Basic Symptoms in The Early Detection of Psychosis: Background

Basic symptoms
in the
early detection of psychosis
Frauke Schultze-Lutter, Ass./Prof., Ph.D., Dipl.-Psych.

Department of Psychiatry and Psychotherapy, Heinrich-Heine Universität, Düsseldorf (DE)
Background
Already in 1932, the German psychiatrist Wilhelm Mayer-Gross

“wondered why, hitherto, one has so
infrequently made use of the impressive
experience that is represented by the first
irruption of a thought disorder, a decrease in
activity, an aberration in sympathy and other
emotions into the healthy personality” (p. 296)
and provided a 50-page chapter on the early signs of emerging
psychosis
Background
“Knowledge of basic symptoms and of the stages

and modalities of their development can be used in
research and the clinic, for diagnostic and
differential-diagnostic purposes, for therapy and
rehabilitation, and in particular for the early
detection, early intervention and (secondary)
prevention of psychosis.”
(Gerd Huber 1987, Introduction to the BSABS)
1
Definition of basic symptoms
 subtle, subclinical self-experienced disturbances in drive,

stress tolerance, affect, attention, memory, thinking, speech,
perception and motor action as well as vegetative functions
 phenomenologically different from mental states known to the
patient/subject from what s/he considers his/her ‘normal’ self
 frequently not directly observable to others
 frequently motivating observable coping behaviours, e.g.,
withdrawal
 can be present before the first psychotic episode, between and
after psychotic episodes, even during psychotic episodes
themselves
Basic symptom concept
Development of basic symptom criteria

of a clinical high-risk state of psychosis
(Klosterkötter et al., 2001; Schultze-Lutter et al., 2001)
2
The Cologne Early Recognition study
(Klosterkötter et al., 2001)
A prospective study of the predictive ability of basic symptoms
Sample: patients of 5 specialized outpatient

departments assumed to suffer from Lübeck
beginning schizophrenia
Inclusion criteria: examination with PSE9 and BSABS
Exclusion criteria: schizophrenia, delusional, psychotic,
substance-induced or organic mental
disorder, mental retardation, >50 yrs. Cologne
Aachen
First assessment: before 1991 Bonn
Follow-up: 1995-1999 (follow-up: 9.6 7.6 yrs.)
No. of patients: male female total

st Ulm-Weissenau
1 examination: 210 175 385
Follow-up: 84 76 160
COPER – “cognitive-perceptive basic

symptoms” criterion
 At least 1 of the following 10 basic symptoms

 thought interference
 thought perseveration
 thought pressure
 thought blockages
 dist.of receptive speech
 decreased ability to discriminate between ideas and perception,
phantasy and true memories
 unstable ideas of reference
 derealisation
 visual perception disturbances (excl. hypersensitivity, blurred vision)
 acoustic perception disturbances (excl. Hypersensitivity)
 at least weekly frequency within past 3 months
 first occurrence or significant increase in frequency at least
12 months ago
COGDIS – “cognitive disturbances”

criterion (Schultze-Lutter, 2001)
 At least 2 of the following 9 basic symptoms

 inability to divide attention
 thought interference
 thought pressure
 thought blockages
 disturbance of receptive speech
 disturbance of expressive speech
 dististurbance of abstract thinking
 unstable ideas of reference
 captivation of attention by details of the visual field
 at least weekly frequency within past 3 months
3
Predictive accuracy of basic symptom
criteria
Model of the early course of psychosis
EPA guidance on the definition of

a clinical high-risk state of psychosis
(Schultze-Lutter et al., 2015)
4
Method: evidence-based
 Meta-analyses of 42 independent samples (N=4’952) in 45

studies that report on conversion rates to psychosis in CHR
samples and were identified in a systematic literature
search conducted in June 2014 with special attention to
 annual conversion rates (0.5, 1, 2, 3, 4, and >4 years),
 single risk criteria (APS, BIPS, GRFD, COGDIS, and
COPER)
 type of assessment / operationalisation of UHR criteria
 age composition of sample (mostly children and
adolescents, mixed, and mostly adults)
Comparison of single CHR criteria
significant
Results of main & sensitivity analyses
 annual conversion rates: compared to even the lowest conversion

rate in UHR, COPER or COGDIS samples at any follow-up,
conversion rates of help-seeking patients not meeting the examined
CHR criteria were clearly significantly lower (2(1)5.175; p<0.025)
 single risk criteria: (1) at 3-year follow-ups conversion rates in
COGDIS (and COPER) samples were higher than in UHR samples
(2(1)5.522; p<0.05); (2) conversion rates in GRFD samples were
low, showed no significant pooled sample effect, and were equal to
or even lower than conversion rates of CHR-negative samples
 type of UHR assessment instrument: no differences in conversion
rates
 age composition of sample: lower conversion rates in CAD
compared to YOUTH throughout, and additionally to ADULT at 2 and
> 4 years. YOUTH conversion rates never differed significantly from
those in ADULT.
5
Recommendations
(1) Do use APS, BIPS and COGDIS alternatively

(2) Do not use GRFD by itself, but consider GR as a factor increasing pre-
test probability
(3) Prevention of mental disorders also aims at a reduction of the burden of
mental disorders  Do not use a significant decline in occupational
and/or social functioning as an obligate CHR requirement for the lack of
evidence for an improvement of prediction by this addition
(4) Lack of knowledge about CHR criteria in the general population  Do
only assess / screen persons already distressed by and seeking help
for mental problems
(5) Do use CHR criteria and communicate potential CHR with outmost care
in children and young adolescents, in whom they should nevertheless
be assessed and monitored
(6) Trained specialists with sufficient experience in CHR should carry out the assessment or
supervise it if referral not possible
COGDIS & APS/BIPS combined

(Schultze-Lutter et al., 2014)
1.0 -
0.9 -
cumulative hazard rate
0.8 -
0.7 - ‘COGDIS+UHR’ , n=127
0.6 -
0.5 -
0.4 -
‘only UHR’, n=37
0.3 -
0.2 - ‘only COGDIS’, n=30
0.1 -
0-¦ ¦ ¦ ¦ ¦ ¦ ¦ ¦ ¦
0 6 12 18 24 30 36 42 48
months
Schizotypy and CHR criteria (N=277)

(Flückiger et al., 2019)
Chapman Scales SPI-A SIPS
6
CHR symptoms as mediators between
childhood adverse events and suicidality
(Schmidt et al., 2017)
Attenuated
positive
symptoms
N=73 CHR patients

Model fit indices: ²(51)=59.68, p=0.190; Comparative Fit Index=0.95; Tucker–Lewis Index=0.94; root-mean-square error of
approximation=0.046, p=0.496; Weighted Root Mean Square Residual=0.59. Standardized indirect effect through beliefs–
coping–depressiveness: IE=0.44; 95%-CIs: 0.10-0.78; p<0.001 and through cognitive disturbances: IE=0.16, 95%-CIs:
0.01-0.34; p=0.045.
*p < 0.05, **p < 0.01, ***p < 0.001.
Basic symptoms
and other clinical high-risk symptoms
in the general population
&
insight into their nature derived from
developmental effects
Prevalence & clinical significance
7
BEAR study: Prevalence of CHR symptoms
(N=2 683; age: 16-40) (Schultze-Lutter et al., 2018)
lifetime, current,
lifetime current
excl. traits excl. traits
(n=659, (n=460,
(n=567, (n=370,
24.6%) 17.1%)
21.1%) 12.8%)
any APS 316 (11.8) 200 (7.5) 265 (9.9) 154 (5.7)
any BIPS 10 (0.37) 3 (0.11) 9 (0.34) 2 (0.08)

any basic a
478 (17.8) 413 (15.4) 264 (9.8)
symptom
any COPER
416 (15.5) a 369 (13.8) 222 (8.3)
symptom
any COGDIS a
320 (11.9) 263 (9.8) 169 (6.3)
symptom
Prevalence of CHR criteria

(age: 16-40)
Any CHR criterion

n=64 (2.38%)
Clinical significance of CHR symptoms

 SE Wald df p-value Exp() 95% CIs of Exp()
Presence of any non-psychotic mental disorder
any CHR symptom 1.361 0.132 10.607 1 <0.001 3.901 3.013 5.051
CHR symptoms 117.007 3 <0.001
only basic symptoms 1.072 0.171 39.063 1 <0.001 2.920 2.087 4.086
only APS/BIPS 1.588 0.214 55.168 1 <0.001 4.895  3.219 7.443
both 2.003 0.298 45.277 1 <0.001 7.412 4.136 13.284
any CHR criterion 1.777 0.258 47.404 1 <0.001 5.911 3.564 9.802
CHR criteria 46.204 3 <0.001
only COPER/COGDIS 1.677 0.295 32.377 1 <0.001 5.350 3.002 9.534
only APS/BIPS 1.559 0.648 5.787 1 0.016 4.756  1.335 16.943
both 3.351 1.120 8.959 1 0.003 28.534 3.179 256.085
Presence of a functional deficit
any CHR symptom 1.948 0.176 122.200 1 <0.001 7.013 4.965 9.905
CHR symptoms 148.719 3 <0.001
only basic symptoms 1.399 0.239 34.099 1 <0.001 4.049 2.532 6.475
only APS/BIPS 2.309 0.252 84.192 1 <0.001 10.060  6.144 16.472
both 2.871 0.320 80.439 1 <0.001 17.661 9.430 33.076
any CHR criterion 2.865 0.268 114.141 1 <0.001 17.554 10.378 29.695
CHR criteria 113.698 3 <0.001
only COPER/COGDIS 2.766 0.304 82.954 1 <0.001 15.890 8.763 28.813
only APS/BIPS 3.053 0.639 22.802 1 <0.001 21.186  6.050 74.190
both 3.459 0.918 14.205 1 <0.001 31.780 5.260 192.005
8
Predictors of CHR symptoms
Combined and exclusive presence of APS/BIPS and basic

symptoms were predicted by a family history of mental disorders.
The combined, but not exclusive, presence of either kind of
symptoms was predicted by female sex, lower school education,
and current alcohol and current drug misuse.
Basic symptoms (alone or in combination with APS/BIPS), but not
APS/BIPS alone, were predicted by younger age.
APS/BIPS (alone or in combination with basic symptoms), but not
basic symptoms alone, were predicted by lifetime trauma, and
lifetime alcohol and lifetime drug misuse.
Basic symptoms alone and APS/BIPS alone but not their
combination was related to no current partner and unemployment.
Basic symptoms alone but not APS/BIPS alone or in combination
was predicted by single marital status.
No variable predicted exclusive presence of APS/BIPS.
Exp() / Odds ratios were mainly around 2.
3-year conversion rate in the community

(Schultze-Lutter et al., in 2nd review, Schizophr Res)
11,1
4,7
1,2
0,2 0,1 0,6
in 20-24-year-olds in 35-39-year-olds in total sample in RISK subsample in RISK with any in RISK with any
(acc. to Kirkbride et al., 2006. Arch. Gen. (N=834) (n=434) CHR criterion (n=43) EPA-recommended
Psychiatry. 63(3), 250‐258) CHR criterion (n=18)
Age effects
9
Effect of age on APS prevalence
(logistic regression with 20-24-year-olds as reference)
 SE Wald (df=1) p Exp () 95% CI
8-12 yrs. 1.23 0.47 6.86 .009 3.41 1.36-8.52

13-15 yrs. 1.25 0.52 5.65 .017 3.48 1.22-9.71
16-17 yrs. 0.31 0.48 0.42 .519 1.36 0.53-3.48
Any APS
18-19 yrs. -0.05 0.52 0.01 .927 0.95 0.34-2.64
25-29 yrs. -0.02 0.43 0.00 .973 0.99 0.42-2.31
30-40 yrs. 0.17 0.41 0.17 .682 1.18 0.53-2.65
8-12 yrs. 2.02 0.59 11.75 .001 7.50 2.37-23.74
13-15 yrs. 1.97 0.64 9.43 .002 7.20 2.04-25.39
Any 16-17 yrs. -0.24 0.85 0.08 .781 0.79 0.15-4.16
perceptive
18-19 yrs. 0.44 0.69 0.42 .517 1.56 0.41-5.97
APS
25-29 yrs. -0.15 0.68 0.05 .821 0.86 0.23-3.26
30-40 yrs. -0.23 0.68 0.11 .740 0.80 0.21-3.02
8-12 yrs. -0.16 0.81 0.034 .846 0.86 0.18-4.18
13-15 yrs. 0.68 0.71 0.92 .338 1.97 0.49-7.88
Any non- 16-17 yrs. 0.43 0.56 0.58 .446 1.53 0.51-4.58
perceptive
18-19 yrs. -0.35 0.69 0.25 .616 0.71 0.18-2.74
APS
25-29 yrs. -0.23 0.55 0.17 .685 0.80 0.27-2.36
30-40 yrs. 0.60 0.46 1.72 .190 1.82 0.74-4.48
Effect of age on basic symptom prevalence

(logistic regression with 20-24-year-olds as reference)
 SE Wald (df=1) p Exp () 95% CI
8-12 yrs.* 1.018 0.420 5.872 0.021 2.768 1.22-6.31

13-15 yrs. 1.432 0.451 10.061 0.001 4.186 1.73-10.14
16-17 yrs. 0.595 0.381 2.431 0.113 1.812 0.86-3.83
Any BS
18-19 yrs. 0.980 0.357 7.551 0.006 2.664 1.32-5.36
25-29 yrs. -0.566 0.413 1.879 0.156 0.568 0.25-1.28
30-40 yrs. 0.000 0.355 0.000 0.999 1.000 0.50-2.00
8-12 yrs.* 0.946 0.492 3.696 0.049 2.577 0.98-6.76
13-15 yrs. 1.584 0.497 10.164 0.002 4.875 1.84-12.91
Any 16-17 yrs. 0.671 0.443 2.296 0.116 1.956 0.82-4.66
cognitive
18-19 yrs. 1.225 0.402 9.280 0.001 3.405 1.55-7.49
BS
25-29 yrs. -0.496 0.490 1.024 0.299 0.233 0.23-1.59
30-40 yrs. 0.000 0.425 0.000 1.000 0.435 0.44-2.30
8-12 yrs. 0.972 0.612 2.521 0.094 2.643 0.80-8.77
13-15 yrs. 0.818 0.720 1.289 0.255 2.265 0.55-9.29
Any 16-17 yrs. 0.882 0.537 2.694 0.088 2.416 0.84-6.93
perceptive
BS 18-19 yrs. 0.094 0.642 0.021 0.8674 1.098 0.31-3.87
25-29 yrs. -0.504 0.638 0.625 0.431 0.604 0.17-2.11
30-40 yrs. -0.161 0.568 0.080 0.765 0.851 0.28-2.59
Modell of the relationship of between basic

symptoms and brain maturation, and APS and
maturation of cognitive abilities
10
Further information & news on:
www.basicsymptoms.org
Comments …
…. Questions?
Schizophrenia Proneness
Instrument, Adult (SPI-A) and
Child & Youth (SPI-CY) version:
Assessing basic symptoms
and basic symptom criteria for
predicting psychosis
Frauke Schultze-Lutter, Assis. Prof., Ph.D., Dipl.-Psych.
Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
11
Assessing basic symptoms
The Schizophrenia Proneness Instrument,

Adult version (SPI-A) / Child and Youth version (SPI-CY)
2012; Spanish
General assessment criteria
Age range: For the most part, SPI-CY items can be assessed from
the age of 8 onwards.
Self-experience The SPI-CY only rates symptoms that are subjectively

& experienced by the young person and are experienced
Novelty: as new and/or different from ‘normal’ troubles. These
symptoms should have been absent, or only present at
a significantly lower frequency, in what the young
person considers his or her premorbid stage.
Thus, a symptom is scored only when experienced by
the young person as a disturbance, deficiency or
complaint, irrespective of its appearance in behavior,
gesture, miming or speech.
 Parents’ reports only as a starting point for
questions.
Exception: ‘disturbances of abstract thinking’ (D7)
12
General assessment criteria
Exclusion criteria: Before a symptom can be rated as a basic symptom,

the interviewer should exclude the possibility that it
is an effect of drug use, especially of cannabis or
ketamine (Morgan et al. 2012), a side-effect of
medication, a manifestation of a somatic illness or a
by-product of a hypnagogic / hypnopompic state.
If a substance-related or somatic causation cannot
be ruled out for the time of the interview, periods
free of substance-use or illness have to be
examined. If the disturbance is also reported for
such time periods, it is rated in its current severity.
Main severity criterion: Frequency within the last 3 months
Possible applications of basic symptoms
Rating criteria
13
ADYNAMIA
Predominately frequency rating (I)
0 = absent; (I) never present

1 = rare; (I) less than once in a week
2 = mild; (I) once in a week
3 = moderate; (I) several times in a week
4 = moderately severe; (I) daily, longer periods of improvement possible
5 = severe; (I) daily, short periods of improvement possible (<24h)
6 = extreme; (I) daily and persistent
7 = has always been present in same severity (trait)

8 = definitely present, but severity unknown
9 = symptom definition questionably met
A1 Reduced energy and vitality
An impairment in strength or power, feeling weak, floppy or tired, or

‘cannot-do-as-many-things-as-I-used-to-do’. Almost always, coping by
increased effort and the exercise of willpower is tried, thus this symptom
might hide behind spontaneous reports of coping strategies such as ‘have
to try harder’, ‘have to work/learn slower’, or ‘need more breaks’.
Needs to be differentiated especially from:

• ‘difficulties concentrating’ (A11)
• ‘reduced drive and initiative’ (A3)
• ‘decrease in positive emotional responsiveness towards others’ (A6)
• ‘impaired tolerance to physical or mental labour’ (A4.1)
• lack of sleep and more severe sleep disturbances
Parents’ reports of possible behavioural correlates of this symptom can be

used as a starting point for targeted questions
A2 Reduced persistence and patience
An impairment in perseverance, endurance or diligence, increased

impatience, or a reduced ability to stick with one task or to sit quietly,
manifesting itself in tasks that require sustained mental effort such as:
school or homework, watching a movie, reading, drawing/painting, doing
handicrafts, playing computer games and the like. Leads to frequent
interruptions of activities and/or frequent change between activities.

• ‘reduced energy and vitality’ (A1)
• Attention-Deficit/Hyperactivity Disorder (ADHD)  ‘9’ (or ‘7’)

14
A3 Reduced drive and initiative
A reduction in motivation, ambition, inventiveness, determination or

planning for the future that resembles idleness or lazing around, but the
contentment that generally accompanies idleness is absent. Primarily a
decrease in drive and initiative, rather than failing to take an interest.
Can feel like psychomotor inhibition; the young person feels blocked and
cannot do things, despite having definitely planned to do them. Eventually
it might become observable as the negative symptom ‘avolition’.

• ‘reduced persistence and patience’ (A2)
• ‘increased indecisiveness’ (D1)
• ‘lack of ‘thought energy’ or goal-directed thoughts’ (A14)

A4 Impaired tolerance to certain stressors
A reduced stress tolerance or lack of resilience experienced in response to

any kind of labor (A.4.1) or to certain situations, or the anticipation of these
situations (A.4.2-4) that have not been particularly burdensome before. The
prevailing feeling is one of being exhausted or worn out by the respective
task or situation, and this is often accompanied by other expressions of
impaired stress tolerance, such as: restlessness or nervousness, sleep
disturbances, rumination, the inability to mentally ‘switch off’,
concentration disturbances, body perception disturbances and/or somatic
disturbances (e.g. tachycardia, sweating, problems breathing, digestion
problems).
Parents’ reports of possible behavioural correlates of these symptoms can

be used as a starting point for targeted questions
A4.1 … to physical and/or mental labour
A general decrease in stress tolerance or resilience manifesting itself in an

increased propensity for physical and mental exhaustion and fatigue, a
general lack of strength, weakness or tiredness, and a feeling of limited
ability and efficiency. It must be combined with at least with one other sign
of reduced stress tolerance (i.e., restless or nervous, sleep disturbances,
rumination, inability to ‘switch off’, concentration disturbances and body
perception disturbances); these should occur during or after performing
everyday physical and/or mental activities, that had not been experienced
as particularly stressful before (school, homework, sports, spare-time
activities, getting up, eating, tidying the room etc.) even though these tasks
have not become more demanding or significantly increased in number.

15
A4.2 … to unusual, unexpected or
specific novel demands
The extraordinary demands referred to here are not part of the daily routine
and imminent or very recent. Typical examples are an unanticipated
demand (e.g., an unannounced test in school), a special event (e.g., family
gathering, an appointment with the city council/job centre, test for a driving
license), an upcoming or recent change of environment or living situation
(e.g., moving, holidays, workmen in the house/apartment) or a
medical/psychological test.

• stage fright or exam nerves
A4.3 … to certain social everyday

situations
These stressors are everyday social situations that are generally
emotionally neutral and have not previously been regarded as unpleasant
or negative. They include:
• conversations,
• visiting people,
• crowds, the hustle and bustle of city or street life, in supermarkets, at
public and social events or on public transport,
• visual and/or auditory (over-)stimulation
These situations may be avoided for fear of a negative impact on mental
state, and this can result in social withdrawal.

• ‘disturbances of receptive speech’ (D11)
• ‘disturbance of expressive speech’ (D12)
• 'feeling overly distracted by stimuli' (D16)
A4.4 … to working under pressure of

time or rapidly changing different
demands
A reduced ability to carry out a task within a reasonable time, or to deal
with rapidly changing tasks. Self-reported difficulties coping with time
pressure (hectic, rushing) and experience of time-sensitive tasks as
unbearable, exhausting or confusing.
Young people will often try to cope with such situations by avoiding them
or by strictly planning their work in advance.

• ‘inability to divide attention’ (D8)
• exam nerves
16
A5 Change in mood and emotional
responsiveness
(1) a change in underlying mood that occurs spontaneously, is unrelated to
negative events, is perceived as uncontrollable, and is different from
temporary fluctuations of affect known from ‘healthy’ times,
(2) the ability to experience positive as well as negative emotions is
reduced or lost, or, in extreme cases, a ‘feeling of loss of feelings’ is
reported.
These symptoms often occur together and it can be hard to distinguish
which is more severe. If this proves impossible, A5.1 and A5.2 are rated ‘8’
each, and the combined severity is rated between ‘1’ and ‘6’ on A5.
In severe cases, A5.2 might be observed as flat affect

• ‘intermittent, recurrent depressive mood swings’ (A7)

A6 Decrease in positive emotional

responsiveness towards others
A decreased feeling of love, affection, sympathy, pity or positive interest in
other people, or a loss of interest in previously important activities,
hobbies or pleasurable events that may be expressed as emotional
dullness or even complete loss of positive emotions towards people or
interests that had formerly been held dear. A6 can also relate to the
emotional response to intimate relationships as well as empathic response
to the fate of acquaintances or strangers.

• ‘change in emotional responsiveness’ (A5.2)
• decreased expression of emotions or flat affect
• lack of interpersonal empathy
• anhedonia

A7 Intermittent, recurrent depressive mood

swings
Periods of low or depressive mood that occur without a recognizable
reason and remit spontaneously. They can be accompanied by odd bodily
sensations that, in this case are not rated separately, and may last for
hours, days or even weeks. Depressive-agitated, hypomanic or manic
syndromes can occur in combination with these periods or follow them.

• ‘change in basic mood’ (A5.1)

17
A8 Disturbance in presenting oneself
A disturbance of the availability of and control over the repertoire of non-

verbal expression, especially gestures, facial expressions, glances and
voice modulation, a loss of the ability to express oneself non-verbally.
Behavior, facial expressions and gestures do not express what is actually
felt, and are somehow shallow, diminished, distorted, inappropriate and not
under full control anymore. In severe cases, this might be observable as
the negative symptom of flat affect, even if no decrease in the experience
of emotions or emotional responsiveness (A5.2) is reported, or as
inappropriate affect.

• ‘somatopsychic bodily depersonalization’ (B8.2)
• 'autopsychic depersonalization' (C6)
• ‘decreased capacity to discriminate between different kinds of emotions’
(D13)
A9 Increased emotional reactivity in

response to everyday events
Everyday events that had not been previously associated with any strong
or persisting emotional reaction are now upsetting. Usually they are
experienced as causing agitation, inner restlessness, and tension and lead
to depressive ruminations or an inability to turn one’s mind off the event.
but also to sleep disturbance, concentration disturbances (A11, which in
this case are not rated separately), intense affective reactions (crying,
shouting, etc.) and somatic disturbances.
The occurrence of odd bodily sensations as assessed in B8, C7 and C8 is
an exclusion criterion here.

• ‘impaired tolerance to certain social everyday situations’ (A4.3)
• ‘thought perseveration’ (D14)
• unstable affect or even affective incontinence

A10 Increased emotional reactivity in

response to routine social inter-
actions that affect the young person
directly or indirectly
A self-experienced hypersensitivity to daily events either involving the
young person or his or her parents, other carers or friends. In comparison
to the premorbid phase, the young person feels ‘thin-skinned’ and is more
easily moved or offended. As in A9, it is essential that the young person
knows that he or she is over-reacting. Overreacting might be expressed as:
tension, arousal, agitation, nervousness, sleep disturbances, rumination,
concentration disturbances (A11, which in this case are not rated
separately), extensive affective reactions (crying, shouting, etc.) and
somatic disturbances.


18
A11Difficulties concentrating
Problems maintaining attention over time without being distracted.

• ‘slowed-down thinking’ (A13)
• ‘lack of ‘thought energy’ or goal-directed thoughts’ (A14)
• any memory problem (A12) (D4) (D5)
• ‘thought interference’ (D9)
• ‘thought pressure’ (D10)
• ‘disturbance of receptive speech’ (D11)
• ‘thought blockages’ (D15)
• any attention disturbance (D8) (D16) (O2)
• ‘impaired tolerance to certain stressors’ (A4)
• increased emotional reactivity (A9) (A10) (C2)
A12 Being forgetful or scatterbrained
Memory disturbances that cannot be assigned to a disturbance in working

(D4) or short-term memory (D5) or to a ‘loss of automatic skills’ (D19) in
which (semi-)automatic skills and routines seem to have been ‘forgotten’.
Information can be remembered immediately and even after a short while of
about 30 minutes but not after a longer lag time. While information seems
to have been stored initially in the short-term memory, transfer into long-
term memory seems to be disturbed. This symptom can manifest itself in
frequently losing things.

• ‘feeling overly distracted by stimuli’ (D16)

A13 Slowed-down thinking
An experience of slowness in thinking; sense that thinking has become

slower and harder, irrespective of the difficulty level of the task that is
being attempted. The young person frequently tries to compensate by
increased focusing of attention and/or a conscious ‘over-concentration’.
Slowness and difficulty with thinking might occur as a result of other
cognitive disturbances. It might be due to impaired short-term storage of
data (D5) or an inadequate retrieval of knowledge from the long-term
memory (A12, D6), and if caused by these is only rated at the respective
symptom.

• ‘disturbances of expressive speech’ (D12)

19
A14 Lack of ‘thought energy’ or goal-directed
thoughts (from age 13 onwards)
A disturbance of initiating thought, or of lacking ‘thought energy’ or
intellectual purpose; an impaired ability to initiate, plan and structure
certain actions such as cooking or active participating in a conversation.
A14 can be the subjective counterpart of an observable lack of goal
orientation or task structuring.

• ‘slowed-down thinking’ (A13)
• ‘increased indecisiveness’ (D1)
• ‘loss of automatic skills’ (D19)
• social anxiety

PERCEPTION DISTURBANCES
Predominately frequency rating (II)
0 = absent; (II) never present

1 = rare; (II) less than once in a month
2 = mild; (II) short periods about once in a month
3 = moderate; (II) several times in a month or weekly
4 = moderately severe; (II) several times in a week
5 = severe; (II) daily, periods of improvement possible
6 = extreme; (II) daily, but not necessarily continuously

Decreased ability to discriminate between

ideas and perception, phantasy and true
memories
20
B1 Decreased ability to discriminate
between ideas and perception, fantasy
and true memories
A difficulty locating the source of an experience/memory and thus results
in inability to distinguish between:
(1) ideas and perception or (2) pure fantasy and true memories.
This item should not be rated if it involves hallucinations and delusions, or
unusual perceptual disturbances (e.g., illusions, hearing the own name
being called, feeling the presence of something or someone invisible) or
ideas of reference, or other perceptual disturbances; and the problem
discriminating is restricted to stimuli resembling or related to these
experiences, as questioning such experiences is a sign of intact reality
testing rather than psychopathology.

• self-experienced memory disturbances (A12, D5-6)
• dissociative disorder
• dreams
Unstable ideas of reference
B2 Unstable ideas of reference
A subjective, subclinical experiences of self-reference that are almost

immediately rectified on further consideration; present when all of the
following are present:
(I) the young person feels that he or she is being referred to,
(II) but neither has a clear explanation for this feeling nor is he or she
looking for one outside his or her own mental processes, and
(III) immediately or very quickly overcomes this feeling.
Vague ideas of reference in interpersonal situations, particularly involving
peers, are common, especially in early adolescence, and need to be
carefully explored for their potential psychopathological character in terms
of a clear divergence from earlier ‘normal’ experiences (e.g. suddenly also
related to elder adults), before being rated as unstable ideas of reference.

• ideas and delusion of reference
21
Visual & acoustic perception disturbances
Visual & acoustic perception disturbances:

general comments
Perceptual disturbances differ from those seen in schizotypal personality
disorder or attenuated psychosis in that the young person who
experiences the basic symptom does not believe that it is caused by or
related to events in the real world, but instead immediately recognizes it as
a sensory aberration or mental problem. This knowledge that the
misperception has no counterpart in the real world is immediate and
unquestioned. Thus, in contrast to:
• hallucinations, the changes are not regarded as real and and are not
believed to take place in the outside world,
• illusions, real objects are not briefly mistaken for something different,
• schizotypal phenomena, perceptual basic symptoms relate to real objects
and do not include hallucinatory-like experiences.
The effects of drug intoxication, especially of cannabis, ketamine and other
hallucinogenic drugs (like LSD, psilocybin or mescaline), have to be
carefully ruled out when rating perceptual disturbances – as do somatic
causes. If these cannot be ruled out unequivocally, ‘9’ (questionably
present) has to be rated.
Visual perception disturbances
22
B3, O1, O3 Visual perception disturbances
Misperceptions of aspects of the visual field while the young person is

fully aware of the true appearance and, therefore, tends to attribute his or
her misperception to a problem with eye sight or mental processes:
B3.1 Near and tele-vision
B3.2 Micropsia and macropsia
B3.3 Metamorphopsia
B3.4 Changes in color vision
B3.5 Changed perception of the face or body of others
B3.6 Changed perception of the own face
B3.7 Pseudomovements of optic stimuli
B3.8 Diplopsia, oblique vision
B3.9 Disturbances of the estimation of distances or sizes
B3.10 Disturbances of the perception of lines/contours
B3.11 Dysmegalopsia
B3.12 Maintenance of visual stimuli, ‚visual echoes’
O1 Partial seeing including tubular vision
O3 Photopsia
plus, in SPI-A: Hypersensitivity to light or certain optic stimuli
Acoustic perception disturbances
B4, B5 Acoustic perception disturbances
Misperceptions of acoustic stimuli while the young person is fully aware of

the true sound and, therefore, tends to attribute his or her misperception to
a problem with hearing or mental processes.
These involve:
B4.1 Hypersensitivity to sounds or noise
B4.2 Acoasms
B5.1 Changes in perceived intensity or quality of acoustic stimuli
B5.2 Maintenance of acoustic stimuli, ‚acoustic echoes’
Note: B4.1 is unspecific and not included in the acoustic perception

disturbances relevant to COPER
23
B6 Disturbance of the comprehension of
visual or acoustic stimuli
An impairment in immediate recognition of non-verbal acoustic or visual
stimuli that are clearly perceived and familiar whereby the ability to use
acquired knowledge to identify the stimuli appears impaired. This
impairment is mostly of short duration (for seconds only) and, may thereby
be distinguished from the more persistent auditory or visual agnosia
caused by brain injury or neurological illness.

• other perception disturbances (B3, B4, B5, O1)
• 'derealization' (B7)
• illusions or delusional misperceptions
Derealization
B7 Derealization (from age 13 onwards)
A change in how one relates emotionally to the environment, which may

take two forms:
(1) An estrangement and detachment from the visual world, i.e., from how
one sees the world. The environment appears unreal, altered and
strange. This phenomenon might be accompanied by a decrease in the
dimensionality of visual perception, i.e. by a tendency to perceive 3-
dimensional space in a flat, 2-dimensional way.
(2) An increased emotional affinity for the environment. The world or
certain aspects of it are exceptionally emotional impressive; this
experience often occurs in tandem with a captivation by details of
perception (O2) or is accompanied by positive feelings/euphoria.

• ‘perceptual changes (B3, B4, B5, O1)
• illusions or delusional misidentifications
• ‘changes in the perceived intensity or quality of acoustic stimuli’ (B5.1)
• ‘somatopsychic bodily’ (B8.2) or ‘autopsychic depersonalization’ (C6)
24
B8 Body perception disturbances
Peculiar somatic sensations that are unlike any pains or bodily symptoms
experienced premorbidly. Cenesthesias can be mimicked or masked by
hypochondriacal phenomena. Mimicry occurs when unusual sensations
arise from excessive attention to bodily processes, and should not be rated
here. Masking occurs when unusual or peculiar sensations cause
excessive attention to bodily processes, and should be rated here.
Not separately rated here, when they are solely an expression of a
decreased tolerance to certain weather conditions or certain other
stressors (A4), or when they arise from anticipation of an emotionally
stressful event.

• delusions of external influence related to the body, somatic
misperceptions related to hypochondriac delusions, and somatic
hallucinations
• neurological conditions such as multiple sclerosis or peripheral
neuropathy
B8 Body perception disturbances
These involve:
B8.1 Unusual bodily sensations of numbness and stiffness
B8.2 Somatopsychic bodily depersonalization
B8.3 Migrating bodily sensations wandering through the body
B8.4 Electric bodily sensations, feelings of being electrified
B8.5 Bodily sensations of movement, pulling or pressure inside the body
or on its surface
B8.6 Bodily sensations of abnormal heaviness, lightness, emptiness,
falling, sinking, levitation or elevation
plus, in SPI-A: Sensations of the body or parts of it extending, dimishing,

shrinking, enlarging, growing or constricting
NEUROTICISM
Predominately frequency rating (I)
0 = absent; (I) never present

1 = rare; (I) less than once in a week
2 = mild; (I) once in a week
3 = moderate; (I) several times in a week
4 = moderately severe; (I) daily, longer periods of improvement possible
5 = severe; (I) daily, short periods of improvement possible (<24h)
6 = extreme; (I) daily and persistent

25
C1 Decreased need for social contacts
A decrease in desire for social contacts, such as spending time with family
or friends. Generally, the young person is not distressed by this increased
preference of spending time alone, and simply acknowledges the change
without showing much emotion.

• suspiciousness or paranoid ideations
• social anxiety
• avoidance strategies

C2 Increased emotional reactivity in

response to adversities of strangers
A pronounced and persistent emotional impression being left on the young
persons by the misfortunes of people who are completely unknown to
themselves, their family, or their acquaintances. Usually these misfortunes
are apprehended through electronic media or print. In comparison to the
premorbid phase, the young person feels as if he or she is more ‘thin-
skinned’ and so is more easily affected by sad news and recognizes that
she or he is over-reacting.
If body perception disturbances (B8, C7, C8), concentration disturbances
(A11), or ‘thought perseveration’ (D14) result from C2, these should only to
be rated at the respective item

• ‘increased emotional reactivity in response to everyday events’ (A9) or
to routine social interactions’ (A10)

C3 Increased excitability and irritability
A difficulty in controlling emotional responses, leading to sudden changes

in mood in response to insignificant events. The response can be angry,
leading to flare-ups, ranting and shouting, or sad, leading to over-
sentimental emotional reactions that are recognized as over-reactions.
When the young person cannot contain his or her excitability or irritability
this symptom might manifest as unstable affect or even affective
incontinence.

• ‘increased emotional reactivity in response to certain stimuli’ (A9, A10,
C2)

26
C4 Obsessive-compulsive phenomena
An inability to control obsessive-compulsive phenomena, especially

doubts, fears, impulses and actions. Like all obsessive phenomena, the
thoughts, images and impulses must be repetitive and intrusive, but they
do not have to be perceived as inappropriate or unreasonable; nor do they
have to cause marked anxiety or distress, if the young person attempts to
stop them. The young person may accept without protest prominent, or
even dominant, obsessive symptoms, such as repetitive behaviours or
verbal tics, to the extent that the ability to maintain a critical distance from
obsessive impulses may be lost completely. Furthermore, the obsessions
or compulsions do not have to be time-consuming or persistent or
significantly interfere with normal routine or psychosocial functioning.


C5 Phobic phenomena
A phobic anxiety relating to certain situations, places or objects, e.g.,

agoraphobia, claustrophobia, acrophobia, animal-related phobias and
social phobias. The phobic phenomena, Specific Phobia, Social Phobia or
Agoraphobia, can occur intermittently, and vary in the contents of the fears
as well as in the situations or objects that they are related to. For rating
purposes, it is not necessary for the young person to avoid the phobic
stimuli.

• ‘impaired tolerance to certain social everyday situations’ (A4.3)

C6 Autopsychic depersonalization
(from age 13 onwards)
Feeling alienated or detached from one’s own thoughts, emotions and

behavior. For example, thoughts and emotions appear to be peculiarly
weak, insipid or lacking in substance or his or her thoughts and actions
appear somehow unreal, remote or automatic. To be rated here, the young
person must have insight into the experience, and the experience should
not be due to perceptual disturbances (B3, B4, B5, B6, B8, C7, C8) or a
decreased ability to experience or express emotions (A5, A6, A8).
Rare subtypes are: mirror experiences and demarcation experiences.

• ‚somatopsychic bodily depersonalization‘ (B8.2)
27
C7 Unusual bodily sensations of pain in a
distinct area
Fairly circumscribed, painful and often long-lasting sensations with a
piercing, tearing or shooting quality that are completely different from any
pains experienced premorbidly. Frequently, these painful sensations
appear in certain parts of the body at certain times of day. The onset may
be acute, like a spasm, or gradual, slowly increasing and decreasing in
intensity. Precise location of the pain within the body is often difficult if not
impossible.

• ‘migrating bodily sensations’ (B8.3)
C8 Dysesthesias caused by touch or

perceptions
Unpleasant or even painful bodily sensations in response to touch, other
tactile or thermal stimuli, or acoustic or visual perceptions (rarely).
Dysesthesias are always caused by an external stimulus.
It is important to exclude neurological conditions that might cause
dysesthesias such as multiple sclerosis or (poly-)neuropathy caused by
diabetes and other conditions. Furthermore, ‘dysesthesias’ should not be
rated here if they only occur within the acute phases of withdrawal from
alcohol, nicotine or illicit drugs.

• ‘hypersensitivities to sounds or noise (B4.1) or to light or optic stimuli

THOUGHT & MOTOR DISTURBANCES
Predominately frequency rating (II)
0 = absent; (II) never present

1 = rare; (II) less than once in a month
2 = mild; (II) short periods about once in a month
3 = moderate; (II) several times in a month or weekly
4 = moderately severe; (II) several times in a week
5 = severe; (II) daily, periods of improvement possible
6 = extreme; (II) daily, but not necessarily continuously

28
D1 Increased indecisiveness with
regard to insignificant choices
between equal alternatives
An inability to decide between two or more equal alternatives that are so

similar that previously no conscious effort would have been required to
make the choice and that occurs in relation to simple everyday choices that
have no consequences.

• ‘decreased spontaneity, increased self-reflection’ (D3)

D2 Impaired social skills
A newly acquired difficulty in initiating or maintaining social contacts,

which might be expressed as insecurity, tension or shyness in social
situations that would previously have been handled with ease. Not rated
when caused by, or can be regarded as an appropriate reaction, to,
traumatic events or persistently problematic social interactions such as
bullying. When severe, ‘impaired social skills’ can lead to social
withdrawal.

• ‘Impaired tolerance to certain social everyday situations’ (A4.3)
• ‘Increased emotional reactivity in response to routine social interactions
that affect the young person directly or indirectly’ (A10)
• ‚decreased need for social contacts’ (C1)
• ‘phobic phenomena’ (C5) or Social Phobias
• Developmental Disorders

D3 Decreased spontaneity, increased self-

reflection (from age 13 onwards)
A tendency for excessive self-monitoring of thinking and behavior,
sometimes to the extent that the young person is unable to behave as
spontaneous and carefree in situations where this is appropriate. Increased
self-awareness is part of normal development, but when D3 is present, the
young person shows such an exaggerated increase in self-reflection that it
interferes with everyday life and inhibits spontaneity. The young person
recognizes that he or she is ‘thinking too much’, but is unable to do
anything about it.

• ‘increased indecisiveness' (D1)
• depressive rumination

29
D4 Disturbance of immediate recall
Problems with very short-term working memory. The young person

complains about not being able to remember things for even a very short
period of time (about 5 to 40 seconds). Typical descriptions of the
symptom include forgetting the beginning of a sentence before reaching
the end, or being unable to hold facts ‘online’ for further use in mental
processes. Attention-Deficit Disorder and Dyscalculia should be excluded.

• ‘difficulty holding things in mind for less than an hour’ (D5)
• ‘disturbance in retrieving knowledge from long-term memory’ (D6)
• attention problems (D8, D16, O2)

D5 Difficulty holding things in mind for

less than an hour
Problems with short-term memory. The young person reports that he or
she is not able to hold things in their mind for at least 20 minutes. Not rated
when a pre-existing Attention-Deficit Disorder is present.

• ‘‘forgetfulness, scatterbrainedness’ (A12)
• ‘disturbance of immediate recall’ (D5)
• ‘disturbance in retrieving knowledge from long-term memory’ (D6)

D6 Disturbance in retrieving knowledge

from long-term memory (from age 13 onwards)
A deficit in the adequate retrieval of knowledge already memorized or
know-how. This symptom is concerned with recalling skills or knowledge
pertinent to a particular situation or given task. The competing ideas or
behavior impulses are generally associated with the task or situation at
hand. Forgetting details of past events or of acquired, but rarely used,
knowledge (e.g., details from history lessons of the last semester) is not
scored here.

• ‘disturbance of the comprehension of visual or acoustic stimuli’ (B6)
• ‘disturbance of expressive speech’ (D12)
• ‘thought pressure’ (D10)

30
Disturbances of abstract thinking
D7 Disturbances of abstract thinking

Deficits in the comprehension of any kind of abstract, figurative or

symbolic phrases or content, as well as the phenomena of ‘concretism’ (a
limitation of the ability to go beyond the literal meaning of words,
sentences or phrases). Uniquely, this basic symptom can be identified by
testing, i.e., by asking the young person to explain the meaning of
proverbs. If only obvious on testing, then ‘8’ (definitely present, but
frequency unknown) is rated.
Difficulties in the apprehension and decoding of affective states can lead to
concerns over whether a comment was serious (literally) or ironic
(metaphorical), but are not rated here.


Inability to divide attention
31
D8 Inability to divide attention
A difficulty in dealing with demands that involve more than one sensory
modality at a time and thus does not concern demands that would require
quick switching of attention. The young person has difficulty integrating
sensory input from more than one sense, such as visual and auditory
stimuli. Generally at least one demand is performed on a (semi-)automatic
level thus not requiring full attention.

Thought interference
D9 Thought interference
Irrelevant thoughts are intruding on and disturbing the young person’s

train of thought. These intrusive thoughts are emotionally neutral, have no
special meaning to the young person, and no association with the intended
thought. Usually intrusive thoughts appear out of the blue, but occasionally
they may be evoked by external stimuli. Intrusive thoughts that relate to
emotionally loaded subjects, e.g., a loved one, a recent fight or argument, a
future task (e.g., “I mustn’t forget to…”) or good or bad news, do not count
as thought interference and are not rated here.

• ‘thought blockages’ (D15)
• ‘motor interference’ (D17)
32
Thought pressure
D10 Thought pressure
A self-reported ‘chaos’ of thoughts. A great number of different thoughts or

images randomly enter the mind and disappear again in quick succession,
without the young person being able to suppress or guide them. In contrast
to the fifth subtype of ‘thought blockages’ (D15) in which chains of
association drift away from the intended direction of thinking, in ‘thought
pressure’ the successive thoughts are not linked by any common thread,
and are completely unrelated to each other or to the young person’s
intended line of thought.
In contrast to the loosening of association seen in formal thought
disorders, ‘thought pressure’ is a subjective impairment that is generally
not observable, apart from occasional pauses in the conversation whilst
the affected person attempts to suppress the intruding thoughts.

Disturbances of receptive language
HOUSE
33
D11 Disturbance of receptive speech
A disturbance in the understanding of words that are either read or heard.

When reading or listening to others, the young person struggles to
comprehend the meaning of words, word sequences or sentences. This
disturbance occurs with the young person’s first language (or, if bi-lingual,
the language in that he or she thinks), even if the young person
concentrates on the text or speech and has perceived it accurately.
Exclude reading or writing disorders, a developmental disorders of
receptive speech, an Attention-Deficit Syndrome and acquired aphasia with
epilepsy (Landau-Kleffner syndrome). Ensure that the reported disturbance
represents a clear deterioration from a previous level of achievement.

• visual or acoustic perception disturbances (B3, B4, B5, B6, O1, O3)
• memory problems (A12, D4, D5, D6)

Disturbance of expressive speech
E S O H U ??
D12 Disturbance of expressive speech
A subjective difficulty in finding the right words when trying to express

oneself. The young person recognizes that his or her verbal fluency and
clarity of expression are impaired or slowed. The words required to
express simple ideas are not forthcoming or are available only after a
delay. Sometimes the words that are recalled that are only vaguely
associated with the correct word. When severe, a self-experienced ‘talking
beside the point’ can occur .

• ‘disturbance in presenting oneself’ (A8)
• observed digressive or vague speech
• impoverishment of speech
• Avoidant Personality Disorder or Social Phobia
• aphasia due to epilepsy and elective mutism (Landau-Kleffner syndrome)

34
D13 Decreased capacity to discriminate
between different kinds of emotions
A tendency to perceive all emotions in the same way. The young person is
unsure what kind of emotion he or she is experiencing at any particular
time, because different types of emotions no longer feel distinct. This
symptom is not rated when the difficulty is to do with describing the finer
details of an emotional response, rather than being able to tell what the
emotion actually is. The inability to tell positive from negative feelings, and
the tendency to experience every heighted emotion as unpleasant, can be
associated with a blunted affect, which may be observable in behavior and
facial expression.

• ‘change in mood’ (A5.1)
• ‘change in emotional responsiveness’ (A5.2)

Thought perseveration
D14 Thought perseveration
An annoying and obsessive rehearsal of unimportant, emotionally neutral,

thoughts or images that relate to trivial events of the mainly recent past.
These ‘memories’ are so unimportant and lacking in emotion that even the
young person recognizes that they do not justify the excessive attention
that they are involuntarily receiving from him or her.
Not rated here are ruminations about trivial events that arise due to
increased emotional reactivity (A9, A10, C2) or impaired stress tolerance
(A4).

• ‘obsessive-compulsive phenomena’ (C4)
• depressive rumination
35
Thought blockages
D15 Thought blockages (from age 13 onwards)
Sudden interruption in the flow of thoughts, or of the mind suddenly going

blank, of the fading (slipping) of thoughts or of losing the thread of
thoughts. The original topic may be recalled subsequently or completely
lost. The different subtypes involve:
 pure blocking
 pure fading
 fading in combination with simultaneous thought interference
 blocking followed by thought interference
 loss of the thread/train of thoughts

• ‘motor blockages’ (D18)
D16 Feeling overly distracted by stimuli
Over-attentiveness or unintended hyper-vigilance that is characterized by

an inability to block or filter out irrelevant stimuli. The young person’s
attention is focuses randomly on external stimuli to which he or she would
normally give little attention.


36
D17 Motor interference
Spontaneous and unintended movements or utterances that typically

interfere with intended motor actions or speech and are not due to thought
disturbance. Typically the symptom consists of single pseudo-
spontaneous movements that are part of the normal repertoire of voluntary
movements, but are out of context, or interfere with intended movements.
The intruding movements are neither part of a neurological disorder (such
as Tourette syndrome or tics) nor medication side effects.

• motor stereotypies
• made volitional acts
D18 Motor blockages
Interruption or complete blockage of intended movements. Complete motor

blockages are spasmodic, in that they appear suddenly and vanish quickly.
In complete motor blockages, the young person is unable to move or
speak, although she or he is fully awake. Generally, in the fully awake state,
motor blockages affect the whole body, but usually, after being present for
only a short while (minutes), they can be overcome by willpower.

• bodily sensations of motor weakness
D19 Loss of automatic skills
Difficulty performing simple skills that were previously automatic, typically

habitual actions (e.g., tying shoes, getting dressed, washing, shaving,
brushing hair) or partially automated actions (e.g., riding a bicycle, knitting,
working in the kitchen, handling joysticks, or typing). These actions have
been performed in the past more or less automatically, but now cannot be
performed any more or only with effort and deliberate concentration. Thus
they might need more time and more attention.

• ‘inability to divide attention’ (D8)

37
Captivation of attention by details of the
visual field
O2 Captivation of attention by details of

the visual field
Domination of the visual field by a random single aspect of it that holds
young person’s attention. An ordinary visual stimulus or a part of it stands
out in a striking manner so that it appears almost isolated from the rest of
the environment. This effect is so striking that captures the young person’s
whole attention. She or he has to look at this detail, event though he or she
does not want to. Normally the young person will have difficulty in turning
away from it.

• ‘derealization’ (B7)
in SPI-A:
Disturbances of olfactoric, gustatoric or
tactile perceptions
Quantitative and/or qualitative changes in olfactory, gustatory or tactile

perceptions. Smells or tastes appear less intense or too intense and
intrusive, appear different in kind, e.g., a Coke suddenly tastes salty or
sour; or there seems to be a fishy smell everywhere. Following a possible
short first check, the person quickly realizes that the change is only due to
him/her, e.g., if the next gulp tastes normal again or the smell lingers
despite moving on.
In disturbances of perception of sensory stimuli, the surface of objects
feels different to the touch.
Especially in the case of a decreased intensity of tastes, an affective
change, e.g., a major depression that has resulted in a lack of interest in
food and also in a decrease or loss of appetite, should be distinguished
from a decrease in the ability to perceive tastes (or smells), which can also
result from (allergic) coryza.
38
Summary of basic symptom criteria
… to keep updated …
www.basicsymptoms.org
39

Basic Symptoms in The Early Detection of Psychosis: Background

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Basic Symptoms in The Early Detection of Psychosis: Background

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Basic symptoms

Frauke Schultze-Lutter, Ass./Prof., Ph.D., Dipl.-Psych.

Already in 1932, the German psychiatrist Wilhelm Mayer-Gross

“Knowledge of basic symptoms and of the stages

(Gerd Huber 1987, Introduction to the BSABS)

 subtle, subclinical self-experienced disturbances in drive,

Basic symptom concept

Development of basic symptom criteria

A prospective study of the predictive ability of basic symptoms

Sample: patients of 5 specialized outpatient

No. of patients: male female total

COPER – “cognitive-perceptive basic

 At least 1 of the following 10 basic symptoms

COGDIS – “cognitive disturbances”

 At least 2 of the following 9 basic symptoms

 at least weekly frequency within past 3 months

Model of the early course of psychosis

EPA guidance on the definition of

 Meta-analyses of 42 independent samples (N=4’952) in 45

Comparison of single CHR criteria

Results of main & sensitivity analyses

 annual conversion rates: compared to even the lowest conversion

(1) Do use APS, BIPS and COGDIS alternatively

COGDIS & APS/BIPS combined

Schizotypy and CHR criteria (N=277)

Chapman Scales SPI-A SIPS

N=73 CHR patients

Prevalence & clinical significance

any BIPS 10 (0.37) 3 (0.11) 9 (0.34) 2 (0.08)

Prevalence of CHR criteria

Any CHR criterion

Clinical significance of CHR symptoms

Combined and exclusive presence of APS/BIPS and basic

3-year conversion rate in the community

 SE Wald (df=1) p Exp () 95% CI

8-12 yrs. 1.23 0.47 6.86 .009 3.41 1.36-8.52

Effect of age on basic symptom prevalence

 SE Wald (df=1) p Exp () 95% CI

8-12 yrs.* 1.018 0.420 5.872 0.021 2.768 1.22-6.31

Modell of the relationship of between basic

The Schizophrenia Proneness Instrument,

General assessment criteria

Self-experience The SPI-CY only rates symptoms that are subjectively

Exclusion criteria: Before a symptom can be rated as a basic symptom,

Main severity criterion: Frequency within the last 3 months

Possible applications of basic symptoms

Predominately frequency rating (I)

0 = absent; (I) never present

7 = has always been present in same severity (trait)

A1 Reduced energy and vitality

An impairment in strength or power, feeling weak, floppy or tired, or

Needs to be differentiated especially from:

Parents’ reports of possible behavioural correlates of this symptom can be

A2 Reduced persistence and patience

An impairment in perseverance, endurance or diligence, increased

Needs to be differentiated especially from:

Parents’ reports of possible behavioural correlates of this symptom can be

A reduction in motivation, ambition, inventiveness, determination or

Needs to be differentiated especially from:

Parents’ reports of possible behavioural correlates of this symptom can be

A4 Impaired tolerance to certain stressors

A reduced stress tolerance or lack of resilience experienced in response to

Parents’ reports of possible behavioural correlates of these symptoms can