Validating the Dsmiiir Prodromal Symptoms

Listed in the DSM-IIIR were nine prodromal symptoms of schizophrenia, generated by consensus and not empirically [167]: social isolation or withdrawal; marked impairment in role functioning; markedly peculiar behaviour; marked impairment in personal hygiene; blunted, flat or inappropriate affect; dissociative or metaphoric speech; odd or bizarre ideation; unusal perceptional experiences; marked lack of initiative, interests or energy.

The first attempt at cross-sectionally validating these prodromal signs was made by Jackson et al. [168] in a sample of 313 first episodes of various functional psychoses. Where the standard DSM-IIIR assessment is utilized, inter-rater reliability is poor, as is test-retest reliability [97]. Analysing the comparative frequencies and diagnostic efficiencies of the prodromal signs in a retrospective design, the authors found relatively poor distinguishing efficacies between diagnoses. In a second study, McGorry et al. [169] followed up the prevalence of these nine prodromal symptoms prospec-tively in a large representative sample (n = 2525) of Australian school children at mean ages of 12, 14 and 16 years. The result supported the low discriminatory efficacy of these prodromal symptoms found in comparisons of diagnosed functional mental disorders: the prevalences ranged from 8% to 51% indicating a high frequency in the healthy population and a low specificity for schizophrenia.

A third study to improve the diagnostic efficiency and predictive power of these prodromal symptoms was conducted by McGorry et al. [170]. Of 200 individuals experiencing a first-onset psychosis and aged 14 to 46 years (mean: 25.23), 61 (30.5%) suffered from schizophrenia, 49 (24.5%) from schizophreniform disorder. Two sources were interviewed, patients and relatives, to obtain detailed information on the prodromal period. This information was registered in the RP-MIP. The result was that three items and more had a higher predictive power than single items. When the duration of the prodromal phase and especially prepsychotic deterioration in functioning were taken into account, the predictive power rose considerably. This means that the gradient of change - in clinical terms the observed deterioration - plays an important role in prognosis. Hence, the key finding was that prodromal deterioration which is relatively prolonged - a feature of course in combination with a symptom cluster -predicts schizophrenia within a first episode of psychosis sample as quite likely, but not with sufficient certainty. Meanwhile, the prodromal symptoms of schizophrenia listed in the DSM-IIIR were dropped from the DSM-IV.

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