Observational Study
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World J Psychiatry. Mar 19, 2022; 12(3): 425-449
Published online Mar 19, 2022. doi: 10.5498/wjp.v12.i3.425
Clinical high-risk criteria of psychosis in 8–17-year-old community subjects and inpatients not suspected of developing psychosis
Frauke Schultze-Lutter, Petra Walger, Maurizia Franscini, Nina Traber-Walker, Naweed Osman, Helene Walger, Benno G Schimmelmann, Rahel Flückiger, Chantal Michel
Frauke Schultze-Lutter, Petra Walger, Naweed Osman, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf 40629, North-Rhine Westphalia, Germany
Frauke Schultze-Lutter, Department of Psychology, Faculty of Psychology, Airlangga University, Surabaya 60286, Indonesia
Frauke Schultze-Lutter, Benno G Schimmelmann, Rahel Flückiger, Chantal Michel, University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern 3000, Switzerland
Maurizia Franscini, Nina Traber-Walker, Department of Child and Adolescent Psychiatry and Psychotherapy, University of Zürich, Zürich 8032, Germany
Helene Walger, Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich 80336, Bavaria, Germany
Benno G Schimmelmann, University Hospital of Child and Adolescent Psychiatry, University Hospital Hamburg-Eppendorf, Hamburg 20246, Germany
Author contributions: Schultze-Lutter F and Schimmelmann BG designed the study; Walger P, Franscini M, Traber-Walker N, Flückiger R and Michel C were involved in the acquisition of data; Schultze-Lutter F and Michel C analyzed and interpreted the data for the work and drafted the first version of this work; all authors revised the article critically for important intellectual content, and agreed to the submitted version.
Supported by the conjoint research grant of the Swiss National Science Foundation, SNSF, No. 144100; and the German Research Foundation, DFG, No. 231563730, within the Lead Agency Process (SNSF as exclusive evaluating and approving lead agency).
Institutional review board statement: The study was reviewed and approved by the Kantonale Ethikkommission Bern, the Institutional Review Board of the University of Bern (No. 174/10), the Kantonale Ethik-Kommission Zürich, the Institutional Review Board of the University of Zurich (No. 2010-0415/3), and the Ethikkommision Köln, the Institutional Review Board of the Medical Faculty of the University of Cologne (No. 11-071).
Informed consent statement: All study participants, and their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: Schimmelmann BG received honoraria for presentations by Takeda and InfectoPharm outside the reported work. All other authors reported no conflict of interest.
Data sharing statement: Data is available upon reasonable request for clearly defined scientific purposes from the corresponding author at frauke.schultze-lutter@lvr.de. Participants of the BEARS-Kid study gave informed consent for sharing of anonymized data.
STROBE statement: The authors have read the STROBE Statement checklist of items, and the manuscript was prepared and revised according to the STROBE Statement checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Frauke Schultze-Lutter, MSc, PhD, Assistant Professor, Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Bergische Landstraße 2, Düsseldorf 40629, North-Rhine Westphalia, Germany. frauke.schultze-lutter@lvr.de
Received: April 14, 2021
Peer-review started: April 14, 2021
First decision: July 14, 2021
Revised: July 26, 2021
Accepted: September 19, 2021
Article in press: September 19, 2021
Published online: March 19, 2022
Abstract
BACKGROUND

In children and adolescents compared to adults, clinical high-risk of psychosis (CHR) criteria and symptoms are more prevalent but less psychosis-predictive and less clinically relevant. Based on high rates of non-converters to psychosis, especially in children and adolescents, it was suggested that CHR criteria were: (1) Pluripotential; (2) A transdiagnostic risk factor; and (3) Simply a severity marker of mental disorders rather than specifically psychosis-predictive. If any of these three alternative explanatory models were true, their prevalence should differ between persons with and without mental disorders, and their severity should be associated with functional impairment as a measure of severity.

AIM

To compare the prevalence and severity of CHR criteria/symptoms in children and adolescents of the community and inpatients.

METHODS

In the mainly cross-sectional examinations, 8–17-year-old community subjects (n = 233) randomly chosen from the population register of the Swiss Canton Bern, and inpatients (n = 306) with primary diagnosis of attention-deficit/hyperactivity disorder (n = 86), eating disorder (n = 97), anxiety including obsessive–compulsive disorder (n = 94), or autism spectrum disorder (n = 29), not clinically suspected to develop psychosis, were examined for CHR symptoms/criteria. Positive items of the Structured Interview for Psychosis-Risk Syndromes (SIPS) were used to assess the symptomatic ultra-high-risk criteria, and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) was used to assess the 14 basic symptoms relevant to basic symptom criteria. We examined group differences in frequency and severity of CHR symptoms/criteria using χ2 tests and nonparametric tests with Cramer’s V and Rosenthal’s r as effect sizes, and their association with functioning using correlation analyses.

RESULTS

The 7.3% prevalence rate of CHR criteria in community subjects did not differ significantly from the 9.5% rate in inpatients. Frequency and severity of CHR criteria never differed between the community and the four inpatient groups, while the frequency and severity of CHR symptoms differed only minimally. Group differences were found in only four CHR symptoms: suspiciousness/persecutory ideas of the SIPS [χ2 (4) = 9.425; P = 0.051, Cramer’s V = 0.132; and Z = -4.281, P < 0.001; Rosenthal’s r = 0.184], and thought pressure [χ2 (4) = 11.019; P = 0.026, Cramer’s V = 0.143; and Z = -2.639, P = 0.008; Rosenthal’s r = 0.114], derealization [χ2 (4) = 32.380; P < 0.001, Cramer’s V = 0.245; and Z = -3.924, P < 0.001; Rosenthal’s r = 0.169] and visual perception disturbances [χ2 (4) = 10.652; P = 0.031, Cramer’s V = 0.141; and Z = -2.822, P = 0.005; Rosenthal’s r = 0.122] of the SPI-CY. These were consistent with a transdiagnostic risk factor or dimension, i.e., displayed higher frequency and severity in inpatients, in particular in those with eating, anxiety/obsessive–compulsive and autism spectrum disorders. Low functioning, however, was at most weakly related to the severity of CHR criteria/symptoms, with the highest correlation yielded for suspiciousness/persecutory ideas (Kendall’s tau = -0.172, P < 0.001).

CONCLUSION

The lack of systematic differences between inpatients and community subjects does not support suggestions that CHR criteria/symptoms are pluripotential or transdiagnostic syndromes, or merely markers of symptom severity.

Keywords: Psychotic disorders, Risk assessment, Minors, Community, Inpatients, Psychosocial functioning

Core tip: Clinical high-risk of psychosis (CHR) criteria and symptoms are more prevalent but less psychosis-predictive and clinically relevant in minors compared to adults, and, therefore, alternatively proposed as pluripotential, transdiagnostic risk factors, or severity markers of mental disorders. If any of these explanatory models were true, their prevalence should differ between 8–17-year-old community subjects (n = 233) and inpatients (n = 306), included in our study, and their severity should be associated with psychosocial functioning. Yet, CHR criteria and symptoms hardly differed between groups and were at most weakly associated with functioning. Consequently, our study did not support any alternative explanatory model of CHR criteria.