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Psychiatry Research 220 (2014) 659663

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Validation of the German version of the Clinical Assessment Interview


for Negative Symptoms (CAINS)
Maike Engel n, Anja Fritzsche, Tania Marie Lincoln
University of Hamburg, Department of Clinical Psychology and Psychotherapy, Von-Melle-Park 5, 20146 Hamburg, Germany

art ic l e i nf o a b s t r a c t

Article history: Validated assessment instruments could contribute to a better understanding and assessment of
Received 6 December 2013 negative symptoms and advance treatment research. The aim of this study was to examine the
Received in revised form psychometric properties of a German version of the Clinical Assessment Interview for Negative
29 April 2014
Symptoms (CAINS). In- and outpatients (N 53) with schizophrenia or schizoaffective disorder were
Accepted 27 July 2014
Available online 1 August 2014
assessed with standardized interviews and questionnaires on negative and positive symptoms and
general psychopathology in schizophrenia, depression, the ability to experience anticipatory and
Keywords: consummatory pleasure, and global functioning. The results indicated good psychometric properties,
Negative symptoms high internal consistency and promising inter-rater agreement for the German version of the CAINS. The
Assessment
two-factor solution of the original version of the CAINS was conrmed, indicating good construct
Clinical rating
validity. Convergent validity was supported by signicant correlations between the CAINS subscales with
German version
the negative symptom scale of the Positive and Negative Syndrome Scale, and with consummatory
pleasure. The CAINS also exhibited discriminant validity indicated by its non-signicant correlations
with positive symptoms, general psychopathology and depression that are in line with the ndings for
the original version of the CAINS. In addition, the CAINS correlated moderately with global functioning.
The German version of the CAINS appears to be a valid and suitable diagnostic tool for measuring
negative symptoms in schizophrenia.
& 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction cognitive functioning (e.g., attentional bias or abstract thinking),


which have now been recognized to be conceptually distinct from
Negative symptoms of schizophrenia are characterized by blunted negative symptoms (Harvey et al., 2006). Another conceptual issue
affect, alogia, anhedonia, avolition and asociality (Blanchard and is the overlap with measures of functional outcome (Forbes et al.,
Cohen, 2006; Kirkpatrick et al., 2006; Blanchard et al., 2011). They 2010), in the sense that the measure rates performance decits
are associated with poor functional and long-term outcomes (Norman rather than negative symptoms as such. Furthermore, the con-
et al., 2000; Strauss et al., 2010) and do not respond well to available textual factors, such as living in a socially impoverished environ-
treatments (Stahl and Buckley, 2007). It has therefore been agreed that ment, are not taken into account (Forbes et al., 2010). Finally, it is
increased efforts are needed to enhance the understanding and seen as problematic that the measures focus entirely on observa-
treatment of negative symptoms and that these efforts include the ble symptoms and have failed to assess internal experiences
development of better assessment scales (National Institute of Mental (Horan et al., 2006; Blanchard et al., 2011).
Health (NIMH); Kirkpatrick et al., 2006). To better reect the current understanding of negative symp-
The commonly used negative symptom assessments, such as toms and address the limitations of available symptom measures
the Scale for the Assessment of Negative Symptoms (SANS; the Collaboration to Advance Negative Symptom Assessment in
Andreasen, 1982) and the Positive and Negative Syndrome Scale Schizophrenia (CANSAS) developed the Clinical Assessment Inter-
(PANSS; Kay et al., 1987) have been criticized for a number of view for Negative Symptoms (CAINS; Horan et al., 2011). The
reasons (Blanchard et al., 2011). One of the most relevant concerns CAINS assesses decits in emotional expression based on behavior
is that both of these measures include items that measure observed throughout the interview and decits in emotional
experience based on the patients' reports (Kring et al., 2013).
n
Affective attening and alogia are combined into the expressive
Corresponding author. Tel.: 49 40 42838 9240.
impairment factor and asociality, avolition and anhedonia into
E-mail addresses: maike.engel@uni-hamburg.de (M. Engel),
anja.fritzsche@uni-hamburg.de (A. Fritzsche), the experiential impairment factor (Horan et al., 2011). The
tania.lincoln@uni-hamburg.de (T.M. Lincoln). CAINS has been validated in three studies based on a total of

http://dx.doi.org/10.1016/j.psychres.2014.07.070
0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.
660 M. Engel et al. / Psychiatry Research 220 (2014) 659663

approximately 500 patients with schizophrenia and schizoaffec- who participated in a 2-day PANSS training workshop including manual review and
evaluation of videotaped assessments.
tive disorder (Forbes et al., 2010; Horan et al., 2011; Kring et al.,
As a further indicator of convergent validity we included the Temporal
2013). The ndings from these studies conrm the two-factor Experience of Pleasure Scale (TEPS; Gard et al., 2006). The TEPS is a self-report
structure and indicate strong convergent and discriminant validity, questionnaire that comprises 10 items that measure the ability to experience
adequate testretest reliability, and good inter-rater agreement anticipatory pleasure (e.g. I look forward to a lot of things in my life.) and eight
(Kring et al., 2013). items that measure the ability to experience consummatory pleasure (e.g. I enjoy
taking a deep breath of fresh air when I walk outside.). The English version of the
The aim of the present study was to examine the psychometric TEPS has good internal consistency (Cronbach0 s alpha 40.79; Gard et al., 2006) and
properties of a German version of the CAINS in a sample of testretest reliability (r 0.81, p o 0.001; Gard et al., 2006). For the purpose of this
inpatients and outpatients with schizophrenia or schizoaffective study the TEPS was translated into German and translated back into English by a
disorder. research assistant with English as her native-speaking language, who had not seen
the original version.
To evaluate the discriminant validity of the CAINS we employed the German
version of the Beck Depression Inventory, revision (BDI-II; Khner et al., 2007), a
2. Method 21-item self-report instrument that measures the presence and severity of
depressive symptoms during the last two weeks. The BDI items are rated from
2.1. Participants and procedure 0 to 3 in terms of intensity. Total scores range from 0 to 63, with higher scores
indicating more severe depressive symptoms. Reliability coefcients are consis-
tently high in clinical and non-clinical samples (Cronbach0 s 0.800.94; Khner
The total sample included 53 participants with acute or remitted schizophrenia
et al., 2007). Due to scheduling and time constraints 10 participants were unable to
(n42) or schizoaffective disorder (n 11). Diagnoses were made by the treating
complete the BDI-II.
psychiatrists and conrmed by one of the researchers (M.E.) using the psychosis
To assess the association of the CAINS with functioning, we included the Global
modules B and C of the Structured Clinical Interview for DSM-IV (SCID; First et al.,
Assessment of Functioning (GAF; American Psychiatric Association, 1987). The GAF
2002). Exclusion criteria were: 1) neurological disorder or head injury with loss of
is a measurement of social, occupational, and psychological functioning.. Patients
consciousness, 2) acute substance use disorder, and 3) inability to effectively agree
are rated between 0 (most severe) and 90 (least severe). The GAF has been found to
and participate in the assessment due to severe psychiatric symptoms.
be a reliable and valid measure of social, occupational, and psychological function-
Acute and remitted participants were recruited from inpatient mental health
ing of adults in clinical populations (Jones et al., 1995).
clinics (n 30) and outpatient treatment settings (n 23) in and around Hamburg/
Germany. Mental health professionals in the in- and outpatient institutions were
contacted and informed about the study. These professionals then asked patients
with schizophrenia or schizoaffective disorder on their ward or institution whether 2.3. Strategy of data-analysis
they would be willing to participate in the study. After obtaining written informed
consent, patients participated in a 1.5 h assessment that began with the SCID We calculated means and standard deviations for each CAINS-item and further
diagnostic screening interview and included several symptom measures (as analyzed the corrected item-total correlation. A correlation value less than
described below) in randomized order. Study procedures were approved by the 0.3 indicates that the corresponding item does not correlate very well with the
ethics committee of the Psychotherapeutenkammer Hamburg. subscale (Field, 2009). To assess the internal consistency of the CAINS, Cronbach0 s
The sample was 56.6% male with a mean age of 35.64 years (S.D. 10.10) and a alpha was calculated for both subscales and the total scale. A value between 0.70.8
mean of 10.94 years of education (S.D. 1.57). Most participants had never been is an acceptable value for Cronbach0 s alpha and a value above 0.8 indicates good
married (81.1%) or were divorced (11.3%), 47.2% were unemployed and 18.9% were reliability (Field, 2009). Construct validity of the CAINS was established with
receiving disability benets. Almost all (n 50) participants were currently taking exploratory factor analysis (principal axis extraction with promax rotation; Bhner,
antipsychotic medication. 2006). Effects of gender and patient status were calculated by t-tests with p-values
corrected for multiple comparisons (Bonferroni correction; pcorr r 0.005). Conver-
gent validity was conducted by examining whether the CAINS was signicantly
2.2. Measures correlated with negative symptoms (PANSS negative scale) and the ability to
experience pleasure (TEPS). Discriminant validity was conducted by examining
The Clinical Assessment Interview for Negative Symptoms (CAINS; Kring et al., whether the CAINS was uncorrelated with positive (PANSS, positive scale) and
2013) is a 13-item interview that assesses the presence and severity of negative general symptoms (PANSS, general psychopathology) and depression (BDI-II). In
symptoms. It provides standardized interview probes and descriptive anchor addition, the correlation between the CAINS and global functioning (GAF) was
points. All items are scored on a ve-point scale from 0 (no impairment) to 4 examined.
(severe decit). The CAINS includes items that assess motivation and pleasure
(consummatory and anticipatory pleasure) for relevant social, vocational and
recreational activities and emotion expression. By agreement with developers of
the original CAINS (Drs. Horan and Blanchard), we translated its latest version 3. Results
(Kring et al., 2013) into German according to guidelines proposed by Beaton et al.
(2000). The CAINS was rst translated to German and then back to English by a
research assistant with English as her native-speaking language, who had not seen
3.1. Item-level and subscale analyses for the CAINS
the original version. This retranslated version was compared to the original, and a
revised second translation was made. Finally, the translator, the translation The scree plot and the principal-axis factor analysis (Table 1)
reviewer, and other members of the team discussed the second translated version replicated the two dimensional structure reported in earlier
and decided on the nal version ready for the eld. The manual of the CAINS was
studies (Horan et al., 2011; Kring et al., 2013). The mean value
also translated into German. A clinical rater with master-degree in clinical
psychology and extensive prior experience in conducting patient symptom inter- for all communalities was 0.58. The correlation between the two
views (M.E.) was trained in the CAINS interview. Training included review of the scales was moderate (r 0.44, N 53). Item and scale means and
manual, and ratings of seven videotaped assessments that were provided by the standard deviations for the CAINS are depicted in Table 2. All item
developers of the original CAINS. The targeted competency level was an Intraclass means were between 0.94 and 2.89 on a ve-point scale from 0 to
Correlation Coefcient (ICC) of Z0.90 between the last two ratings of the
videotaped assessments and the gold standard ratings provided by the developers
4. Table 2 also presents the internal consistency reliability esti-
of the original CAINS. To determine inter-rater agreement for the German version mates for the CAINS subscales and the overall scale. Cronbach0 s
of the CAINS, 10 interviews were co-evaluated by a trained research assistant who alpha of the overall CAINS scale was slightly lower than for the
was not involved in the scale translation or evaluation. This rater participated in a motivation/pleasure scale and slightly higher than for the expres-
1-day rater-training workshop that involved review of the manual, ratings of
sion scale. Whereas the alphas of the CAINS overall and motiva-
videotaped assessments. Rater competency was tested in role plays and evaluated
by the amount of agreement with the gold standard ratings of the videotaped tion/pleasure scale would have decreased (Cronbach0 s
assessments. alpha o0.86) by removal of any item, the alpha of the expression
To determine convergent and discriminant validity of the CAINS we used the scale would have increased by deleting item 13 (Cronbach0 s
Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987). The PANSS assesses alpha 0.91). However, there was still good correlation of item
severity of psychotic symptomatology during the last 7 days. It includes 30 items
that assess negative and positive symptoms and general psychopathology and is
13 with the other items of the subscale (corrected item to total
used widely in research settings. Items are rated on a seven point scale, ranging scale correlation 0.33) so that it appeared justied to retain that
from absent to extreme. The PANSS interview was performed by the rst author item (Table 2).
M. Engel et al. / Psychiatry Research 220 (2014) 659663 661

3.2. Inter-rater agreement Table 2


Item and subscale statistics for the CAINS (N 53).
The average Intraclass Correlation Coefcient (ICC) for the
M S.D. r Scale alpha
CAINS motivation/pleasure was 0.96 (p r0.001) ranging from
0.73 (p 0.031; item 7) to 1.00 (p r0.001; item 4). The ICC for Motivation and pleasure subscale score 19.75 6.09 0.868
the CAINS expression scales was 0.95 (p r0.001) ranging from Item 1: Social, family relationships 1.23 1.07 0.43
0.84 (p r 0.01; item 11) to 1.00 (p r0.001; item 10). The ICC for the Item 2: Social, friendships 1.51 1.14 0.51
Item 3: Social, past-week pleasure 2.68 0.83 0.53
total scale was 0.94 (p r0.001). Item 4: Social, expected pleasure 2.83 0.85 0.71
Item 5: Vocational, motivation 1.53 0.91 0.35
3.3. Effects of gender and patient status Item 6: Vocational, expected pleasure 2.89 0.85 0.48
Item 7: Recreation, motivation 1.74 1.08 0.63
Item 8: Recreation, past-week pleasure 2.58 1.03 0.75
Men and women did not differ on any of the CAINS, PANSS or Item 9: Recreation, expected pleasure 2.77 0.93 0.67
TEPS scales or on the BDI-II and the GAF. There were no signicant Expression subscale score 4.64 4.15 0.798
differences between in- and outpatients on the CAINS scales, the Item 10: Expression, facial 1.55 1.03 0.65
Item 11: Expression, vocal prosody 1.00 0.96 0.67
PANSS negative and general psychopathology scale, the TEPS
Item 12: Expression, gestures 1.15 1.06 0.69
scales, BDI-II and GAF. However, inpatients received higher scores Item 13: Expression, speech 0.94 1.95 0.33
than outpatients on the PANSS positive scale (mean 14.45, S. CAINS total score 24.40 8.76 0.866
D.5.56 versus mean 10.43, S.D. 3.09; t24.09, d.f. 51), and
the GAF (mean48.74, S.D. 1.29 versus mean 33.23, S.D. 0.94; Note: CAINS Clinical Assessment Interview for Negative Symptoms; r corrected
item-total scale correlation; Scale alpha Cronbach's alpha. All items were rated on
t  4.94, d.f. 51). a ve-point scale (04) with higher scores reecting greater impairment.

3.4. Convergent and discriminant validity


in the previous studies. However, we found somewhat higher
mean scores on the items assessing pleasure across social, voca-
The indicators of convergent and discriminant validity are
tional and recreational domains, indicating lower levels of plea-
presented in Table 3. In support of convergent validity both CAINS
sure in our sample compared to the sample in the study by Kring
scales were highly correlated with the PANSS negative subscale.
et al. (2013). Cultural differences might partially explain this
Moreover, both CAINS scales were signicantly negatively related
nding as cultures have been found to differ with regard to the
to the consummatory pleasure scale as assessed with the TEPS, but
experience of pleasure (Scherer et al., 1988; Mesquita and Walker,
unexpectedly not to the anticipatory pleasure scale. The CAINS
2002). Moreover, the lack of pleasure may not be equally clinically
scales were not related to positive symptoms and general psycho-
relevant in all cultures (Mesquita and Walker, 2002). Several
pathology as assessed with the PANSS or with self-reported
studies found Americans to appraise emotional situations as more
depression as assessed with the BDI-II, indicating discriminant
pleasant than individuals from Eastern cultures. Moreover, Amer-
validity. In addition, the CAINS motivation/pleasure subscale (but
icans reported a much higher frequency of positive than negative
not the CAINS expression subscale) was moderately and negatively
emotions (Kitayama et al., 2000; Mesquita and Karasawa, 2002).
correlated with the global assessment of functioning (GAF).
Thus, Americans seem to have a more positive outlook on life than
Asians. It can be speculated that they also experience more
positive emotions than Germans and that is even evident in
4. Discussion
patient samples. However, cultural comparison studies are needed
to investigate this question. Furthermore, the inclusion of inpa-
This study validated a German version of the CAINS in a sample
tients in our sample might have contributed to this difference. The
of patients with schizophrenia or schizoaffective disorder. The
validation studies of the original CAINS focused on outpatients
demographic characteristics of our study sample such as sex,
only, who are likely to have more possibilities to engage in
education, marital and employment status were similar to those
relevant social, vocational or recreational activities than inpatients
found in studies that validated the original version of the CAINS
and therefore experience more pleasure. However, other than
(Forbes et al., 2010; Horan et al., 2011; Kring et al., 2013). The range
trends, no statistically signicant differences between in- and
of scores from 0.94 to 2.89 in the present data reects a
outpatients emerged, indicating that the impact of patient status
moderately symptomatic patient sample. Furthermore, the scores
was small at the most.
on the CAINS expression subscale were comparable to those found
The internal consistency of the overall scale was good as was
the internal consistency for the motivation/pleasure scale. The
Table 1
Two-factor solution for the CAINS items. internal consistency of the expression scale was acceptable. Kring
et al. (2013) reported similar Cronbach0 s alpha for the overall
CAINS item Factor 1 Factor 2 (0.76), the motivation/pleasure (0.74) and the expression scale
(0.88). Structural analyses replicated the two-factor structure that
Item 8: Recreation, past-week pleasure 0.88
Item 9: Recreation, expected pleasure 0.84
was reported for the original version of the CAINS (Kring et al.,
Item 7: Recreation, motivation 0.82 2013). The item-level analyses indicated that all corrected item-
Item 4: Social, expected pleasure 0.76 scale correlation values were higher than 0.4. Thus, all items
Item 3: Social, past-week pleasure 0.60 sufciently represent their corresponding subscale. We also found
Item 6: Vocational, expected pleasure 0.56
high inter-rater agreement for all items of both the motivation/
Item 5: Vocational, motivation 0.53
Item 1: Social, family relationships 0.43 pleasure and expression scales (all ICCs above 0.95). Thus, rating-
Item 2: Social, friendships 0.43 problems do not seem to be the cause of the modest item-total
Item 11: Expression, vocal prosody 0.94 correlation of some items (e.g. item 13). The German interview
Item 12: Expression, gestures 0.86 questions, anchor, descriptions and the detailed manual seem to
Item 10: Expression, facial 0.79
be clear and helpful for the raters.
Item 13: Expression, speech 0.59
As expected, correlations between both CAINS scales and
Note: CAINS Clinical Assessment Interview for Negative Symptoms. PANSS negative scale were high, indicating strong convergent
662 M. Engel et al. / Psychiatry Research 220 (2014) 659663

Table 3 reliability (across 2- to 3-week period) in an initial test of stability.


Covergent and discriminant validity of the CAINS scales. However, further research is needed to evaluate the sensitivity of
the original and the German version of the CAINS.
CAINS motivation/ pleasure CAINS expression
subscale subscale Concluding, validity and reliability of the German version of the
CAINS were comparable to the original version of the CAINS
PANSS described by Kring et al. (2013). Thus, the German version of the
Negative subscale 0.65nn 0.64nn CAINS seems to be a sufciently valid and reliable assessment tool
Positive subscale 0.02  0.10
General subscale 0.21 0.05
that can be recommended for studies evaluating the underlying
TEPS mechanisms of negative symptoms and treatment effectiveness in
Anticipatory  0.07  0.01 German speaking countries.
subscale
Consummatory  0.52nn  0.44nn
subscale
BDI-II a 0.30 0.22 Role of funding sources
GAF  0.37nn  0.22
Funding sources had no role in study design or in the collec-
Note: CAINS Clinical Assessment Interview for Negative Symptoms; PANSS Posi-
tive and Negative Syndrome Scale; BDI-II Beck Depression Inventory, revision; tion, analysis and interpretation of data or in the writing of this
TEPS Temporal Experience of Pleasure Scale; GAF Global Assessment of report.
Functioning Scale.
nn
p o0.01.
a
Due to missing data, N 43.
Acknowledgments

validity. However, we only found consummatory, but not antici- We thank all participants for their participation and Kirstin
patory pleasure to be signicantly negatively related to the Burckhardt and Annika Clamor for their support with the transla-
motivation/pleasure and expression scales. On the one hand this tion of the CAINS.
was unexpected as previous research has mostly found self-
reported anticipatory (but not consummatory) decits to be References
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