Psicothema (2022) 34(3) 383-391

Psicothema
https://www.psicothema.com/es • ISSN 0214–7823

Colegio Oficial de Psicólogos del Principado de Asturias

Article

A new Algorithm for Detecting Clinical High Risk of Psychosis in

Adolescents
Mercedes Paíno1, Ana María González-Menéndez1, Óscar Vallina-Fernández2 and Mar Rus-Calafell3
1 Department of Psychology, University of Oviedo, Spain.
2 Sierrallana Hospital, Cantabria Health Service, Torrelavega, Cantabria, Spain.
3 Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-University of Bochum, Bochum, Germany.

ARTICLE INFO ABSTRACT

Received: November 01, 2021 Background: The delimitation of the clinical high risk of psychosis (CHRp) is characterized by the wide variety
Accepted: January 14, 2022 of symptoms assessed from different approaches and the difficulty in detecting clinical stages that are a long way
from the onset of psychosis. This study aimed to create a systematic procedure for an effective and accurate early
detection of CHRp in educational settings. Method: A representative sample of 1,824 adolescents (average age, 15.79;
Keywords:
Psychosis risk 53.8%, women) was used to develop an online assessment system and a new 3-track, 3-level algorithm that combines
Adolescence symptoms of the main risk approaches: ultra-high risk (UHR), basic symptoms (BS), and anomalies in the subjective
Online recruitment self-experience (ASE) with functional deficit. Results: The acceptability and feasibility of the online screening system
Algorithm were confirmed by the data. Of the total participants, 68 (3.7%) were identified as high-risk and 417 (22.9%) were
Early prevention identified as moderate, which also supports the functionality of the proposed algorithm. Conclusions: The system
indicates a dynamic model of progression of the different symptoms in the early stages of psychosis, and it may
constitute a first line of identification for severe mental disorders in young people in the earliest stages, allowing
application of initial preventive measures.

Un Nuevo Algoritmo para la Detección del Alto Riesgo Clínico de Psicosis en

Adolescentes

RESUMEN

Antecedentes: La delimitación del alto riesgo clínico de psicosis (CHRp, por sus siglas en inglés) se caracteriza por
Palabras clave:
la gran variedad de síntomas evaluados desde diferentes enfoques y la dificultad que existe para detectar los estadios
Riesgo de psicosis
Adolescencia clínicos más alejados del inicio de la psicosis. Este estudio tiene como objetivo la creación de un procedimiento
Reclutamiento online sistemático para una detección temprana eficaz y precisa del CHRp en entornos educativos. Método: A partir de una
Algoritmo muestra representativa de 1.824 adolescentes (edad, media= 15,79 años; 53,8%, mujeres) se ha desarrollado un sistema
Prevención temprana de evaluación online y un algoritmo de tres vías y tres niveles de riesgo que combina los síntomas de los principales
enfoques de riesgo: ultra-alto riesgo (UHR), síntomas básicos (SB) y anomalías en la autoexperiencia subjetiva (ASE),
además del déficit funcional. Resultados: A la luz de los datos obtenidos se han confirmado la aceptabilidad y viabilidad
del sistema de cribado online. Del total de participantes, 68 (3,7%) fueron identificados como de alto riesgo y 417
(22,9%) como de riesgo moderado, lo que también avala la funcionalidad del algoritmo propuesto. Conclusiones: El
sistema apoya la existencia de un modelo dinámico de progresión de los diferentes síntomas en las primeras etapas de
la psicosis, y puede constituir una primera línea de identificación de los trastornos mentales graves en los jóvenes en las
etapas más tempranas, de cara a la aplicación de las medidas preventivas iniciales.

Cite as: Paíno, M., González-Menéndez, A. M., Vallina-Fernández, O., & Rus-Calafell, M. (2022). A new Algorithm for Detecting Clinical High Risk of Psychosis in Adolescents.
Psicothema, 34(3), 383-391. https://doi.org/10.7334/psicothema2022.10
Corresponding author: Mercedes Paíno, [email protected]

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Research has shown that a considerable number of young only adolescents (up to the age of 19), but often include young
people are at risk of developing psychosis throughout their lives, adults (i.e. Flückiger et al. 2019; Schultze-Lutter et al., 2020),
with serious consequences on personal, educational, family, so- which increases the probability of transition rates.
cial, economic, and health levels (Catalan et al., 2020; Fusar-Poli The present study aimed to create a systematic procedure for
et al., 2020a; Malla & McGorry, 2019). Implementing detection the effective and accurate early detection of CHRp in educational
and prevention programs for psychosis in teens therefore offers settings in the context of our Psychosis Prevention Program
the most cost-effective option by providing life-long benefits to (P3; http://www.p3-info.es); integrating the main three risk
those affected and their families (Campion et al., 2019; Chong approaches (UHR, BS, and ASE) and combining all three with
et al., 2016; Fusar-Poli et al., 2020b). A combination of a rapid, the presence of functional deficits. We established two main
rigorous, and updated screening procedure aimed at detecting research objectives: 1) to create a systematic online screening
individuals considered to be at risk of psychosis according to procedure, adapting different brief and recent psychometric
early detection approaches, and the immediate referral of these assessment instruments of psychological risk characteristics
cases to specialized services, will constitute the most efficient in adolescents to be delivered through our Virtual Laboratory
and comprehensive procedure for early prevention of psychosis in P3 (http://www.p3-info.es); and 2) to develop and test the
in young people. accuracy of a novel algorithm with three tracks (following the
Research has also shown that the delimitation of the CHRp main approaches to risk plus global functioning) in identifying
or “at-risk mental state of psychosis” is characterized by the individuals at risk of psychosis in a representative sample of
wide variety of symptoms assessed from different approaches adolescents. In line with these objectives, we hypothesized
to early detection (Ramella Carvaro & Raballo, 2014; Sanfelici that: i) the online screening system would be acceptable and
et al., 2020). These approaches include: a) the ultra-high risk feasible for the selected sample of adolescents; ii) the proposed
criteria (UHR), focusing on the detection of so-called attenuated algorithm would identify and distinguish different groups of risk
psychotic symptoms or “positive” symptoms, referring to the individuals according to combined risk levels of the three tracks;
presence of anomalous experiences, such as depersonalization, iii) the detected percentage of adolescents at CHRp would be
suspicious or magical thinking below the psychosis threshold; lower than the lowest rates of 10-15% reported in recent studies,
b) the basic symptoms perspective (BS), initially described from thanks to the forecast and accuracy provided by this algorithm
a phenomenological approach by Huber and Gross (1989), con- and given the average age of the sample; iv) following this
sisting of perceived subjective alterations of different domains algorithm, a greater number of moderate risk adolescents will be
such as perception, sustained attention, cognitive processing, also detected, similar to the 23% average found in recent studies.
and language, which can be present in the prodromal phase as
part of the earliest manifestations of psychosis (Miret et al., Method
2016); and, more recently c) the non-psychotic anomalies in the
subjective self-experience (ASE) approach, grouping symptoms, Participants
such as hyperreflexivity (Pérez-Álvarez, 2016; Sass & Parnas,
2003) or exaggerated self-awareness, with prospective support as The population of interest consisted of students born between
risk markers and central features of psychotic disorders (Koren 2000 and 2003, who were enrolled in educational centers in
et al., 2020; Værnes et al., 2019). the Principality of Asturias. A representative sample of 1,824
These different approaches to CHRp result in disparity in the adolescents was obtained, following stratification and probability
percentages of individuals detected to be at risk, depending on procedures consisting of dividing the entire population into
the risk criteria chosen, the screening tool used, and the sample different subgroups or disaggregated strata and obtaining a sub-
setting. A recent meta-analysis of factors associated with the sample in each of them. In addition, a two-stage sampling was
onset of psychosis in individuals at CHRp (Oliver et al., 2020) performed, first considering the selection of centers (Stratum 1:
determines that global functioning shows evidence suggesting public centers, Stratum 2: private subsidized centers) and then the
an association with transition to psychosis, which supports the selection of the student body (sub-samples of middle school, high
inclusion of this domain in early detection procedures. More- school, and vocational training).
over, numerous assessment instruments have been developed
according to the three approaches. Instruments
A preliminary literature review for the present study, limited
to studies from 2015 onwards and following standardized data The Oviedo Schizotypy Assessment Questionnaire-Abbre-
extraction by two independent reviewers (M.P. and O.V-F), viated (ESQUIZO-Q-A; Fonseca-Pedrero et al., 2010) is the short
reported a big percentage window of high-risk cases with detec- version of a self-report questionnaire for assessing schizotypal
tion rates ranging from 0.9% to 80% depending on the approach, traits in adolescents. ESQUIZO-Q-A comprises a total of 23
assessment tool, and sample included in the study, with the items with 5 categories distributed across 3 empirically derived
lowest rates being usually around 10-15% (Chen et al., 2016; subscales: Reality Distortion, Anhedonia, and Interpersonal
Dolphin et al., 2015; Fonseca-Pedrero et al., 2016a). According Disorganization. Its internal consistency levels range from .67
to this review, the risk of psychosis is 23.8%, consistent with to .71, and it has different sources of validity (Fonseca-Pedrero
the rates reported in recent meta-analysis studies (Catalan et al., et al., 2010; Fonseca-Pedrero et al., 2011). The provided cut-
2020; Fusar-Poli et al., 2020a). Note also that studies that report off points were dichotomized as follows: 0 = “no symptoms”
high-risk percentages are not usually conducted with samples of (if scores < 50 th percentile on any of the three subscales of

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ESQUIZO-Q-A) and 1 = “moderate-severe symptoms” (if all Procedure

three scores > 50 th percentile).
Prodromal Questionnaire-Brief Version (PQ-B; Loewy et Cross-sectional design, using an online platform to deliver the
al., 2011; Spanish validation by our group (Fonseca-Pedrero et symptom screening. This study was conducted between March
al., 2016b)) consists of 21 true/false items assessing the presence 2018 and May 2019. The Education Office of the Government of
and frequency of prodromal psychotic experiences in the last the Principality of Asturias and the university’s Research Ethics
month. It also includes a sub-section about the severity of the Committee approved it. It received the support of the Mental
interference and distress from these experiences on a 5-point Health Unit of the local Department of Health. The data file
Likert scale. The internal consistency of the PQ-B total score was registered in the General Data Protection Register of the
was 0.93 (Fonseca-Pedrero et al., 2016b). The following cut-off Spanish Data Protection Agency.
scores were used: higher than 6 points on the Total score and 29 Initial contact with schools was made by telephone and email,
points or higher on the Distress score (Kline et al., 2015). via the school principal or the counsellor. A total of 50 schools
Global Functioning: Social and Global Functioning: Role were contacted, 37 of which agreed to take part in the study. Since
(GF: Social & GF: Role; Cornblatt et al., 2007). The GF Social many of the participants were minors, written parental consent was
scale assesses the quantity and quality of peer and family required. Online questionnaires were administered via computer or
relationships. The GF Role scale anchor points adapted to tablet, by school-class, with 3 researchers in charge. Adolescents
adolescents, refer to performance in school, in terms of the were informed in writing and orally of the voluntariness of
level of support required. In consultation with the measure’s participation and the confidentiality of their answers. No
originator, two short adapted versions were used for the present compensation was given for participating in the study.
study. For both scales, scores range from 1 (extreme dysfunction)
to 10 (superior functioning). Based on the original scales, the Data analysis
cut-off point to determine “major impairment” was < 5.
Frankfurt-Pamplona Subjective Experience Scale (EEFP; Descriptive statistics on socio-demographic and
Cuesta et al., 1995; short version of the Frankfurt Complaint environmental characteristics for the entire sample were ex-
Questionnaire, FCQ; Süllwold, 1986), consists of 18 items, pressed as frequencies and percentages from different available
aiming to assess subtle anomalous subjective experiences in survey instruments (see Table 1).
attenuated psychosis (e.g., difficulties in attention, memory, Algorithm development: based on the data from the most
perception). This measure has shown high internal consistency used clinical approaches to psychosis risk, the algorithm consists
(Cronbach’s alpha= 0.91) and displays convergent validity of a combination of the cut-off points indicated in the original
(Raballo et al., 2007; Stip et al., 2003). Due to the lack of cut- scales or, alternatively, weighted scores based on extreme
off points, extreme values of the 90 th percentile were considered values. The designed algorithm aimed to identify 3 risk tracks
here for presence of BS. considering the severity of the “pre-psychotic” symptomatology
Self-Experience Lifetime Frequency Scale (SELF; Heering et reported in the screening: (T1) Track 1 ≈ UHR + low GF (Global
al., 2016, version translated and adapted to Spanish following Functioning), which combines 3 Schizotypy subscales (Reality
international guidelines (Muñiz et al., 2013)). This 12-item scale Distortion, Anhedonia, and Interpersonal Disorganization) +
was designed to screen for symptoms of depersonalization and the 2 Prodromal subscales (PQ-B, Frequency and Distress) +
covers a wide range of experiences of self-disturbance. Indi- the 2 Global Functioning scales (GF: Social and GF: Role); (T2):
viduals are asked to report on a 5-point Likert scale about the Track 2 ≈ BS + low GF, which combines the Basic Symptoms
lifetime frequency and level of burden of these symptoms. The Scale (EEFP) + the 2 Global Functioning scales (GF: Social and
original factorial structure analysis yielded two components: GF: Role); and (T3) Track 3 ≈ ASE + low GF, combining the
Disturbed Self-awareness and Symptoms of Depersonalization, SELF scale + the 2 Global Functioning scales (GF: Social and
both with good internal consistency: Cronbach’s α = 0.88 and GF: Role). The three resultant variables were broken down into
0.79, respectively. For this study, at least 3 items scoring > 3 3 risk levels, thus: Level 2 = High risk (above the cut-off point
in Frequency and >2 in associated Distress were required to in all the included scales of each track), Level 1 = Moderate risk
consider the presence of self-disorder. (above the cut-off point in one of the included measures -in two
Oviedo Infrequency Response Scale-Revised (INF-OV; measures for T1-) and Level 0 = No or low risk (below the cut-
Fonseca-Pedrero et al., 2009). The INF-OV was developed to off point in all the scales; -may exceed the cut-off point in just
detect participants who respond in an untruthful, random o one of them for T1-) (for a more detailed explanation see also
pseudo-random way to the used self-reports. Designed also as a Table 2). The algorithm could be synthesized in the following
self-report type assessment tool, INF-OV comprises 12 likert- formula:
type statements with five categories. Adolescents scoring ≥
three items of the INF- OV incorrectly are eliminated from the (T1 ≈ UHR + low GF) OR (T2 ≈ BS + low GF) OR (T3 ≈
final sample. The INF-OV has been used in previous studies ASE + low GF) = AT RISK MENTAL STATE (2/1/0)
(Fonseca-Pedrero et al., 2011; Fonseca-Pedrero et al., 2016b). A
revised version was used in this study, where two items were The algorithm also allows us to establish 6 high-risk groups
removed after finding that they didn’t discriminate. by combining the different risk levels (high/moderate) of the
[For complementary survey measures used, see Table 1]. three tracks (Table 3). Classification is made depending on

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scoring 2 on at least one track, track 1 being the most sensitive tracks, but the behavior of the algorithm was different for Track
one (higher weight). Group 1 (highest risk) includes all those 2 and Track 3: most of the cases categorized as high risk (point
who scored 2 on all three tracks; Groups 2 and 3 include those 2) on Track 2 scored 1 (moderate risk) on Track 3, and vice
who scored 2 on two tracks, and Groups 4 to 6, include those versa, but they obtained a 0 (low risk) for Track 1 (UHR track).
with the lowest high risk of psychosis, who scored 2 on just one Of the 417 (22.9%) identified as moderate risk (point 1) by the
track. algorithm, 29 (1.6% of the total sample) were of moderate risk
Data analyses were performed with XLSTAT 2020.1.3 (point 1) in all three tracks. Of those who scored 1 (moderate
Basic+ (Addinsoft, 2019) and the SPSS 20.0 statistical package risk) in two of the three tracks, most were in Tracks 2 and 3
for Mac OS X (IBM Corp Released, 2011). (105 cases; 5.8%), with 0 (low risk) being obtained for Track
1 (UHR). Mirroring the results of the high-risk groups, Track
Results 1 seemed to be more restrictive in identifying moderate-risk
cases. Finally, the remaining 244 (13.4% of the total sample)
Socio-demographic and environmental characteristics of the were of moderate risk only on one track.
sample:
Table 1.
Socio-demographic and environmental characteristics of included participants.
The general characteristics of the study population are
presented in Table 1. After removing 200 participants via the Total sample (N=1,824)
N %
Oviedo Infrequency Response Scale (INF-OV) (Fonseca-
Sex Male 843 46.2
Pedrero et al., 2009) or due to being out of age range, a total
Female 981 53.8
of 1,824 adolescents were included in the study. Of these, 843
Age Mean: 15
(46.2%) were males and 981 (53.8%) females, recruited from
SD: 1,17
123 classrooms, with an average age of 15.79 (SD=1.25). The
Range: 14-19
largest concentration of participants was 14-17 at the time of
Educational stage Middle school 1,013 55.5
assessment (91.8% of the total). Main demographic results High school 739 40.5
showed: a) 6.4% declared that they were immigrants; b) 3.4% Vocational education 72 4
were from families living in deprivation; c) 35% reported Nationality Spanish 1709 93.7
having experienced at least one distressing traumatic event; d) Latin-American 54 3
9.6% of the sample reported having used cannabis 1 or 2 times European (non-Spanish) 24 1.3
in the last three months, and 4.6% reported using it daily or Dual (+Spanish) 20 1.1
almost daily; and e) 4.5% of the students had failed the previous Non-European 15 0.9
academic year. Family affluence1 Low 57 3.4
Medium 755 45.7
Algorithm results: High 841 50.9
Parents’ nationality1 Both Spanish 1,446 87.5
Sixty-eight participants (3.7%) were identified as high-risk, One Spanish 88 5.3
having scored 2 on one (or more) of the three risk tracks. A total Both non-Spanish 119 7.2
of 417 (22.9%) were identified as moderate-risk, having scored Traumatic experience/s2 No/Yes2 982/842 53.8/46.2
1 on one of the three tracks. Analyses by tracks showed that 44 Associated Distress
of the 68 high-risk participants were detected by Track 1, which Mean: 1.12
SD: 1,25
means that these individuals would have scored above the cut-off
Range: 0-4
point in the three included scales [Schizotypy AND Prodromes
Substance use3 Cannabis (No/Yes) 1,457/367 79.9/20.1
AND Low Global Functioning]. For more information on the
Tobacco4 (No/Yes) 851/791 51.8/48.2
risk levels of tracks and the specific percentages obtained with
OH4 (No/Yes) 1,104/538 67.2/32.8
the algorithm, see Table 2.
Others4 (No/Yes) 1,569/74 95.6/4.5
Analyses by high-risk groups (Table 3) showed that 8 of
Any Fail in the preceding Yes 727 39.8
the 68 participants (0.4% of total sample) scored as high risk school period No 926 50.8
(point 2) on all three tracks (Group 1). Twenty-three (1.3%) Any Fail in the preceding Outstanding 321 17.6
participants scored as high risk (point 2) on two tracks: those school period Above average 622 34.1
who scored 2 on Track 1 and also scored 2 on another track also Good 390 21.4
obtained a moderate-risk score (point 1) on the remaining track Pass 238 13.0
(Tracks 2 or 3); these participants were categorized as Group 2. Fail 82 4.5
Those who scored 2 on Track 2 and Track 3 were low risk/non-
Note: 1: Obtained with the Family Affluence Scale (FAS; Boyce et al, 2006; Fismen
risk (point 0) on Track 1, accounting for Group 3 (lower level of et al., 2016), missing cases n=171 (9.4%); 2: Yes = point > 1 (any traumatic event) by
risk). The rest (N=37, 2.0% of the total sample) were in Groups 4 the Screening of Early Traumatic Experiences in Patients with Severe Mental Illness
to 6, which included participants who scored 2 on just one track. (ExpTra-S; Paino et al., 2020); 3: Yes = point > 1 (any consumption in the last three
It is important to note that all cases that were classified as high- months) in the Alcohol, Smoking and Substance Involvement Screening Test (WHO-
ASSIST V3.0; Newcombe et al., 2005; WHO, 2010); 4: Missing cases n=182 (1%).
risk (point 2) by Track 1 were of moderate risk on the other two

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Table 2. provides a risk profile based on the combination of the risk scores
Frequencies and percentages of participants detected at risk of psychosis by the three obtained (2, 1, 0) based on each track, and it reinforces the idea that
algorithm tracks.
although the three approaches to the risk of psychosis may appear
Level 2 (High Risk) Level 1 (Moderate Risk) Level 0 (Low Risk)
to be in conflict, they are not necessarily mutually exclusive.
N (%) N (%) N (%) The study of mental states at high risk for the development
Track 1 (T1) 44 (2.4%) 252 (13.8%) 1,491 (81.7%)
of severe mental disorders has mainly been conducted in young
Track 2 (T2) 37 (2.0%) 244 (13.4%) 1,500 (82.2%)
people presenting active, distressing symptomatology and/or see-
Track 3 (T3) 26 (1.4%) 236 (12.9%) 1,512 (82.9%)
king help. They are assessed using long clinical interviews for
Note: Track 1 ≈ UHR + low GF (Global Functioning) (Risk levels= 2: above the detection (Addington, 2020; McGorry et al., 2006). However,
cut-off point in the three included scales; 1: above the cut-off point in [Schizotypy
CHRp states are difficult to detect for two main reasons: (1) young
AND low GF] OR [Schizotypy AND Prodromes] OR [Prodromes AND low GF]; 0:
below the cut-off point in all the scales OR exceeding the cut-off point in just one people who present attenuated psychotic experiences are less
of them-; Track 2 ≈ BS + low GF (Risk levels = 2: above the cut-off point in [Basic likely to look for help due to stigma, and (2) clinicians are less
Symptoms Scale AND GF Social AND GF Role]; 1 = above the cut-off point in one familiar with these experiences (in comparison with, for example,
of the three included scales; 0 = below the cut-off point in all the scales). Track 3 ≈ anxiety or depression). This severely limits access to mental health
ASE + low GF (Risk levels = 2: above the cut-off point in [SELF scale “anomalous
self-experience” AND GF Social AND GF Role]; 1 = above the cut-off point in one of
services for these individuals and hinders interventions that could
the three included scales; 0 = no alteration in any of them). prevent the development of disorders, so a more proactive search
Missing cases Track 1= 37 (2.0%); Track 2= 43 (2.4%); Track 3=50 (2.7%) to identify them is needed. The implementation of detection and
identification procedures based on self-reports, easily accessible
Table 3. and available online (Alfonsson et al., 2014; van Ballegooijen et
Identified high-risk groups according to combined risk levels of the three tracks.
al., 2016), can be very useful in detecting young people at risk of
Combined Risk Group N % severe mental health problems, helping to eliminate barriers.
Group 1 (T1 =2* AND T2 =2 AND T3=2) 8 0.4 The three levels of risk encountered in the present study
Group 2 (T1 =2 AND T2 =2 AND T3=1) OR (T1 =2 AND T2 =1 19 1.0 coincide with the three initial stages of the staging model suggested
AND T3=2) by McGorry and colleagues for teenage populations (0. No sym-
Group 3 (T1 =0 AND T2 =2 AND T3=2) 4 0.2 ptoms -in first-degree teenage relatives of probands-, 1a. non-
Group 4 (T1 =2 AND T2 =1 AND T3=1) 17 0.9 specific symptoms, 1b. UHR, moderate with functional decline)
Group 5 (T1 =1 AND T2 =2 AND T3=1) OR (T1 =1 AND T2 =1 3 0.2 (Carrión et al., 2017; McGorry et al., 2006) and verified in the
AND T3=2) PROCAN study (Adolescent Mental Health: Canadian Psychiatric
Group 6 (T1 =0 AND T2 =2 AND T3 =1) OR (T1 =0 AND T2 =1 17 0.9 Risk and Outcome, Addington et al., 2019; 2020). There is an
AND T3 =2) additional advantage of our research: the aforementioned studies
TOTAL 68 3.7 focus on clinically established and help-seeking young people,
Note: T1 = Track 1 ≈ UHR + low GF; T2 = Track 2 ≈ BS + low GF; T3 = Track 3 ≈ while the present research focuses on young people from the
ASE + low GF; *Risk levels: 2= high risk; 1= moderate risk; 0= low risk. Each group general population. The fact that both populations reflect the same
is exclusive. stages confirms the existence of a progression in the presence and
intensity of different symptomatology (UHR, BS, ASE) in the very
Discussion early phases of psychosis.
The exploration of the algorithm’s behavior revealed that
The purpose of this study was the creation -within our P3 the concurrence between attenuated psychotic symptomatology
program- of a systematic procedure for effective early risk (UHR) and self-disorders is consistent with the results obtained
detection in school settings, incorporating the new technological in studies in help-seeking adolescents (Koren et al., 2013;
(online assessment), conceptual (integration of proved risk Raballo et al., 2018) and adolescents from the general population
approaches), and methodological (algorithmic) developments. (Koren et al., 2016). In these studies, ASE and UHR evolve in
The acceptability and feasibility of the developed online screening intensity and presence, being more present and active in clinical
system (hypothesis 1) have been confirmed in the light of two samples that seek help and less in community samples, which
criteria: the participation of high schools and the reliability and confirms the gradient of severity throughout the biography of
sufficiency of all the data obtained from the adolescents. A total individuals. This also confirms that both types of symptoms can
of 37 secondary schools of the 50 invited to participate agreed be perfectly integrated to achieve a better detection of prodromal
to take part in the study, including 123 classes, and covering the states of psychosis and to fine-tune their transition risk (Nelson
three school types and the three school stages. This has resulted et al., 2021). Concurrence is also found among studies that have
in more than 2,000 participants being recruited and assessed, combined clinical UHR and basic symptoms (Schultze-Lutter et
confirming the viability of our system as a first line screening al., 2020), obtaining more accurate predictive results when the two
method for mental disorders in young people. The functionality approaches are combined.
of the proposed algorithm has also been proved (hypothesis 2), as The third and fourth hypotheses have also been confirmed, as
it appears useful for detecting adolescents with high or moderate a low percentage of high-risk adolescents (3.7%) was detected as
risk of psychosis, considering three different tracks based on the expected, in comparison with the moderate risk group (22.9%),
most used clinical approaches to psychosis risk. To our knowledge, when the calculation of the risk was based on the combined scores
this is the first algorithm that integrates the three main approaches of tracks. The high-risk percentage found in our study is similar to
to at-risk mental state in combination with global functioning. It prevalence rates of meta-analytical studies focused on psychotic-

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like experiences (PLEs) in adolescents (reported to average around of risk, providing particular clinical attention to adolescents with
7-9%) (Healy et al., 2019; Kelleher et al., 2012). Our percentage the highest levels (high-risk groups 1 and 2). For these cases,
of moderate risk is more consistent with the average rates of the recommendation would be to refer them directly to mental
adolescents at CHRp detected by considering other different health services. Those falling into the next high-risk group (group
criteria such as attenuated psychotic symptoms, brief-limited-in- 3) could be called in for a more thorough assessment, including
termittent psychotic symptoms, or genetic risk and deterioration close monitoring of early signs. The lowest high-risk groups (4
syndrome (Catalan et al., 2020; Fusar-Poli et al., 2020a) as well as to 6), could be followed up by using telephone interviews or
in our present revision. internet monitoring. Finally, those detected as “moderate risk”
The emerging question then is to propose an explanatory model could be scheduled for longer term follow-ups and re-assessment
for the process of psychosis risk, taking into account algorithm via our online screening program. In order to further validate our
measures and results. Following the parallelism between the pre- integrative approach and proposed algorithm, the present study
sent results and the clinical staging model, one proposal could should be replicated in other non-Spanish samples.
be a dynamic process of increased risk of psychosis rather than In conclusion, our results show that the detection of risk for
a hierarchical one (Flückiger et al., 2019; Schultze-Lutter et al., psychosis based on unitary approaches is far from satisfactory
2018; Wright et al., 2018). In line with recent proposals (Nelson et and in need of reconceptualization. The incorporation of new
al., 2017; Thompson & Broome, 2020), the detailed results from technological, methodological, and substantive developments
the application of our algorithm indicate a pattern where cases for the rapid detection of risk cases can provide a cost-effective
detected as high risk by Track 1 (UHR track) are also detected prevention alternative. In addition, the comparison of the validity
as high or moderate risk on the other two tracks (BS and ASE of the three main approaches to risk and their attempt at integration
tracks), but not vice versa. This means that the combination of may be of great value in enriching the current operational criteria
UHR symptoms with global functional deficit (Track 1) could be and in trying to define a better perspective for approaching the risk
more restrictive and accurate in identifying high-risk cases than of psychosis in the adolescent population. The current findings
the use of indicators based only on BS or ASE, even if combined can inform the refinement and increase the accuracy of predictive
with low functioning indexes. These results are also in line with models in this field.
those found in a recent meta-analysis by Oliver et al. (2020). This
comprehensive review points out the highly suggestive evidence Acknowledgments
for an association of two factors with the onset of psychosis in
individuals of clinical high risk: attenuated positive psychotic The authors wish to thank the researchers who provided
symptoms and global functioning (i.e., Track 1 in the present additional information, including Dr. Auther, Dr. Heering (original
study). Based on all of the above, and considering that the average measures) Dr. Juncal (algorithm development), and Mr. Gallego-
period of time between detection of BS or ASE and the onset of Acedo (sampling and weighting methods), as well as the Council
psychosis is longer than that between UHR detection and first for Education of the Principality of Asturias and the Mental Health
episode (Ramella Carvaro & Raballo, 2014; Ruhrmann, 2010), it Research and Treatment Center, Faculty of Psychology, Ruhr-
appears that BS and ASE (Tracks 2 and 3 in the present study) Universität Bochum.
are more appropriate for the early detection of the more distal
prodromal states or moderate risk, compared to the more proximal Funding
or high-risk ones indexed by UHR criteria or Track 1.
Some limitations should be considered when interpreting our This research has been funded by the Ministry of Economy and
results. Firstly, the sample included exclusively high school students, Competitiveness (MINECO) (reference PSI 2016-79524-R).
potentially including but not clearly identifying help-seeking
adolescents. Secondly, there are inherent limitations of the use of References
self-reported measures (Fan et al., 2006) to perform the proposed
algorithm. Thirdly, and according to the psychosis proneness- Addington, J., Liu, L., Farris, M. S., Goldstein, B. I., Wang, J. L., Kennedy,
persistence-impairment model, the determining of psychosis risk S. H., Bray, S., Lebel, C., & MacQueen, G. (2020). Clinical staging
in these early stages would involve the interaction of multiple for youth at-risk for serious mental illness: A longitudinal perspective.
risk factors (Linscott & van Os, 2013) such as late environmental Early Intervention in Psychiatry, 10.1111/eip.13062.
disruptions (i.e., early traumatic experiences, cannabis use, aca- https://doi.org/10.1111/eip.13062
demic performance, immigration, or socio-economic status) (Davis Addington, J., Liu, L., Goldstein, B. I., Wang, J., Kennedy, S. H., Bray, S.,
et al., 2016; Mednick et al., 1998). Although some of these varia- Lebel, C., Stowkowy, J., & MacQueen, G. (2019). Clinical staging for
bles have been collected (see Table 1), they were not included when youth at-risk for serious mental illness. Early Intervention in Psychiatry,
running the algorithm. Lastly, there is no follow-up time point to test 13(6), 1416–1423. https://doi.org/10.1111/eip.12786
rates of transition to psychosis in subjects detected as being at risk. Addinsoft (2019). XLSTAT statistical and data analysis solution. Long
Clinical implications and future research: From here, a longi- Island, NY, USA.
tudinal design is proposed to follow up on participants identified Alfonsson, S., Maathz, P., & Hursti, T. (2014). Interformat reliability of
as being at risk and invite them to participate in early prevention digital psychiatric self-report questionnaires: a systematic review.
programs when necessary. The proposed algorithm may allow us Journal of Medical Internet Research, 16(12), e268.
to establish preventive measures adapted to the different levels https://doi.org/10.2196/jmir.3395

388
 The CHRp Algorithm

Boyce, W., Torsheim, T., Currie, C., & Zambon, A. (2006). The Family Flückiger, R., Michel, C., Grant, P., Ruhrmann, S., Vogeley, K., Hubl, D.,
Affluence Scale as a measure of national wealth: Validation of an Schimmelmann, B. G., Klosterkötter, J., Schmidt, S. J., & Schultze-
adolescent self-report measure. Social Indicators Research, 79, 473- Lutter, F. (2019). The interrelationship between schizotypy, clinical high
487. https://doi.org/10.1007/s11205-005-1607-6 risk for psychosis and related symptoms: Cognitive disturbances matter.
Campion, J., Taylor, M. J., McDaid, D., Park, A. L., & Shiers, D. (2019). Schizophrenia Research, 210, 188-196.
Applying economic models to estimate local economic benefits https://doi.org/10.1016/j.schres.2018.12.039
of improved coverage of early intervention for psychosis. Early Fonseca-Pedrero, E., Gooding, D., Ortuño-Sierra, J., and Paino, M. (2016b).
Intervention in Psychiatry, 13(6), 1424-1430. Assessing self-reported clinical high-risk symptoms in community-
https://doi.org/10.1111/eip.12787 derived adolescents: A psychometric evaluation of the prodromal
Carrión, R. E., Correll, C. U., Auther, A. M., & Cornblatt, B. A. (2017). questionnaire-brief. Comprehensive Psychiatry, 66, 201-208.
A Severity-based clinical staging model for the psychosis prodrome: https://doi.org/10.1016/j.comppsych.2016.01.013
Longitudinal findings from the New York Recognition and Prevention Fonseca-Pedrero, E., Gooding, D. C., Ortuño-Sierra, J., Pflum, M.,
Program. Schizophrenia Bulletin, 43(1), 64–74. Paino, M., & Muñiz, J. (2016a). Classifying risk status of non-clinical
https://doi.org/10.1093/schbul/sbw155 adolescents using psychometric indicators for psychosis spectrum
Catalan, A., Salazar de Pablo, G., Vaquerizo Serrano, J., Mosillo, P., disorders. Psychiatry Research, 243, 246–254.
Baldwin, H., Fernández-Rivas, A., Moreno, C., Arango, C., Correll, https://doi.org/10.1016/j.psychres.2016.06.049
C. U., Bonoldi, I., & Fusar-Poli, P. (2020). Annual Research Review: Fonseca-Pedrero, E., Muñiz, J., Lemos-Giráldez, S., Paino, M., & Villazón-
Prevention of psychosis in adolescents - systematic review and meta- García, U. (2010). ESQUIZO-Q: Oviedo Schizotypy Assessment
analysis of advances in detection, prognosis and intervention. Journal Questionnaire. Madrid, Spain: TEA Ediciones S.A.
of Child Psychology and Psychiatry, and allied Disciplines, 10.1111/ Fonseca-Pedrero, E., Paino, M., Lemos-Giráldez, S., Sierra-Baigrie, S.,
jcpp.13322. https://doi.org/10.1111/jcpp.13322 Ordoñez-Camblor, N., & Muñiz, J. (2011). Early psychopathological
Chen, F., Wang, L., Wang, J., Heeramun-Aubeeluck, A., Yuan, J., & features in Spanish adolescents. Psicothema, 23, 87-93.
Zhao, X. (2016). Applicability of the Chinese version of the 16-item Fonseca-Pedrero, E., Paino-Piñeiro, M., Lemos-Giráldez, S., Villazón-
Prodromal Questionnaire (CPQ-16) for identifying attenuated psychosis García, U. & Muñiz, J. (2009). Validation of the Schizotypal Personality
syndrome in a college population. Early Intervention in Psychiatry, Questionnaire-Brief form in adolescents. Schizophrenia Research, 111,
10(4), 308–315. https://doi.org/10.1111/eip.12173 53–60. https://doi.org/10.1016/j.schres.2009.03.006
Chong, H. Y., Teoh, S. L., Wu, D. B., Kotirum, S., Chiou, C., & Fusar-Poli, P., Lai, S., Di Forti, M., Iacoponi, E., Thornicroft, G., McGuire,
Chaiyakunapruk, N. (2016). Global economic burden of schizophrenia: P., & Jauhar, S. (2020b). Early intervention services for first episode
a systematic review. Neuropsychiatric Disease and Treatment, 12, 357– of psychosis in South London and the Maudsley (SLaM): 20 years of
373. https://doi.org/10.2147/NDT.S96649 care and research for young people. Frontiers in Psychiatry, 11:577110.
Cornblatt, B. A., Auther, A. M., Niendam, T., Smith, C. W., Zinberg, J., https://doi.org/10.3389/fpsyt.2020.577110
Bearden, C. E., & Cannon, T. D. (2007). Preliminary findings for two Fusar-Poli, P., Salazar de Pablo, G., Correll, C. U., Meyer-Lindenberg,
new measures of social and role functioning in the prodromal phase of A., Millan, M. J., Borgwardt, S., Galderisi, S., Bechdolf, A., Pfennig,
schizophrenia. Schizophrenia bulletin, 33(3), 688–702. A., Kessing, L. V., van Amelsvoort, T., Nieman, D. H., Domschke, K.,
https://doi.org/10.1093/schbul/sbm029 Krebs, M. O., Koutsouleris, N., McGuire, P., Do, K. Q., & Arango, C.
Cuesta, M. J., Peralta, V. & Irigoyen, I. (1995). Escala de Experiencias (2020a). Prevention of Psychosis: Advances in detection, prognosis, and
Subjetivas Frankfurt-Pamplona. Actas Luso-Españolas de Neurología intervention. JAMA Psychiatry, 77(7), 755–765.
y Psiquiatría, 23 (4), 193-199. https://doi.org/10.1001/jamapsychiatry.2019.4779
Davis, J., Eyre, H., Jacka, F. N., Dodd, S., Dean, O., McEwen, S., Debnath, Healy, C., Brannigan, R., Dooley, N., Coughlan, H., Clarke, M., Kelleher, I.,
M., McGrath, J., Maes, M., Amminger, P., McGorry, P. D., Pantelis, C., & Cannon, M. (2019). Childhood and adolescent psychotic experiences
& Berk, M. (2016). A review of vulnerability and risks for schizophrenia: and risk of mental disorder: a systematic review and meta-analysis.
Beyond the two-hit hypothesis. Neuroscience and Biobehavioral Psychological Medicine, 49(10), 1589–1599.
Reviews, 65, 185–194. https://doi.org/10.1016/j.neubiorev.2016.03.017 https://doi.org/10.1017/S0033291719000485
Dolphin, L., Dooley, B., & Fitzgerald, A. (2015). Prevalence and correlates Heering, H.D., Goedhart, S., Bruggeman, R., Cahn, W., de Haan, L, Kahn,
of psychotic like experiences in a nationally representative community R. S., Meijer, C. J., Myin-Germeys, I., van Os, J., & Wiersma, D.
sample of adolescents in Ireland. Schizophrenia Research, 169, 241- (2016). Disturbed Experience of Self: Psychometric Analysis of the
217. https://doi.org/10.1016/j.schres.2015.09.005 Self-Experience Lifetime Frequency Scale (SELF). Psychopathology,
Fan, X., Miller, B. C., Park, K.-E., Winward, B. W., Christensen, M., 49, 69-76. https://doi.org/10.1159/000441952
Grotevant, H. D., & Tai, R. H. (2006). An exploratory study about Huber, G., & Gross, G. (1989). The concept of basic symptoms in
inaccuracy and invalidity in adolescent self-report surveys. Field schizophrenic and schizoaffective psychoses. Recenti Progressi in
Methods, 18(3), 223–244. https://doi.org/10.1177/152822X06289161 Medicina, 80(12), 646–652.
Fismen, A. S., Smith, O. R., Torsheim, T., Rasmussen, M., Pedersen Pagh, IBM Corp Released (2011). IBM SPSS Statistics for Mac OS X, Version
T., Augustine, L., Ojala, K., & Samdal, O. (2016). Trends in Food Habits 20.0. Armonk, NY: IBM Corp.
and Their Relation to Socioeconomic Status among Nordic Adolescents Kelleher, I., Connor, D., Clarke, M. C., Devlin, N., Harley, M., & Cannon,
2001/2002-2009/2010. PloS one, 11(2), e0148541. M. (2012). Prevalence of psychotic symptoms in childhood and
https://doi.org/10.1371/journal.pone.0148541 adolescence: A systematic review and meta-analysis of population-
based studies. Psychological Medicine, 9, 1-7.
https://doi.org/10.1017/S0033291711002960

389
 Paíno et al. / Psicothema (2022) 34(3) 383-391

Kline, E., Thompson, E., Demro, C., Bussell, K., Reeves, G., & Schiffman, Nelson, B., McGorry, P. D., Wichers, M., Wigman, J., & Hartmann, J. A.
J. (2015). Longitudinal validation of psychosis risk screening tools. (2017). Moving from static to dynamic models of the onset of mental
Schizophrenia Research, 165,116-122. disorder: A review. JAMA Psychiatry, 74(5), 528–534.
https://doi.org/10.1016/j.schres.2015.04.026 https://doi.org/10.1001/jamapsychiatry.2017.0001
Koren, D., Lacoua, L., Rothschild-Yakar, L. & Parnas, J. (2016). Newcombe, D. A., Humeniuk, R. E., & Ali, R. (2005). Validation of
Disturbances of the basic self and prodromal symptoms among young the World Health Organization Alcohol, Smoking and Substance
adolescents from the community: A pilot population-based study. Involvement Screening Test (ASSIST): report of results from the
Schizophrenia Bulletin, 42, 1216-1224. Australian site. Drug and Alcohol Review, 24(3), 217–226.
https://doi.org/10.1093/schbul/sbw010 https://doi.org/10.1080/09595230500170266
Koren, D., Reznik, N., Adres, M., Scheyer, R., Apter, A., Steinberg, T. & Oliver, D., Reilly, T. J., Baccaredda Boy, O., Petros, N., Davies, C.,
Parnas, J. (2013). Disturbances of basic self and prodromal symptoms Borgwardt, S., McGuire, P., & Fusar-Poli, P. (2020). What causes the
among non-psychotic help-seeking adolescents. Psychological onset of psychosis in individuals at clinical high risk? A meta-analysis
Medicine, 43, 1365-1376. https://doi.org/10.1017/S0033291712002322. of risk and protective factors. Schizophrenia Bulletin, 46(1), 110-120.
Koren, D., Tzivoni, Y., Schalit, L., Adres. M., Reznik, N., Apter, A., https://doi.org/10.1093/schbul/sbz039
& Parnas, J. (2020). Basic self-disorders in adolescence predict Paino, M., Ordóñez-Camblor, N., Fonseca-Pedrero, E., García-Álvarez,
schizophrenia spectrum disorders in young adulthood: A 7-year follow- L., & Pizarro-Ruiz, J. P. (2020). Development and validation of an
up study among non-psychotic help-seeking adolescents. Schizophrenia instrument for the detection of early traumatic experiences (ExpTra-S)
Research, 216, (97-103). https://doi.org/10.1016/j.schres.2019.12.022. in patients with psychosis. Frontiers in Psychology, 11, 528213.
Linscott, R. J., & van Os, J. (2013). An updated and conservative systematic https://doi.org/10.3389/fpsyg.2020.528213
review and meta-analysis of epidemiological evidence on psychotic Pérez-Álvarez, M., García-Montes, J. M., Vallina-Fernández, O., & Perona-
experiences in children and adults: on the pathway from proneness Garcelán, S. (2016). Rethinking schizophrenia in the context of the
to persistence to dimensional expression across mental disorders. person and their circumstances: seven reasons. Frontiers in Psychology,
Psychological Medicine, 43(6), 1133–1149. 7, 1650. https://doi.org/10.3389/fpsyg.2016.01650
https://doi.org/10.1017/S0033291712001626. Raballo, A., Cattaneo, C., & Castignoli, G. (2007). Anomalous subjective
Loewy, R. L., Pearson, R., Vinogradov, S., Bearden, C. E., & Cannon, T. D. experiences as a tentative new direction for a youth-targeted
(2011). Psychosis risk screening with the prodromal questionnaire–brief psychometric high-risk approach. European Psychiatry, 22, S101eS220
version (PQ-B). Schizophrenia Research,129, 42-46. Raballo, A., Monducci, E., Ferrara, M., Fiori, P., & Dario, C. (2018).
https://doi.org/10.1016/j.schres.2011.03.029. Developmental vulnerability to psychosis: selective aggregation of
Malla, A., & McGorry, P. (2019). Early intervention in psychosis in young basic self-disturbance in early onset schizophrenia. Schizophrenia
people: A population and public health perspective. American Journal Research, 201, 367-372. https://doi.org/10.1016/j.schres.2018.05.012
of Public Health, 109(S3), S181–S184. Ramella Carvaro, V., & Raballo, A. (2014). Early detection of schizophrenia:
https://doi.org/10.2105/AJPH.2019.305018. a clinical-psychopathological revision of the ultra-high risk approach.
McGorry, P. D., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H. J. Journal of Psychopathology, 20, 442-450.
(2006). Clinical staging of psychiatric disorders: a heuristic framework Ruhrmann, S., Schultze-Lutter, F., Salokangas, R. K., Heinimaa, M.,
for choosing earlier, safer and more effective interventions. The Linszen, D., Dingemans, P., Birchwood, M., Patterson, P., Juckel,
Australian and New Zealand Journal of Psychiatry, 40(8), 616–622. G., Heinz, A., Morrison, A., Lewis, S., von Reventlow, H. G., &
https://doi.org/10.1080/j.1440-1614.2006.01860.x Klosterkötter, J. (2010). Prediction of psychosis in adolescents and
Mednick, S. A., Watson, J. B., Huttunen, M., Cannon, T. D., Katila, H., young adults at high risk: results from the prospective European
Machon, R., Mednick, B., Hollister, M., Parnas, J., Schulsinger, F., prediction of psychosis study. Archives of General Psychiatry, 67(3),
Sajaniemi, N., Voldsgaard, P., Pyhala, R., Gutkind, D., & Wang, X. 241–251. https://doi.org/10.1001/archgenpsychiatry.2009.206
(1998). A two-hit working model of the etiology of schizophrenia. In M. Sanfelici, R., Dwyer, D. B., Antonucci, L. A., & Koutsouleris, N. (2020).
F. Lenzenweger & R. H. Dworkin (Eds.), Origins and development of Individualized diagnostic and prognostic models for patients with
schizophrenia: Advances in experimental psychopathology (p. 27–66). psychosis risk syndromes: a meta-analytic view on the state of the art.
American Psychological Association. Biological Psychiatry, 88, 349-360.
https://doi.org/10.1037/10305-002 https://doi.org/10.1016/j.biopsych.2020.02.009
Miret, S., Fatjó-Vilas, M., Peralta, V., & Fañanás, L. (2016). Basic symptoms Sass, L. A., & Parnas, J. (2003). Schizophrenia, consciousness, and the self.
in schizophrenia, their clinical study and relevance in research. Revista Schizophrenia Bulletin, 29(3), 427–444.
de Psiquiatría y Salud Mental, 9, 111-122. https://doi.org/10.1093/oxfordjournals.schbul.a007017
https://doi.org/10.1016/j.rpsmen.2016.04.005 Schultze-Lutter, F., Michel, C., Flükiger,R. & Theoridou, A. (2020).
Muñiz, J., Elosua, P, & Hambleton, R. K. (2013). International test Subjective disturbances in emerging psychosis: basic symptoms and
commission guidelines for test translation and adaptation: second edition. self-disturbances. In A. Thompson & A. D. Broome (Eds.), Risk factors
Psicothema, 25, 151-157. https://doi.org/10.7334/psicothema2013.24. for psychosis. Paradigms, mechanisms and prevention, pp 59-80.
Nelson, B., McGorry, P. & Fernandez, A. (2021). Integrating clinical staging Elsevier. Academic Press.
and phenomenological psychopathology to add depth, nuance, and Schultze-Lutter, F., Michel, C., Ruhrmann, S., & Schimmelmann, B.
utility to clinical phenotyping: a heuristic challenge. Lancet Psychiatry, G. (2018). Prevalence and clinical relevance of interview-assessed
8(2), 162-168. https://doi.org/10.1016/S2215-0366(20)30316-3 psychosis-risk symptoms in the young adult community. Psychological
Medicine, 48(7), 1167–1178.
https://doi.org/10.1017/S0033291717002586

390
 The CHRp Algorithm

Stip, E., Caron, J., Renaud, S., Pampoulova, T., & Lecomte, Y. (2003). van Ballegooijen, W., Riper, H., Cuijpers, P., van Oppen, P., & Smit, J.
Exploring cognitive complaints in schizophrenia: The Subjective Scale H. (2016). Validation of online psychometric instruments for common
to Investigate Cognition in Schizophrenia. Comprehensive Psychiatry, mental health disorders: a systematic review. BMC Psychiatry, 16, 45.
44(4), 331-340. https://doi.org/10.1186/s12888-016-0735-7
Süllwold, L. (1986). Die Selbstwahrnehmung defizitärer Störungen. Wright, A. C., Fowler, D., & Greenwood, K. E. (2018). Developing a
Psychologische Aspekte des Basisstörungskonzepts. In L. Süllwold dynamic model of anomalous experiences and function in young people
& G. Huber (Eds.), Schizophrene Basisstörungen (pp. 1–38). Berlin, with or without psychosis: a cross-sectional and longitudinal study
Heidelberg, New York: Springer. protocol. BMJ Open, 8: e022546.
Thompson, A. & Broome, A. D. (2020). Risk factors for psychosis. https://doi.org/10.1136/bmjopen-2018-022546
Paradigms, mechanisms and prevention. Elsevier: Academic Press. WHO (2010). The Alcohol, Smoking and Substance Involvement Screening
Værnes, T. G., Røssberg, J. I., & Møller, P. (2019). Anomalous self- Test (ASSIST): Manual for use in primary care. World Health
experiences are strongly associated with negative symptoms in a Organization.
clinical high-risk for psychosis simple. Comprehensive Psychiatry, 93,
65-72. https://doi.org/10.1016/j.comppsych.2019.07.003

391
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