Instruments Developed by the Hafner Group

The Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS)

The IRAOS [24-26] is the most differentiated of the currently available retrospective early-recognition instruments. It is now available in an enlarged version [27], applicable to all types of psychotic illness and fully compatible with the first version [24-26]. It comprises the assessment of individual biography and social development in the most important social roles, of premorbid adjustment, emergence and accumulation of prodromal signs, of symptoms, abnormal behaviour, functional impairment and social disability. On the basis of IRAOS data it is possible to assess symptom onset, prodromal and psychotic onset, accumulation of symptoms and impairments, and social course. The IRAOS is used by psychiatrists or psychologists.

The development of the IRAOS started with the compilation of a list of prodromal signs and symptoms on an empirical basis. First the literature was skimmed through for symptoms of incipient schizophrenia. A total of 240 symptoms were identified and were included in a questionnaire submitted to experts. Psychiatrists with at least two years work experience at four psychiatric hospitals were asked to rate the relevance of the prodromal and psychotic symptoms listed in incipient schizophrenia.

The list of symptoms generated in this way was integrated in the IRAOS in the form of closed questions and supplemented by open questions that the patient or his/her key informant are asked on the symptoms marking the onset of the disorder and on the timepoint of their emergence. During the revision of the IRAOS the symptom list was expanded to include 128 items, in order to be able to determine at which point in time the person assessed first fulfilled the criteria for an ICD-10 diagnosis of schizophrenia, affective disorder or other psychosis.

Biographical data on social development and illness course are collected on the basis of six roles relevant in the professional and family context and to the individual's objective social status. In this way individual social development, baseline at illness onset and possible interruptions or delays in social ascent can be determined. Besides the general sociodemographic data the IRAOS provides information on the patient's physical health, family situation and history of mental illness. Major life events are assessed on the basis of a layered time matrix divided into units which increase in length with growing distance to the interview (weeks, months, years). Individual anchor events, such as birthdays, holidays and family celebrations are recorded, which help the interviewee to remember the time of symptom emergence in relation to these events. Symptom emergence and remission are recorded in a calendar of episodes.

In a test-retest design two independent interviewers evaluated the IRAOS symptoms in a period varying from 7 to 15 months (mean: 10.4 months). As kappa values were low due to skewed symptom distributions, we report pairwise agreement rates (PAR): for 47% of the IRAOS symptoms PAR was between 0.60 and 0.79, and for another 27.3% it was between 0.80 and 1.00. Only in 4.5% of the symptoms was PAR below 0.40.

To control for recall deficits or memory biases, data were collected from three sources: patient, his/her closest relative and documents (e.g. medical records). The comparison of prodromal signs and symptoms as perceived by the patients and their significant others and registered by a family doctor, in school records etc. offered an important chance for testing the reliability of the information given by the patients. Hambrecht and Hafner [164] compared individual IRAOS data obtained from the patients in the ABC first-episode sample with the data provided by their family members who were in sufficiently close contact with the patients during the period of onset and early illness. Self-perceived symptoms such as subjective thought disorders, which usually cannot be observed by others, had relatively low kappa and percentual agreement rates. High agreement rates of 0.8 and 0.9 were achieved on observable behaviour such as attempted suicide or disturbances of concentration and thinking. Concerning the time of symptom emergence, single psychotic phenomena such as delusions and hallucinations were frequently observed by the relatives with an average of only one month's delay. Nonspecific and negative symptoms, such as mild depression or loss of energy, were frequently noticed by the family members with a mean delay of six months. Still somewhat later (up to 12 months), these symptoms were noted in the documents such as medical case records etc., demonstrating that the patients communicated the onset of their first symptoms with a shorter delay to their relatives than to their doctors. The authors found a surprisingly high degree of agreement in overall estimates of the time of illness onset and of the milestones of the early course between the patients and their family members. As a result, the retrospectively collected IRAOS data yields a valid representation of the early course of schizophrenia at least as far as mean values are concerned.

Meanwhile, the IRAOS has been applied not only in the ABC study, but also by a great number of research teams working on the early and later course of psychosis in many countries (e.g. 165,166).

The Early Recognition Inventory (ERIraos)

The ERIraos is a two-step procedure. First, potential at-risk persons are identified using a checklist. Then the persons thus identified are examined at an early intervention centre using the complete symptom list of the inventory as well as the modules and associated instruments designed for the assessment of risk factors.

The 17-item screening instrument of the ERIraos, the checklist, is designed to make persons at an increased risk of psychosis aware of this risk in order to enable them to get in touch with an early intervention centre. The checklist should sharpen the awareness of general practitioners, counselling services, psychologists, teachers etc. and facilitate the recognition of psychosis risk as early as the prodromal phase. If a defined cut-off is reached, the person in question should be referred to an early intervention centre for a more detailed risk assessment. The checklist is designed to avoid a hastened exclusion of at-risk persons (so-called false negatives) thus providing a low threshold in order to make sure that as few false decisions as possible are made at this stage of diagnosis.

The checklist is available as an interview and as a questionnaire. The checklist interview is administed by a general practitioner or some other professional contact person, whereas the questionnaire version is done by the respondent without assistance.

The core element of the ERIraos is the symptom list, which includes 110 symptoms of beginning schizophrenia. It mainly contains prodromal symptoms of schizophrenia (unspecific symptoms, depressive symptoms, basic symptoms), but in addition it also includes psychotic symptoms, because in some at-risk persons obvious psychotic symptoms of short duration are already present in the prodromal phase. The inclusion of psychotic symptoms makes it possible to identify transition to psychosis, a prerequisite for recognizing psychotic episodes earlier than under the current conditions of treatment. It also allows one to study the course of schizophrenia from onset to full blown psychosis and the long-term course of the disorder.

The ERIraos symptom list is divided into 12 sections:

501 Introductory questions

502 Changes in mood, interest and drive

503 Disturbance of sleep and appetite

504 Changes in personality

505 Dysfunctional behaviour

506 Anxiety and obsessive-compulsive symptoms

507 Thought disorder

508 Disorders of self and delusions

509 Impaired bodily sensations (coenaesthesia)

510 Abnormal perceptions

511 Motor disorder

512 Observed behaviour

For risk persons, both the present state and previous course of illness before the first interview are recorded. To monitor the success of intervention, the ERIraos symptom list is carried out prospectively at different timepoints. The months in between the follow-ups are rated retrospectively. Of main interest at the first interview are the questions of how far the illness, e.g. the prodromal phase, has already progressed, and the sequence of symptom occurrence. Included in the ERIraos are roughly two thirds of the IRAOS symptoms, but its aim is to assess not only symptom onset, but also the increase in symptom severity (distress) and functional impairment. The symptom list of the ERIraos should help us to decide whether the persons assessed require intervention or not because of a risk for schizophrenia.

In order to improve predictions of illness risk by considering further risk factors, four modules were additionally integrated in the ERIraos and supplemented by two associated instruments. These are family (genetic)

risk, complications during pregnancy and childbirth, developmental retardation during infancy, comorbidity (especially if linked to alcohol and drugs), delinquency and schizotypal personality. The diagnostic criteria for schizotypy can be evaluated on the basis of the symptom list. A fourth module is presented as a questionnaire and given after the interview to assess ordinary life situations, serving as a further assessment of schizotypal features. The module on medication includes questions on the type and dosage of already prescribed medications, either current or earlier [172].

To determine the reliability of the ERIraos symptom list, videotaped interviews were presented to 9 or 10 interviewers at three rating sessions. The symptom ratings of the interviewers were compared with the standard ratings of the trainer team. Kappas for ''symptom present in the year before interview'' range between 0.56 and 0.77; for the rating of ''subjective stress associated with the symptom'' between 0.54 and 0.77. The reliabilities increased from the first to the third assessment.

An analysis based on 83 checklist interviews was also carried out. Prodromal symptoms assessed by the checklist have been present at least in 24.1% (ideas of reference) at-risk persons and in a maximum of 84.3% (tension, nervousness, restlessness). Checklist symptoms are more frequent in the late prodrome compared to the early prodrome (p<0.05 for ten symptoms). The most frequent prodromal symptoms are nonspecific (negative symptoms: loss of energy, loss of concentration, social withdrawal; depressive symptoms: depressive mood, loss of self-confidence, increased fatigability).

ERIraos data of 75 patients, interviewed at the early intervention centres in Bonn, Cologne, Dusseldorf and Munich, have been collected. Symptom onset dates back between 4.7 and 9.1 years. The earliest symptom is ''preoccupation with mysterious things'', but this item probably indicates a persistent schizotypal personality trait. The most frequent early symptoms are nonspecific (worries about mental functions, depressed mood, tension and restlessness) and are negative symptoms/social disabilities and depressive symptoms. In all, 73% of the patients fulfilled the checklist criteria already one year before inclusion in the early intervention programme.

In addition to the prodromal symptoms, 85% of the sample report further risk factors: 60% report difficulties in everyday situations, indicating schizotypal personality traits, 58% report alcohol or drug use, 21% obstetric or birth complications, 21% delinquency and 11% familial load with psychosis. In the subgroup with additional risk factors, the percentage of patients fulfilling the checklist criteria one year before inclusion in the early intervention study is increased from 73% to 87%.

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