS) and the schizophrenia proneness instrument-child and youth version (SPI-CY). Despite similar current and past 12-month global functioning, both UHR and EOP had significantly higher SIPS total and subscale scores compared to PC, with moderate-large effect sizes. Expectedly, UHR had significantly lower SIPS positive symptom scores than EOP, but similar SIPS negative, disorganized, and general symptom scores. Compared to PC, both EOP and UHR had more severe basic thought and perception disturbances, and significantly more often met cognitive disturbances criteria (EOP = 50.0 %, UHR = 40.9 %, PC = 14.8 %). Compared to UHR, both EOP and PC significantly less often met cognitive-perceptive BS criteria (EOP = 35.0 %, UHR = 68.2 %, PC = 25.9 %). BS were significantly more prevalent in both EOP and UHR than PC, and UHR were similar to EOP in symptom domains. Given the uncertain outcome of adolescents at clinical high-risk of psychosis, future research is needed to determine whether the combined assessment of early subjective disturbances with observable APS can improve the accuracy of psychosis prediction.

[Modular psychotherapy with children and adolescents]. / Modulare Psychotherapie im Kindes- und Jugendalter.

The implementation of evidence-based psychotherapy with children and adolescents has been limited so far. This is mainly due to the fact that patients in service settings tend to have higher rates of comorbidities and more frequently changing therapy needs than those in research settings. Thus, modular psychotherapies are promising, as they allow the treatment protocol to be adapted to patients' individual needs. Because no review on modular psychotherapy for children and adolescents exists, we conducted a systematic literature research. The results of the 15 randomized controlled trials identified demonstrate that modular psychotherapy is associated with significant reductions in symptom levels as well as with higher rates of diagnostic remission compared to control conditions. Because of the lack of evidence, future studies should investigate the incremental efficacy of modular approaches and test the validity of underlying theoretical models as well as of decision flowcharts. Modular psychotherapy approaches have the potential to personalize evidence-based interventions for children and adolescents across various therapeutical traditions, and to facilitate their implementation into clinical practice.

Duration of unspecific prodromal and clinical high risk states, and early help-seeking in first-admission psychosis patients.

PURPOSE: Prevention of psychosis requires both presence of clinical high risk (CHR) criteria and early help-seeking. Previous retrospective studies of the duration of untreated illness (i.e. prodrome plus psychosis) did not distinguish between prodromal states with and without CHR symptoms. Therefore, we examined the occurrence of CHR symptoms and first help-seeking, thereby considering effects of age at illness-onset. METHODS: Adult patients first admitted for psychosis (n = 126) were retrospectively assessed for early course of illness and characteristics of first help-seeking. RESULTS: One-hundred and nine patients reported a prodrome, 58 with CHR symptoms. In patients with an early illness-onset before age 18 (n = 45), duration of both illness and psychosis were elongated, and CHR symptoms more frequent (68.9 vs. 33.3 %) compared to those with adult illness-onset. Only 29 patients reported help-seeking in the prodrome; this was mainly self-initiated, especially in patients with an early illness-onset. After the onset of first psychotic symptoms, help-seeking was mainly initiated by others. State- and age-independently, mental health professionals were the main first point-of-call (54.0 %). CONCLUSIONS: Adult first-admission psychosis patients with an early, insidious onset of symptoms before age 18 were more likely to recall CHR symptoms as part of their prodrome. According to current psychosis-risk criteria, these CHR symptoms, in principle, would have allowed the early detection of psychosis. Furthermore, compared to patients with an adult illness-onset, patients with an early illness-onset were also more likely to seek help on their own account. Thus, future awareness strategies to improve CHR detection might be primarily related to young persons and self-perceived subtle symptoms.

Patterns and correlates of expressed emotion, perceived criticism, and rearing style in first admitted early-onset schizophrenia spectrum disorders.

The aim of this study was to assess patterns and correlates of family variables in 31 adolescents treated for their first episode of a schizophrenia spectrum disorder (early-onset schizophrenia [EOS]). Expressed emotion, perceived criticism, and rearing style were assessed. Potential correlates were patient psychopathology, premorbid adjustment, illness duration, quality of life (QoL), sociodemographic variables, patient and caregiver "illness concept," and caregiver personality traits and support. Families were rated as critical more frequently by patients than raters (55% vs. 13%). Perceived criticism was associated with worse QoL in relationship with parents and peers. An adverse rearing style was associated with a negative illness concept in patients, particularly with less trust in their physician. Future research should examine perceived criticism as a predictor of relapse and indicator of adolescents with EOS who need extended support and treatment. Rearing style should be carefully observed because of its link with patients' illness concept and, potentially, to service engagement and medication adherence.

[Changes to Schizophrenia Spectrum and other psychotic disorders in DSM-5]. / Psychotische Störungen im DSM-5. Die revisionen.

This article provides an overview of the main changes in the chapter "Schizophrenia Spectrum and Other Psychotic Disorders" from DSM-IV-TR to DSM-5, which, once again, does not make allowance for potential characteristics of children and adolescents. Changes in the main text include abandoning the classical subtypes of Schizophrenia as well as of the special significance of Schneider's first-rank symptoms, resulting in the general requirement of two key features (one having to be a positive symptom) in the definition of Schizophrenia and the allowance for bizarre contents in Delusional Disorders. Further introduced are the diagnosis of a delusional obsessive-compulsive/body dysmorphic disorder exclusively as Obsessive-Compulsive Disorder, the specification of affective episodes in Schizoaffective Disorder, and the formulation of a distinct subchapter "Catatonia" for the assessment of catatonic features in the context of several disorders. In Section III (Emerging Measures and Models) there is a recommendation for a dimensional description of psychoses. A likely source of confusion lies in the double introduction of an "Attenuated Psychosis Syndrome." On the one hand, a vague description is provided among "Other Specified Schizophrenia Spectrum and Other Psychotic Disorders" in the main text; on the other hand, there is a precise definition in Section III as a "Condition for Further Study." There is some cause to worry that this vague introduction of the attenuated psychosis syndrome in the main text might indeed open the floodgates to an overdiagnosis of subthreshold psychotic symptoms and their early pharmacological treatment.

Gender differences in first episode psychotic mania.

BACKGROUND: The aim of this paper was to delineate the impact of gender on premorbid history, onset, and 18 month outcomes of first episode psychotic mania (FEPM) patients. METHODS: Medical file audit assessment of 118 (male = 71; female = 47) patients with FEPM aged 15 to 29 years was undertaken on clinical and functional measures. RESULTS: Males with FEPM had increased likelihood of substance use (OR = 13.41, p <.001) and forensic issues (OR = 4.71, p = .008), whereas females were more likely to have history of sexual abuse trauma (OR = 7.12, p = .001). At service entry, males were more likely to be using substances, especially cannabis (OR = 2.15, p = .047), had more severe illness (OR = 1.72, p = .037), and poorer functioning (OR = 0.96, p = .045). During treatment males were more likely to decrease substance use (OR = 5.34, p = .008) and were more likely to be living with family (OR = 4.30, p = .009). There were no gender differences in age of onset, psychopathology or functioning at discharge. CONCLUSIONS: Clinically meaningful gender differences in FEPM were driven by risk factors possibly associated with poor outcome. For males, substance use might be associated with poorer clinical presentation and functioning. In females with FEPM, the impact of sexual trauma on illness course warrants further consideration.

'A rose is a rose is a rose', but at-risk criteria differ.

BACKGROUND: Over the last 15 years, efforts to detect psychoses early in their prodromal states have greatly progressed; meanwhile, ultra-high risk (UHR) criteria have been the subject of such consensus that parts of them have been proposed for inclusion in DSM-5 in terms of an attenuated psychosis syndrome. However, it is frequently unacknowledged that the definitions and operationalizations of UHR-related at-risk criteria, including the relevant attenuated psychotic symptoms, vary considerably across centers and time and, thus, between prediction studies. METHODS: These variations in UHR criteria are described and discussed with reference to the rates of transition to psychosis, their prevalence in the general population and the proposed new operationalization of the attenuated psychosis syndrome. RESULTS: A comparison of samples recruited according to different UHR operationalizations reveals differences in the distribution of UHR criteria and transition rates as well as in the prevalence rates of at-risk criteria in the general population. CONCLUSION: The evidence base for the introduction of such a new syndrome is weaker than the number of studies using supposedly equal UHR criteria would at first suggest. Thus, studies comparing the effects of different (sub-)criteria not only on transition rates and outcomes but also on other important aspects, such as neurocognitive performance and brain imaging results, are necessary. Meanwhile, the preliminary attenuated psychosis syndrome in DSM-5 should not follow an altogether new definition but, rather, the currently most reliable UHR definition, which must still demonstrate its reliability and validity outside specialized psychiatric services.