The assessment of paranoia in young people: Item and test properties of the Bird Checklist of Adolescent Paranoia.

BACKGROUND: Precise assessment tools for psychotic experiences in young people may help identify symptoms early and facilitate advances in treatment. In this study we provide an exemplar - with a paranoia scale for youth - for improving measurement precision for psychotic experiences using item response theory (IRT). We evaluate the psychometric properties of the new measure, test for measurement invariance, and assess its potential for computerised adaptive testing (CAT). METHOD: The 18-item Bird Checklist of Adolescent Paranoia (B-CAP) was completed by 1102 adolescents including 301 patients with mental health problems and 801 from the general population. After excluding outliers (n = 10), IRT was used to examine item properties, test reliability, and measurement invariance. The properties of an adaptive B-CAP were assessed using a simulation of 10,000 responses. RESULTS: All B-CAP items were highly discriminative (a = 1.14-2.77), whereby small shifts in paranoia led to a higher probability of item endorsement. Test reliability was high (a > 0.90) across a wide range of paranoia severity (θ = -0.45-3.36), with the greatest precision at elevated levels. All items were invariant for gender, age, and population groups. The simulated adaptive B-CAP performed with high accuracy and required only 5-6 items at higher levels of paranoia severity. CONCLUSIONS: The B-CAP is a reliable assessment tool with excellent psychometric properties to assess both non-clinical and clinical levels of paranoia in young people, with potential as an efficient adaptive test. In future, these approaches could be used to develop a multidimensional CAT to assess the full range of psychotic experiences in youth.

Autonomic arousal during psychosis spectrum experiences: Results from a high resolution ambulatory assessment study over the course of symptom on- and offset.

INTRODUCTION: Ecological momentary assessment (EMA) studies show that stressors trigger the onset or increase of psychotic symptoms. These studies, however, predominantly rely on large sampling intervals and self-report assessment. This study aims to identify the autonomic stress-response to psychosis-spectrum experiences by using a one-day high-resolution EMA with continuous skin conductance and heart rate monitoring in a sample with attenuated positive symptoms. METHODS: Sixty-two participants were equipped with a smartphone and wearable sensors to monitor skin conductance level (SCL) and heart rate variability (HRV) for 24 h. Every 20 min, participants answered questions on current stress, hallucination spectrum experiences (HSE), and paranoia. Sampling intervals were categorized into no event, pre-onset, event, pre-offset, and post-offset phases. We contrasted stress, SCL, and HRV between phases using multilevel regression models of sampling intervals nested in participants. RESULTS: For paranoia, we found alterations in the autonomic and self-reported stress response prior to the onset that persisted until the episodes had ended. For HSE, we found no effects. Exploratory separate analyses of the different items aggregated into HSE yielded diverging results for intrusive thoughts, perceptual sensitivity, and hallucinations. CONCLUSION: Physiological parameters are sensitive indicators of the onset of paranoia, which holds implications for preventive mobile interventions. To further explore the autonomic stress-response associated with HSE, further studies of the different HSE are needed.

Cognitive Bias Modification for paranoia (CBM-pa): study protocol for a randomised controlled trial.

BACKGROUND: Persecutory delusions are the most common type of delusions in psychosis and present in around 10-15% of the general population. Persecutory delusions are thought to be sustained by biased cognitive and emotional processes. Recent advances favour targeted interventions, focussing on specific symptoms or mechanisms. Our aim is to test the clinical feasibility of a novel psychological intervention, which manipulates biased interpretations toward more adaptive processing, in order to reduce paranoia in patients. METHODS: The 'Cognitive Bias Modification for paranoia' (CBM-pa) study is a feasibility, double-blind, randomised controlled trial (RCT) for 60 stabilised outpatients with persistent, distressing paranoid symptoms. Patients will be randomised at a 50:50 ratio, to computerised CBM-pa or a text-reading control intervention, receiving one 40-min session per week, for 6 weeks. CBM-pa involves participants reading stories on a computer screen, completing missing words and answering questions about each story in a way that encourages more helpful beliefs about themselves and others. Treatment as Usual will continue for patients in both groups. Patients will be assessed by a researcher blind to allocation, at baseline, each interim session, post treatment and 1- and 3-month follow-up post treatment. The primary outcome is the feasibility parameters (trial design, recruitment rate and acceptability) of the intervention. The secondary outcomes are clinical symptoms (including severity of paranoia) as assessed by a clinical psychologist, and 'on-line' measurement of interpretation bias and stress/distress. The trial is funded by the NHS National Institute for Health Research. DISCUSSION: This pilot study will test whether CBM-pa has the potential to be a cost-effective, accessible and flexible treatment. If the trial proves feasible and demonstrates preliminary evidence of efficacy, a fully powered RCT will be warranted. TRIAL REGISTRATION: Current Controlled Trials ISRCTN: 90749868 . Retrospectively registered on 12 May 2016.

Discussion of difficult assessment cases: psychodynamic perspectives.

I discuss the papers of Kleiger (this issue), Husain (this issue), and Bram (this issue), each of whom described their personality assessment of a very challenging case. Each case illustrates the way in which experienced personality assessors integrate psychoanalytic theory with clinical reasoning, multi-method assessment, and an understanding of the patient-examiner relationship when evaluating patients with serious psychiatric needs. The discussion elaborates particular aspects of each case and integrates the different estuaries through which personality assessors use psychoanalytic theory to develop diagnostic and treatment inferences.

Categorization of aggressive acts committed by chronically assaultive state hospital patients.

OBJECTIVE: This study examined factors motivating inpatient aggression in a sample of chronically assaultive state hospital patients. METHODS: Inpatients who had committed three or more assaults over a one-year period were identified by using an incident report database. Aggressive episodes were categorized as impulsive, organized, or psychotic by using a procedure for classifying assaultive acts based on record review. Each assault type was further subcategorized. The relationship between assault type, victim (staff or patient), and legal status of the assaulter was also assessed. RESULTS: A total of 839 assaults committed by 88 chronically aggressive patients were reviewed. Although most patients had a primary psychotic disorder, the most common type of assault was impulsive (54%), rather than psychotic or organized. Staff were most often victimized by impulsive assaults in situations involving attempts to change a patient's unwanted behavior and refusal of a patient request. Organized and psychotic assaults occurred less frequently (29% and 17%, respectively) and were more likely to target other patients. Organized assaults were most often motivated by a desire to seek revenge. Psychotic assaults were most often committed by an assailant acting under the influence of paranoid ideations. Civilly committed patients were overrepresented in the sample. Criminally committed patients committed more acts of organized aggression, although this finding did not reach significance. CONCLUSIONS: These findings indicate that assaultive behavior among state hospital inpatients is complex and heterogeneous. Because each type of assault requires a different management approach, characterizing aggressive behavior may be important in determining which institutional programs and treatment-plan interventions to implement when addressing inpatient aggression.

[Self-rating scales in schizophrenia: validity assessment of the Paranoid-Depression Scale (PD-S), the Frankfurt Self-feeling Scale (FBS) and of two visual analogy scales]. / Skale samooceny nasilenia objawów schizofrenicznych: ocena trafnosci "Skali nastawien i nastroju" (PD-S), "Frankfurckiej skali samopoczucia" (FBS) oraz dwóch skal analogii wzrokowej.

AIM: To assess the validity of the Paranoid-Depressivity Scale (PD-S, Paranoid-Depresivitäts-Skala), the Frankfurt Self-feeling Scale (FBS, Frankfurter Befindlichkeitsskala), and of two visual analogy scales: the Sense of Illness Scale (WAC) and the Self-feeling Scale (WAS). METHOD: 210 patients with schizophrenia of various clinical courses. Diagnostic validity was evaluated by comparing the results of self-rating with clinical assessment using the CGI, KOSS-C, BPRS, and KOSS-W scales. Content validity was evaluated by analysis of the results' correlation with given clinical and social-demographic variables. Theoretical (construct) validity was evaluated through factorial analysis with Varimax rotation of the principal elements. RESULTS: The correlation between the self-rating scales and the clinical assessment scales was moderate in the case of questionnaire scales and low for the visual analogy scales. Scales of a similar type were found to correlate to a very high degree. Correlation with clinical assessment depended significantly on the phase and degree of disorder--it was lower in periods of exacerbation and higher during remission. The results of the complex questionnaire scales en somme, correlate better with symptoms considered as typical for schizophrenia, than with others, whereas the isolated self-rating constructs (paranoid, depressive) correlate well with the appropriate dimensions of clinical assessment. There was no significant correlation between the clinical symptoms and dimensions, and the results of self-rating using the two visual analogy scales. Factorial analysis revealed that the internal structure of the basic constructs of the questionnaire scales (general attitude, mood, self-feeling) was based on a very rational concept, as well as the fact that the factors isolated have a rational foundation within the theoretical and clinical picture of schizophrenic disorders. CONCLUSIONS: The validity of self-rating scales remains a complex question; analysis of diagnostic, content and theoretical validity seems to confine this method to the role of a complementary, albeit interesting, diagnostic tool; the extent and importance of this role, however, is still to be investigated.

[Self-rating scales in schizophrenia: assessment of the practical applicability of the Paranoid-Depression Scale (PD-S), the Frankfurt Self-feeling Scale (FBS) and of two visual analogue scales]. / Skale samooceny stanu psychicznego w schizofrenii: ocena praktycznosci "Skali nastawien i nastroju" (PD-S), "Frankfurckiej skali samopoczucia" (FBS) oraz dwóch skal analogii wzrokowej.

AIM: To assess the practical feasibility of the Paranoid-Depressivity Scale (PD-S, Paranoid-Depresivitäts-Skala), the Frankfurt Self-feeling Scale (FBS, Frankfurter Befindlichkeitsskala), and two visual analogy scales of: sense of illness (WAC) and self-feeling (WAS). METHOD: 210 patients with schizophrenia of various clinical courses. All patients in the study group were required to complete each scale twice, at 48 hr intervals. For statistical analysis, two sets of data were singled out (1) the relationship between refusal/inability to complete the scale repeatedly and the selected clinical variables; (2) observations made by the doctor, while the patient was completing the scales. RESULTS: Statistical analysis revealed, that clinical factors like restlessness, autism, maladaptation, recurrence/remission and lower educational status imply a significantly lower readiness of the patient towards completion of self-rating scales. The visual analogy scales were those more readily--and easily--completed by the patients; their interpretation, however, is difficult. Given this, the authors of this paper decided to shorten the questionnaire scales, which reducing the whole to aspects of vital diagnostic relevance. Whether this operation would influence the scales' diagnostic value, required ex-post analysis, which was subsequently performed. Summary analysis revealed that the application of the shortening of the PD-S and FBS had no significant impact on these scales' reliability and validity indices; furthermore, it resulted in a significant decline in the number of ambiguities and thus improved the comprehensiveness of the questionnaire's structure. Also, a significant increase in concordance between the self-rating results and the clinicians' diagnoses was observed. CONCLUSIONS: Visual analogy scales are the more readily and easily applied in practice; a comprehensive interpretation is, however, virtually impossible. On the other hand, the PD-S and FBS are the more difficult for the patients to complete, due to their length, but their interpretation does not constitute a major problem. Ex-post analysis reveals, that shortening the complex questionnaires to their core aspects does not affect their psychometric value negatively; in fact--the contrary. The latter statement, however, requires verification in prospective studies.

The course of psychopathologic features in mild to moderate Alzheimer disease.

BACKGROUND: The onset and course of the psychopathologic features of Alzheimer disease have not been established in prospective, longitudinal studies. METHODS: Two hundred thirty-five patients with early, probable Alzheimer disease were recruited at 3 sites and observed naturalistically for up to 5 years. At 6-month intervals, the Columbia University Scale for Psychopathology in Alzheimer's Disease was administered. Markov analyses were used to predict the probability of a specific symptom developing or being maintained at the next visit. For each symptom category, the maximum frequency of occurrence at 4 consecutive points (duration, 2 years) was calculated. RESULTS: Misidentification, wandering or agitation, and physical aggression increased during follow-up. At any visit, the likelihood of a new symptom developing was greatest for behavioral disturbance, intermediate for paranoid delusions and hallucinations, and least for depressed mood with vegetative features. Wandering or agitation occurred at 3 or more of 4 consecutive visits (duration, 2 years) in the majority of patients, paranoid delusions and hallucinations were intermediate in their degree of persistence, and depressed mood with vegetative signs rarely persisted. CONCLUSIONS: Behavioral disturbance, particularly agitation, is common and persistent in patients with Alzheimer disease. Psychotic symptoms are less common and show moderate persistence over time. Depressed mood with vegetative signs is uncommon and rarely persists. These findings suggest leads about the optimal treatment duration for specific subtypes of psychopathologic features.

Assessment of potential violence in the paranoid worker.

Violence in the workplace is sometimes a manifestation of an untreated psychiatric disorder. Paranoid personality disorder, paranoid schizophrenia, and delusional (paranoid) disorder are three psychiatric syndromes in which paranoid ideation is a prominent feature. While the vast majority of people with these conditions are not violent, paranoid workers can exhibit violent behavior as a reaction to beliefs that co-workers or supervisors are threatening or persecuting them. Three cases are described to illustrate the clinical presentation of these disorders and their management in an occupational setting.

[A computer algorithm for diagnostic assessment with DSM-III in the early course of schizophrenic diseases]. / Ein Computer-Algorithmus zur Diagnosevergabe nach DSM-III im frühen Verlauf schizophrener Erkrankungen.

The purpose of the computer algorithm described here is the evaluation of diagnostic criteria according to DSM-III for schizophrenia and schizophreniform disorders. It also dates the first time point of the assessment of these diagnoses. The necessary information comes from a semistructured interview, called IRAOS (Interview for the Retrospective Assessment of the Onset of Schizophrenia). With this interview early indicators of a beginning schizophrenia can be evaluated in their chronological order and their type of course. The algorithm was first used in a sample of patients admitted for the first time with a diagnosis of either schizophrenia or paranoid psychosis. One third of these patients fulfills the DSM-III-criterion of a duration of at least six months. The other patients fulfill criterion B of a schizophreniform disorder. To strengthen the validity of a diagnosis including the criteria A up to E successively, the sample is reduced to 70%. The average time point of the first assessment of the diagnosis by the computer algorithm is about 1.5 years before the index-admission. Together with the IRAOS the computer algorithm allows an operationalized assessment of the real onset of schizophrenia.

Psychiatric assessment of elderly patients in the home: a survey of 176 cases.

One hundred and seventy-six homebound elderly patients referred for psychiatric evaluation by family, physician, or community agency were assessed in the home by a geriatrician psychiatrist, accompanied by those involved with the patient's care, whenever possible. Careful attention was paid to the interaction between psychiatric, medical, and social parameters and their collective effect on the aging patient. The most common discrete psychiatric diagnoses were dementia, with or without secondary symptoms; major depression; and paranoid states without dementia. Assessment resulted in home treatment and maintenance through a variety of supportive interventions frequently accompanied by chemotherapy, emergency psychiatric and medical hospitalization, and placement, as well as education of family and community workers.