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Why are help-seeking subjects at ultra-High

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Article in Psychiatry Research · May 2015

DOI: 10.1016/j.psychres.2015.05.018

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Contents lists available at ScienceDirect

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

Why are help-seeking subjects at ultra-high risk for psychosis

help-seeking?
Irina Falkenberg a,b, Lucia Valmaggia a, Majella Byrnes a, Marianna Frascarelli a,c, Ceri Jones a,
Matteo Rocchetti a, Benjamin Straube b, Steven Badger d, Philip McGuire a,
Paolo Fusar-Poli a,n
a
Department of Psychosis Studies, Institute of Psychiatry, King's College London, United Kingdom
b
Department of Psychiatry and Psychotherapy, Philipps-University Marburg, Germany
c
Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
d
OASIS team, South London and the Maudsley NHS Foundation Trust, London, United Kingdom

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

Article history: In addition to attenuated psychotic symptoms, individuals at high clinical risk of developing psychosis
Received 15 October 2014 display a wide range of psychopathological features. Some of these may be subjectively perceived as
Received in revised form more troubling than others and may therefore be more likely to trigger help-seeking behavior. We aimed
11 May 2015
at investigating the nature and prevalence of symptoms subjectively considered most distressing by
Accepted 20 May 2015
high-risk individuals at the time of their presentation to early recognition services and to determine
their impact on baseline and longitudinal functional and clinical outcomes. The clinical records of 221
Keywords: clients meeting ultra-high risk (UHR) criteria and receiving care at a specialized early intervention
Ultra-high risk (UHR) service (“Outreach and Support in South London”) between 2001 and 2011 were reviewed. Main
Psychosis
outcome measures were reason to seek help as subjectively reported by the clients, comorbid DSM-IV
Help-seeking
SCID diagnoses, transition to psychosis, psychosocial functioning at baseline and after a median follow-
Psychosocial functioning
Transition up period of 4.5 years. Affective symptoms, i.e., depression and/or anxiety, were the most commonly
reported subjective reasons to seek help (47.1%). Sub-threshold psychotic symptoms were reported by
39.8%. There was no significant association between subjective complaints at presentation and transition
to psychosis. However, the group reporting affective symptoms as their main subjective reason to seek
help at baseline had a significantly poorer longitudinal outcome in psychosocial functioning relative to
the group reporting sub-threshold psychotic symptoms. Assessment of subjective complaints in UHR
individuals at initial presentation may help to identify predictors of future functional outcome and tailor
treatments accordingly.
& 2015 Published by Elsevier Ireland Ltd.

1. Introduction Symptoms (BS) criteria. For the UHR criteria to be fulfilled an

`Schizophrenia is a prevalent and potentially debilitating psy-
chotic disorder. The first psychotic episode usually emerges during
adolescence or early adulthood. The long-term course of the illness
is associated with high levels of functional impairment (Rössler et
al., 2005) and a reduction in life expectancy of about 15 years as
compared to the general population (Bell et al., 2009). The last 15
years have yielded a large body of evidence supporting the
prospective identification of subjects at high clinical risk for
psychosis (Fusar-Poli et al., 2013a, 2013b). Two main sets of criteria
are usually used to identify individuals in the putative prodromal or
high-risk state: (1) the Ultra-High Risk (UHR) and the Basic
n
Corresponding author. Tel.: þ 44 2078 480 900.
E-mail address: paolo.fusar-poli@kcl.ac.uk (P. Fusar-Poli).
individual has to present with attenuated psychotic symptoms
(APS), brief limited intermittent psychotic symptoms (BLIPS), or
trait vulnerability plus a marked decline in psychosocial functioning
(Genetic Risk and Deterioration Syndrome: GRD) or a combination
thereof (Phillips et al., 2000). BS are subtle, subjectively experienced
disturbances in different domains such as affect, thinking, speech,
(body) perception, motor action, vegetative functions, and stress
tolerance (Huber and Gross, 1989). Individuals meeting UHR or BS
criteria or a combination of both had transition rates of 18% at six
months up to 36% after 3 years (Fusar-Poli et al., 2012).
To distinguish between psychotic-like experiences occurring
relatively frequently in the general population (Van Os et al., 2009)
and those occurring in individuals who are truly at risk for
developing a psychotic disorder, diagnosis of the UHR state relies
on help-seeking individuals. Thus, “help-seeking” can be consid-
ered an “implicit” criterion for the current definition of the UHR

http://dx.doi.org/10.1016/j.psychres.2015.05.018
0165-1781/& 2015 Published by Elsevier Ireland Ltd.

Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
2 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
syndrome (Fusar-Poli et al., 2013a,2013b). “Help-seeking” is clini-
cally close to impairments in functioning, subjective wellbeing and
quality of life and is ethically required to allow preventative
interventions in this group. We have recently addressed these
aspects at meta-analytical level in a companion publication by our
group (Fusar-Poli et al., in press). We clearly found that UHR
subjects are functionally impaired as compared to matched con-
trols and that the magnitude of their impairments is comparable
to that of other psychiatric disorders (Fusar-Poli et al., in press).
Surprisingly, there are only a few studies exploring the impact of
this implicit inclusion criterion on baseline and longitudinal out-
comes (e.g. Fridgen et al., 2013; Rüsch et al., 2013; Von Reventlow
et al., 2013). There have, however, been attempts to characterize
pathways to (Schultze-Lutter et al., 2009; Shin et al., 2010; Cocchi
et al., 2013; Stowkowy et al., 2013; Von Reventlow et al., 2013;
Wiltink et al., 2013) and engagement with services in those who
seek help (Green et al., 2011). However, only a minority of studies
with relatively small sample sizes assessed symptoms or beha-
viours that initiated the contact (Addington et al., 2002; Stowkowy
et al., 2013). In these, depression and anxiety were the most
commonly reported concerns. There are several reasons to study
help seeking behaviour in UHR subjects. First, the existing criteria
define the UHR state on the basis of the presence of attenuated
psychotic symptoms or brief limited intermittent psychotic symp-
toms, which are, by definition, not stable but may remit sponta-
neously over time (Van Os et al., 2009; Simon and Umbricht, 2010)
and studies on their value as predictors of transition to psychosis
have yielded mixed and inconsistent results (Cannon et al., 2008;
Ruhrmann et al., 2010). Positive symptoms also proved to be poor
predictors of longitudinal outcome, as UHR subjects who do not go
on to develop frank psychosis may still experience ongoing
symptoms and significant impairments in functioning (Morrison
et al., 2007; Yung et al., 2007). Second, it has become clear than
besides APS, a variety of other psychopathological symptoms are
usually present in individuals considered to be at UHR, in parti-
cular affective symptoms (Yung et al., 2008; Woods et al., 2009),
and comorbidity rates with mood, anxiety or substance disorders
are high (Woods et al., 2009). Third, the high number of false
positives and recent suggestions that transition rates are currently
further declining (Yung et al., 2007), have prompted researchers
into investigating the utility of additional predictors within the
variety of non-clinical features of the UHR state. Fourth, the help
seeking behaviour is crucial in enriching the risk of UHR samples
(transition risk of 30% within 2 years (Fusar-Poli et al., 2012)) as
compared to non-help-seeking individuals with psychotic-like
symptoms in the general population (transition rates of 1.2%
within two years (Kaymaz et al., 2012)). The latter difference
between the epidemiological samples in the general population
and the UHR can thus be attributed, at least in part, to the selective
sampling strategies linked to help-seeking behaviours used when
collecting UHR samples rather than to specific UHR criteria (Fusar-
Poli et al., 2014a, 2014b, 2014c).
Despite such high relevance only a few studies have investi-
gated the reasons for help-seeking in this population. An earlier
study indicated that social disability is a common feature in UHR,
suggesting that it may trigger help-seeking behaviours (Velthorst
et al., 2010). Three recent studies have indirectly investigated help-
seeking behaviour in UHR samples. Two of them have focused on
pathways to care in UHR subjects (Fridgen et al., 2013; Von
Reventlow et al., 2013) while one has focused on stigma and
attitude towards help-seeking behaviours or treatments (Rüsch et
al., 2013). The latter study found that more self-labelling as
“mentally ill”and less stigma stress independently predicted more
positive attitudes towards psychiatric medication (Rüsch et al.,
2013). Of the two studies on pathways to care, one (Von Reventlow
et al., 2013) has assessed “Main problem(s) presented” but did not
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
report what these main problems were. The second study found
that the main reasons for the first consultation were onset or
distinct increase of peculiarities in behaviour, appearance or
speech (53.3% of all cases), followed by 50.0% of all cases, who
sought help because of self-perceived changes in well-being
(Fridgen et al., 2013).
To our best knowledge, there are no studies available directly
investigating the subjective reasons for seeking help among UHR
samples. The first aim of the present study was to determine the
main subjective complaints prompting help-seeking behaviour in
UHR individuals. We then aimed at describing the impact of
subjective presenting complaint on symptoms presentation at
baseline, comorbid DSM-IV diagnoses (identified on the SCID),
therapeutic interventions offered as well as longitudinal clinical
and functional outcomes.
2. Methods
2.1. Participants
The project “The long-term outcome of early detection for psychosis” was
reviewed by the South East London Research Ethics Committee (REC), which on
December 7, 2010, has advised that “the project is not one that is required to be
ethically reviewed under the terms of the Governance Arrangements for Research
Ethics Committees in the UK”. Therefore, the OASIS data collection was approved as
an audit study and, as such, has no number. Clinical ethical permission for
participants to be traced, contacted and interviewed was given by the South
London and Maudsley NHS Mental Health Trust (SlaM).The case notes of all the
OASIS (“Outreach and Support in South London”) clients considered to be at ultra-
high risk (UHR) of developing psychosis after receiving a clinical assessment at
OASIS between 2001 and 2011 were reviewed. OASIS is a clinical service located in
Lambeth, Southwark and Lewisham, South London, offering treatment to people at
UHR between 14 and 35 years of age (Fusar-Poli et al., 2013b). The catchment area
has a large ethnic minority population and a high incidence of psychosis (Garety
and Rigg, 2001). People are offered treatment at OASIS if, following assessment
with the Comprehensive Assessment for the At-Risk Mental States (CAARMS (Yung
et al., 2005)) by trained interviewers they met one or more of the following criteria,
as objectively assessed by the clinicians of the team: a) attenuated (i.e. subthres-
hold) psychotic symptoms (APS) b) brief limited intermittent psychotic symptoms
(a history of one or more episodes of frank psychotic symptoms that resolved
spontaneously within 1 week in the past year; BLIPS) or c) a recent decline in
function, together with either the presence of schizotypal personality disorder or a
family history of psychosis in a first degree relative (Genetic Risk and Deterioration
Syndrome, GRD). Additional recent inclusion criteria are based on Basic Symptoms
as defined by the COGDIS cluster on the Schizophrenia Proneness Instrument (SPI-
A; Schultze-Lutter and Klosterkötter, 2002), which is performed by trained raters at
the initial assessment of clients. These additional criteria were implemented in
2006 (Fusar-Poli et al., 2013b), as evidence had emerged that COGDIS criteria alone
predict future psychosis well and that a combination of UHR and CODGIS criteria
was superior to using UHR criteria alone in predicting transition of psychosis in
people at risk (Schultze-Lutter et al., 2014). For CODGIS criteria to be fulfilled, at
least 2 of the following 9 basic symptoms have to be present and to occur at least
‘several times in a month or weekly’ within the past 3 months (corresponding to a
SPI-A score of at least ‘3’): (1) unstable ideas of reference, (2) disturbances of
abstract thinking, (3) inability to divide attention, (4) thought interference, (5)
thought pressure, (6) disturbance of receptive speech, (7) disturbance of expressive
speech, (8) thought blockages, (9) captivation of attention by details of the visual
field. All individuals included in the present study fulfilled UHR criteria, 84.6%
fulfilled both UHR and COGDIS criteria.
Referrals are accepted from health care professionals, the clients themselves or
their friends and relatives. The UHR inclusion criteria (i.e. APS, GRD, BLIP) as
objectively diagnosed by clinicians do not necessarily reflect the presenting
complaints and help-seeking reason as subjectively reported by UHR patients
(see below).
2.2. Measures
2.2.1. Demographic and clinical information
Information was gathered regarding age, gender, ethnicity, employment status,
marital status, current living situation, symptom severity (as measured by the
CAARMS (Yung et al., 2005)), psychosocial functioning at presentation (Global
Assessment of Functioning GAF (Hall, 1995)) and DSM diagnoses of current
comorbid axis I and axis II disorders (Structured Clinical Interview for DSM-IV
SCID (First et al., 1997, 2002)).
 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3

2.2.2. Assessment of main subjective complaints at presentation 2.4.3. Longitudinal analysis

Assessment reports written by psychiatrists after their first contact with the A logistic regression analysis was performed to assess the association between
client were reviewed with respect to the subjective complaints named by the client reasons for help-seeking and clinical outcome (transition to psychosis yes/no).
as their main reason to seek help. Information on main presenting complaints in the Repeated measures ANOVA was used to test for statistically significant changes in
case notes is based on a semi-structured assessment as provided by the OASIS GAF scores over time as a function of reasons for help-seeking.
screening questionnaire which contains a specific question on the presenting
complaint, and by the initial part of the CAARMS assessment in which clinicians'
specifically ask patients to elaborate on their main complaints. Main complaints
3. Results
were categorized as being related to (1) attenuated or self-limited psychotic
symptoms (APS), (2) psychosocial dysfunction (i.e. complaints of impairments in
social, occupational or school functioning), (3) affective symptoms (anxiety and/or 3.1. Sample characteristics
depression), (4) other complaints (e.g. irritability, agitation, stress etc), (5) APSþ affec-
tive symptoms. Categories (1) and (2) were chosen as they reflect the current
The OASIS 2001–2011 initial sample consisted of 290 UHR
conceptualization of the UHR syndrome, category (3) reflects the symptoms of the
most prevalent comorbidity to the UHR state (Woods et al., 2009).
individuals (Mdn age¼22 (14–35) years). Most clients were males
(55.9%) of either white British (39.8%) or black (34.7%) ethnicity. At
the time of referral 43.2% were unemployed, single (81.6%) and
2.2.3. Comorbid diagnoses and treatments
Clinical information regarding comorbid diagnoses that were made by the
living with their parents (43.2%). In terms of UHR subtypes, the
clinicians on the basis of their initial evaluation of the client according to DSM IV majority of clients (71%) fulfilled APS-criteria, BLIPS prevailed in
(SCID) criteria and their treatment recommendations (medication only, cognitive 8.7% and 20.3% had symptoms of more than one category. The
behavioural therapy only, combination of medication and CBT or monitoring only) median level of functioning was 58 (35–85) as measured by the
were extracted from the clinical records. The details are given in a separate study
GAF, indicating a poor functional status (Schennach-Wolff et al.,
which is under review.
2009).
Assessment reports of 69 clients could not be retrieved. These
2.3. Follow-up procedure
individuals were excluded from further analyses. The final data-
base consisted of 221 clients. There were a few clinical differences
Clients were followed up clinically for a median period of 4.5 (interquartile
range¼ 2–6) years. During this period repeated clinical measures were collected
between the final database and the missing subjects which were
(CAARMS, GAF) and transition to a first psychotic episode as defined by CAARMS then controlled for in the subsequent analysis (see Supplementary
criteria was monitored. results for details).

2.4. Data analysis 3.2. Cross-sectional analysis

All analyses were performed in IBM SPSS Statistics 21.
2.4.1. Variables
The predictor variable was the subjective presenting complaint at initial
contact with the high risk service. This was clinically defined according to the
following categories: (1) APS, (2) psychosocial dysfunction, (3) affective symptoms,
(4) other complaints and (5) a combination of APS and affective symptoms.
Outcome variables included: sociodemographic and clinical characteristics, psy-
chopathology, DSM-IV diagnoses, treatment recommendations, transition to psy-
chosis, functional outcome. Moderator variables included: gender, CAARMS
avolition score.
2.4.2. Cross-sectional analysis
Cross-sectional data were analysed descriptively using mean and S.D. or
median and interquartile range (if applicable) for continuous variable and absolute
and relative frequencies for categorical variables. The association between reasons
for help-seeking and sociodemographic, clinical and functional characteristics at
baseline were assessed with the Kruskal–Wallis test, correcting for multiple
comparisons with Bonferroni. Chi-square test and Fisher's Exact Test were
employed for categorical variables. To follow significant Chi-square associations,
standardized residuals were used.
3.2.1. Main reasons to seek help as subjectively reported by the
clients
Affective symptoms, i.e. depression and/or anxiety were the
most commonly reported reasons to seek help (N ¼104, 47.1%).
Sub-threshold psychotic symptoms were reported by 39.8%
(N ¼88) Percentages of the main subjective complaints as reported
by the clients at presentation are given in Table 1.
3.2.2. Association between main complaints and baseline
demographic and clinical characteristics
There was a significant between group difference in gender at
baseline, with male clients most frequently reporting APS (47.9% of
males) and females most frequently reporting affective symptoms
(57,7% of females; χ2 ¼12.83, p ¼0.012), but no significant group
difference in UHR type (χ2 ¼14.733, p ¼0.065). There were no
significant associations between subjective reasons for help-
seeking and age, ethnicity, employment status, living situation,
marital status, or GAF scores (Table 2).

Table 1
Main complaints as subjectively reported by the clients and comorbid SCID diagnoses subsequently made by the clinicians. Numbers in grey cells (2nd row and 2nd column)
give absolute number and percentage of clients reporting any given main complaint/receiving any given comorbid diagnosis (χ2 ¼ 59.06, d.f. ¼16, p o0.001). The percentage
of clients reporting any given main complaint and subsequently receiving any given comorbid diagnosis is displayed in white cells.

Reasons for help-seeking

APS n¼ 88 Psychosocial dysfunction Affective symptoms Other n¼ 14 APS þ affective

(39.8%) n¼ 10 (4.5%) n¼ 104 (47.1%) (6.3%) n ¼5 (2.3%)

Comorbid SCID diagnoses (in % of Depression and/or anxiety 9 (10.2%)a 3 (30%)a 61 (58.7%)a 3 (20%)a 2 (40%)a
reasons for help-seeking) n¼78 (35.3%)
Substance abuse n¼ 26 19 (21.6%)a 2 (20%)a 4 (3.8%)a 2 (13.3%)a 0
(11.8%)
a a a a
Other n¼35 (15.8%) 15 (17%) 2 (20%) 13 (12.5%) 3 (26.7%) 1 (20%)a
None n ¼73 (33%) 40 (45.5%)a 3 (30%)a 23 (22.1%)a 5 (33.3%)a 2 (40%)a
Unknown or not assessed 5 (5.7%)a 0 3 (2.9%)a 1 (6.7%)a 0
n¼9 (4.1%)
Total 88 (100%) 10 (100%) 104 (100%) 14 (100%) 5 (100%)

a
Percent of column total.

Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
4 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Table 2
Association between main complaints and baseline demographic and clinical characteristics (median, range or %).

Subjective reasons for help seeking

APS Psycho-social dysfunction Affective symptoms Other APSþ affective Test statistic

Continuous H (d.f.) p
Age 22 (16–35) 19.5 (17–29) 21 (15–34) 21 (17–27) 20 (14–34) 7.29 (4) 0.12
GAF 60 (35–80) 60 (45–70) 55 (35–85) 60 (45–78) 55 (40–70) 3.91 (4) 0.42
CAARMS subscales severity
Disorders of thought content 4 (0–6) 3 (2–5) 4 (0–6) 4 (0–6) 4 (0–5) 4.12 (4) 0.39
Perceptual abnormalities 3 (0–6) 4 (0–4) 3 (0–6) 3 (0–4) 3 (0–6) 1 (4) 0.91
Disorganized speech 2 (0–6) 2 (0–3) 2 (0–4) 0 (0–6) 2 (0–3) 1.6 (4) 0.81
Subjective experience 3 (0–5) 3 (2–3) 3 (1–6) 3 (2–4) 3 (2–4) 0.48 (4) 0.98
Cognitive change 1 (0–4) 2 (0–2) 1 (0–5) 0 (0–3) 2 (2–3) 1.99 (4) 0.74
Subjective emotional disturbance 2 (0–5) 2 (2–4) 2 (0–5) 2 (0–5) 2 (0–3) 4.23 (4) 0.38
Observed blunted affect 0 (0–5) 2 (0–4) 1 (0–6) 0 (0–2) 2 (0–3) 8.72 (4) 0.07
Observed inappropriate affect 0 (0–5) 0 (0–2) 0 (0–2) 0 (0–2) 0 (0–1) 0.95 (4) 0.92
Alogia 2 (0–5) 2 (0–3) 2 (0–6) 0 (0–3) 0 (0–3) 9.69 (4) 0.04a
Avolition 3 (0–6) 3 (0–4) 4 (0–6) 2 (0–5) 3 (3–5) 12.91 (4) 0.01a
Anhedonia 3 (0–6) 3 (0–5) 3 (0–6) 1 (0–3) 2 (0–4) 5.99 (4) 0.2
Social isolation 3 (0–6) 3 (3–5) 3 (0–6) 2 (0–4) 3 (0–4) 6.89 (4) 0.14
Impaired role function 3 (0–6) 3 (0–5) 3 (0–6) 2 (0–5) 2 (0–4) 4.07 (4) 0.39
Disorganized behaviour 1 (0–5) 0 (0–4) 0 (0–5) 0 (0–3) 2 (0–3) 2.24 (4) 0.69
Aggressive behaviour 2 (0–5) 2 (0–4) 3 (0–5) 3 (0–5) 3 (0–5) 2.25 (4) 0.69
Impaired motor function 1 (0–4) 1 (0–3) 0 (0–3) 0 (0–3) 1 (0–3) 1.49 (4) 0.83
Change in motor function 0 (0–2) 0 (0–3) 0 (0–3) 0 (0) 0 (0–1) 2.39 (4) 0.66
Impaired bodily sensations 0.5 (0–5) 1 (0–3) 0 (0–5) 0 (0–2) 2 (1–4) 6.05 (4) 0.19
Impaired autonomic function 2 (0–5) 3 (0–4) 3 (0–5) 3 (0–5) 2 (0–3) 2.66 (4) 0.62
Mania 0 (0–4) 0 (0–2) 0 (0–6) 0 (0–3) 0 (0–3) 2.83 (4) 0.59
Depression 3 (0–5) 4 (2–4) 3 (0–6) 3 (0–3) 3 (2–5) 9.29 (4) 0.05a
Suicidality & self-harm 2 (0–6) 2 (0–5) 2 (0–5) 2 (0–3) 3 (0–4) 1.79 (4) 0.77
Mood swings 2 (0–4) 2 (0–2) 2 (0–5) 0 (0–4) 3 (0–4) 4.11 (4) 0.39
Anxiety 3 (0–6) 4 (0–4) 4 (0–5) 3 (0–6) 4 (0–4) 5.66 (4) 0.23
OCD symptoms 0.5 (0–5) 0 (0–2) 1 (0–5) 1 (0–5) 2 (0–3) 1.72 (4) 0.79
Dissociative symptoms 0 (0–5) 2 (0–3) 0 (0–4) 0.5 (0–4) 0 (0–2) 2.44 (4) 0.66
Impaired tolerance to normal stress 3 (0–5) 3 (0–4) 3 (0–6) 3 (0–5) 3 (0–4) 4.45 (4) 0.35
Categorical χ2 (d.f.) p
Gender 12.83 (4) 0.012a
Male 47.9% 6% 37.6% 7.7% 0.9%
Female 30.8% 2.9% 57.7% 4.8% 3.87%
Ethnicity 8.314 0.742
Black 34.7% 14.3% 37.5% 41.7% 27.3%
White British 40.3% 71.4% 36.3% 41.7% 45.5%
White other 16.7% - 11.3% - 18.2%
Other 8.3% 14.3% 15% 16.7% 9.1%
Employment status 13.353 0.077
Student 22.5% 57.1% 20% 41.7% 45.5%
Employed 32.4% 14.3% 22.5% 25% 36.4%
Unemployed 17.7% 28.6% 57.5% 33.3% 18.2%
Marital status 6.637 0.829
Single 78.9% 85.7% 73.8% 83.3% 90.9%
Married 1.4% - 7.5% - -
Living together 11.3% 14.3% 12.5% 16.7% -
Divorced/separated 8.5% - 6.3% - 9.1%
Living situation 8.431 0.734
Living alone 18.8% - 19% 25% 30%
Living with parents 47.8% 71.4% 39.2% 33.3% 40%
Cohabiting 24.6% 28.6% 30.4% 16.7% 30%
Other 8.7% - 11.4% 25% -
UHR subtype 14.733 0.065
APS 59% 80% 78.1% 80% 76.9%
BLIPS 16.9% - 4.2% - 15.4%
More than one 9.2% 20% 17.7% 20% 7.7%

a
Uncorrected.

3.2.3. Association between main subjective complaints and
psychopathological assessment
Reasons for help-seeking reported by the clients at baseline was
significantly associated with the “Avolition” subscale (F¼ 2.287,
p¼0.049) and “Depression” subscale (F¼2.687, p¼0.034) in the
structured assessment of psychopathology (CAARMS; Table 2). A
post-hoc test revealed a significant group difference surviving
Bonferroni-correction between the group reporting affective symp-
toms as their main complaint (higher scores on avolition subscale)
and the group reporting attenuated symptoms (lower scores on
avolition subscale, p¼ 0.04).
3.2.4. Subjective reasons for help seeking and comorbid diagnoses
Table 1 provides the comorbid SCID diagnoses made by the
psychiatrists at OASIS in relation to the clients' subjective reasons
for help-seeking and to SCID assessment. The most prevalent
comorbid diagnosis (35.2%) was depression and/or anxiety; 33%

Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
of the clients did not fulfill the criteria for any comorbid diagnosis.
The proportions of specific comorbid SCID diagnoses were: Anxi-
ety or social anxiety: 8.1% (n ¼18), depression: 20.8% (n ¼46),
personality disorder: 4.5% (n ¼10), substance use: 11.8% (n ¼26),
OCD: 3.6% (n ¼8), combined depression and substance use: 0.9%
(n ¼2), combined depression and personality disorder: 0.9% (n ¼2),
personality disorder and substance use: 0.9% (n ¼2), depression
and anxiety: 6.3% (n¼ 14), other: 5% (n ¼11), none: 33% (n ¼73),
unknown/not assessed: 4.1% (n ¼9). There was a significant asso-
ciation between subjective reasons for help-seeking and subse-
quent assignment of SCID diagnoses (χ2 (16) ¼59.06, p o0.001).
This association was mainly driven by the group reporting APS as
their main complaint, who in 45.5% of cases did not receive any
comorbid diagnosis (z¼2.1 p o0.05) as well as by the group
reporting affective symptoms, who in 58.7% of cases received a
comorbid diagnosis of depression and/or anxiety (z ¼4.0, p o
0.001). A logistic regression analysis revealed that the baseline
group differences in gender (χ2 (4) ¼1.17, p ¼0.883) and CAARMS
avolition subscores (B ¼ 0.972, p ¼0.692) did not have a statisti-
cally significant impact on comorbid diagnoses whereas assign-
ment of a comorbid affective diagnosis was related to high scores
on the depression subscale of the CAARMS (B ¼ 0.832, p ¼0.001)
3.2.5. Subjective reasons for help seeking and treatment
recommendations
The intervention most frequently recommended to the clients
after initial assessment was a combination of medication and CBT
(44.3%). CBT was recommended as the only intervention in 37.6%,
monitoring in 13.4% and medication only (i.e. antipsychotic and/or
antidepressant) in 4.6% of cases. However, there was no significant
association between the clients' main subjective complaint and
the type of intervention recommended by the clinicians (Table 3).
3.3. Longitudinal analysis
During the follow-up period, 34 clients (15.4%) made a transi-
tion to psychosis. Of these, 31 individuals developed a
schizophrenia-spectrum disorder (ICD-10: F20-F29) and 3 devel-
oped bipolar disorder (ICD-10: F31). At follow-up, the majority of
clients (63%) were medication free.
3.3.1. Association between main complaints, transition to psychosis
and functional outcome
Logistic regression analysis revealed no significant association
between main complaints at presentation and transition to psy-
chosis over the course of the follow-up period (p¼ 0.696). The
comparison of mean GAF scores at baseline and follow-up in the
group seeking help because of APS versus the group seeking help
because of affective symptoms revealed no significant group
differences (baseline GAF APS group: 56.2 (S.D. ¼1.8), affective
symptoms group: 56.3 (S.D. ¼2.1); F¼ 1.46, p ¼0.23), however, GAF
scores at follow-up were significantly higher in the APS group
relative to the affective symptoms group (follow-up GAF APS
Table 3
Reasons for seeking help and interventions recommended by clinicians (χ2 ¼13.075, d.f. ¼ 20, p ¼0.364).
Reasons for help-seeking APS (n¼ 88)
Psychosocial dysfunction (n¼ 10)
Affective symptoms (n¼ 104)
Other (n¼ 14)
APS þ affective (n¼ 5)
a
Percentage of row total.
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
5
group: 70.0 (S.D. ¼3.1), affective symptoms group: 60.0 (S.
D.¼3.6); F¼4.45, p¼ 0.04; Cohen's d ¼2.9). This result was cor-
rected for differences in the duration of follow-up periods
between subjects and survived Bonferroni-correction.
4. Discussion
The main finding of this study was that the majority of
individuals presenting for the first time in a specialized service
for people at high clinical risk of developing psychosis report
affective symptoms such as depression and/or anxiety as their
central subjective complaint and their main reason to seek help.
These individuals were more likely to be females, with high levels
of comorbid depressive or anxiety diagnoses and affective symp-
toms scored on the CAARMS. Although there were no differences
in treatments received from the service, these subjects had lower
functional outcomes than subjects complaining of attenuated
psychosis symptoms.
Our first objective was to determine the most common sub-
jective reason for seeking help in UHR subjects. The UHR phase has
been found to be associated with considerable subjective distress
(Møller and Husby, 2000). The creation of specialized clinical
services for high-risk individuals and the increasing efforts which
have been put into early-detection research over the last decade
ultimately aim at providing targeted interventions to prevent
psychosis onset or attenuate the symptoms presented by help-
seeking individuals. To date, their reasons to seek help and the
nature of distressing experiences that are part of the UHR
syndrome have, however, not received much research attention.
Our results indicate that despite being a defining feature of the
UHR syndrome, attenuated psychotic symptoms alone may not be
the only distressing factor triggering help-seeking behaviour. A
recent study in the general population of psychotic patients
confirmed that subclinical psychosis symptoms, in particular
experiences of thought control, paranoia and bizarre experiences,
are significantly associated with various forms of help-seeking
behavior (Murphy et al., 2012).
However, we showed that although quite common, they were
less frequent than affective symptoms and may therefore be less
likely to prompt help-seeking behaviour in high-risk individuals.
Conversely, our findings indicate that co-occuring affective symp-
toms may increase the burden of attenuated psychotic symptoms
to the extent that high-risk individuals feel the need to request
help for their condition. This notion is consistent with high
prevalence rates of psychotic-like experiences in the general
population which are not associated with subjective distress and
therefore do not trigger help-seeking behaviour (Van Os et al.,
2009), and also with previous research showing that lower levels
of distress related to APS is associated with delayed help seeking
behaviour in UHR individuals (Chung et al., 2010). The level of
distress in relation to affective and, as a consequence, also to
attenuated psychotic symptoms, may be related to the severity of
Recommended intervention (in % of reasons for help-seeking)
Medication only CBT only Medication þ CBT Monitoring only Total
a a a a
6 (6.5%) 33 (37.7%) 31 (35.1%) 18 (20.8%) 88 (100%)
1 (10%)a 5 (50%)a 3 (30%)a 1 (10%)a 10 (100%)
2 (2.2%)a 38 (36.7%)a 56 (53.3%)a 8 (7.8%)a 104 (100%)
7.7% 30.8% 46.2% 15.4%
– 2 (40%)a 3 (60%)a – 5 (100%)
6 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
depression and anxiety. Unfortunately, we are not able to make
any inferences about this potential relationship, as no severity
measures were acquired in our UHR sample, which has to be
considered a limitation of this study. However, we have specifically
addressed in other papers the impact of affective symptoms on
psychopathology (Fusar-Poli et al., 2014a, 2014b, 2014c), function-
ing (Fusar-Poli et al., in press; Fusar-Poli et al., 2014a, 2014b,
2014c), neurobiology (Modinos et al., 2014) and treatment (Fusar-
Poli et al., 2014a, 2014b, 2014c) of UHR subjects.
Early recognition programs for young people at risk for psy-
chosis aim to increase help-seeking rates to improve clinical
outcomes. The correct labelling of difficulties experienced by these
people as signs of mental illness may thus on the one hand
facilitate help-seeking. On the other hand, this label involves the
danger of stigmatizing young people, in particular those who turn
out to be false positives. The stigma associated with schizophrenia
is generally higher than that associated with depression
(Angermeyer and Matschinger, 2003). It is thus conceivable that
the clients in our sample may have considered it more socially
acceptable to report affective rather than attenuated psychotic
symptoms as their main complaints (cf. Singh et al., 2012; Mittal et
al., 2015).
The pattern of main complaints reported by our clients is
reflected by a relatively high prevalence of comorbid DSM-IV
diagnoses of affective disorder (35.3%) in the same sample. This
is well reflected by higher CAARMS scores at baseline in avolition
and depressive subscales. Of additional interest, these clients were
more likely to be females, in line with consistent evidence
indicating higher prevalence of affective disorders in females as
compared to males (Kessler, 2003). Affective symptoms, in parti-
cular depression, are the earliest and most common symptoms
retrospectively reported by patients in their first episode of a
psychotic illness (Häfner et al., 2005) and have been identified as
common features of the UHR syndrome prior to the emergence of
psychotic symptoms in prospective studies (Häfner et al., 1999).
The emergence of specific affective symptoms may predate that of
positive symptoms and reflect core psychopathological alterations
underlying the onset of psychotic experiences (Mishara and Fusar-
Poli, 2013). A retrospective study in first-episode patients con-
firmed that the most common disorders triggering help-seeking
behaviours were mood and anxiety disorders (N ¼385 (39.1%))
(Rietdijk et al., 2011).
High comorbidity rates with affective disorders in help-seeking
individuals meeting UHR criteria have consistently been reported
in the literature (Velthorst et al., 2009; Addington et al., 2011; for a
meta-analysis see Fusar-Poli et al. (2014a, 2014b, 2014c)). In part,
this may be due to a selection bias which is enriching the risk of
psychosis, as UHR samples have in most cases been recruited in a
clinical context (Fusar-Poli et al., 2014b). However, cognitive
models of psychosis propose that affective dysregulation play a
key role in the formation and maintenance of psychotic symptoms
(Garety et al., 2001). Similarly, phenomenological models of
psychosis onset highlight mood disturbances as key distinctive
features of this phase (Mishara and Fusar-Poli, 2013). This is
consistent with data from the prospective study of subclinical
psychotic experiences in the general population (Van Os et al.,
2009), which suggests that these are more likely to lead to
clinically significant psychotic symptoms if mood deterioration
(Hanssen et al., 2005) or trauma (Spauwen et al., 2006) are also
present. On the other hand, psychotic symptoms are also a
common feature of disorders of anxiety or depression both in
clinical (Hanssen et al., 2003) and epidemiological general popula-
tion samples (Wigman et al., 2012), indicating that there may be a
shared vulnerability to both affective and psychotic phenomena. In
addition, previous evidence also suggests a reciprocal causal
influence between affective and psychotic phenomena, as the
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
predictive value of either psychotic or affective symptoms for
future psychopathology or poorer clinical outcome is greatest
when they co-occur (Krabbendam et al., 2005; Kaymaz et al.,
2007; Wigman et al., 2012). Our results support this notion by
showing that UHR individuals perceiving affective symptoms as
the most burdening ones at the time of their approach and referral
to the early recognition clinic.
The second aim of our study was to test the impact of the
subjective reason for help seeking on longitudinal outcomes. We
found that, despite not having a higher risk of developing
psychosis, patients complaining of affective symptoms were more
prone to have a poorer functional outcome in the future This has
recently been confirmed in a longitudinal long-term study indi-
cating that most URH people not converting to psychosis at follow-
up would present with affective disorders including depression
and anxiety. This study also showed that the majority of these
disorders were present at baseline, with a lower number of cases
of new onset of disorder and that baseline symptomatology was a
poor predictor of these comorbidities (Lin et al., 2015).
The transition rate of 15.4% over a median follow-up period of
4.5 years in our sample was relatively low, compared to meta-
analytical evidence indicating an increase of transition rates over
time, with rates being lowest at 6-months follow-up (18%) and
highest (36%) after three years (Fusar-Poli et al., 2012) and with
the speed of psychosis progression in UHR people being greatest
during the first months after presentation (Kempton et al., 2015).
Low transition rates may in part be due to the fact that the clients
were provided with different types of interventions (e.g. medica-
tion, psychotherapy) whenever necessary. This may in some cases
have delayed or prevented transition to psychosis and may thus in
part explain the lack of association between reasons for help-
seeking and future transition. There is consistent meta-analytical
evidence indicating that focused interventions in UHR can halve
the risk of psychosis progression (risk ratio ¼ 0.54; Stafford et al.,
2013). Indeed in a separate manuscript investigating the impact of
focused treatments in the same sample, we found that use of
antidepressant treatments in UHR subjects with prominent affec-
tive symptoms was associated with a reduced risk of developing
psychosis over time (Fusar-Poli et al., 2014a).
The low transition rate in our sample as well as the lack of
association between reasons for help-seeking and transition rates
may in part also be due to the fact that transition to psychosis as
defined by CAARMS criteria is only assumed if positive symptoms
are present. However, the threshold defining the onset of a
psychotic disorder in people at-risk is arbitrary (Lin et al., 2012).
Nevertheless, a previous analysis in a large UHR sample (N ¼509)
confirmed no evidence of comorbid affective diagnoses on transi-
tion rates (Fusar-Poli et al., 2014b). This study however did not
analyse the effect of comorbid diagnoses on the functional out-
comes of UHR subject. While only a minority of UHR individuals
will go on to develop frank psychosis (Yung et al., 2007), many of
those who do not meet criteria for a psychotic disorder will have
very poor functional outcomes, and will continue to require social
and clinical support (cf. Addington et al., 2011). A recent meta-
analysis estimated that only one third of the initial UHR sample
will eventually develop a clinical remission from the risk state
(Simon et al., 2013). The factors that may predict functional
outcome in people at high-risk for psychoses have not been widely
studied and there is an increasing interest to investigate functional
outcomes other than transition. The largest (N ¼ 101, follow-up
from 3 to 5 years) and most recent study published to date,
however, has shown that reduced neurocognitive performance,
functional impairments, and symptoms other than positive atte-
nuated symptoms at baseline predicted an increased risk of poor
functional outcomes in our sample. Of interest the authors con-
cluded that “poor functional outcomes were not entirely
 I. Falkenberg et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
dependent on positive symptoms and the development of psy-
chosis” (Carrión et al., 2013).
Our finding that affective symptoms triggering help-seeking
behaviour predict poorer functional outcomes at follow-up (med-
ian follow-up period 4.5 years) are thus in line with the above
study. It is interesting that the subjective perception of affective
symptoms was objectively rated by the clinicians both in the
CAARMS and in the SCID comorbid diagnoses. Overall, the con-
current presence of affective symptoms triggering help-seeking
behaviours in young females, and the association with specific
functional outcomes may be used to support the existence of a
UHR endophenotype. In fact, the baseline UHR diagnosis may
actually include several heterogeneous subgroups, each character-
ized by a differential trajectory: a “true prodromal” endopheno-
type later transiting to psychosis together with a “clinical noise”
HR endophenotype (Fusar-Poli et al., 2014c). The latter subgroup
may be at significant risk for ongoing symptoms, and persistence
or new incidence of a range of non-psychotic disorders, mostly
depression and anxiety disorders. The present study adds evidence
for the existence of an affective UHR endophenotype impacting on
baseline symptoms and functional outcomes. Future development
in the field should carefully consider this in the light of service
implementation and pathways to care. Similarly, novel treatments
for UHR subjects should better focus on affective symptoms,
disability and functional recovery rather than aiming at reducing
the severity of attenuated psychotic positive symptoms.
Limitations of the study are well acknowledged. First, the study
used retrospective data thereby inherently limiting its predictive
ability. In particular, given the observational nature of our study it
is important to highlight that association is not causation and the
observed findings could be secondary to modulator effects or
factors not addressed in our analyses. Future studies should
therefore be specifically designed to explore the predictive validity
of subjective complaints with regard to clinical and functional
outcomes in the at-risk population. Second, the use of the GAF
scale as a sole measure of functional outcome may not be ideal, as
it conflates both functional (e.g. occupational) and symptom levels
and variables such as employment or academic status may have
provided a better estimate of everyday functioning. Unfortunately,
this information was not available. However, most UHR studies
published in the available literature have traditionally used the
GAF as standard measure of the functional level at baseline and
follow-up (for a meta-analysis of functional level in UHR see Fusar-
Poli et al., in press). Third, despite focusing on clients' main
subjective complaints in this study, which in a large number of
cases were affective symptoms, this does not imply that attenu-
ated psychotic symptoms are not relevant to the clients or that
they do not wish to receive help for these symptoms. For example,
in the new DSM-5 diagnostic category of Attenuated Psychosis
Syndrome, symptoms should “warrant clinical attention” without
being necessarily the main complaint. Future studies should
therefore assess all the symptoms that are of personal relevance
to the clients and for which they are seeking help. Also, future
studies should explore the association between initial com-
plaints and meeting UHR criteria by investigating both referrals
meeting CAARMS criteria and those excluded after the initial
assessment.
5. Conclusions
Affective symptoms are the most frequent subjective reasons
for seeking help in UHR subjects. They are associated with the
female gender, higher depressive and anxiety symptoms and
comorbid diagnoses and can predict a lower functional outcome
in the long term.
Please cite this article as: Falkenberg, I., et al., Why are help-seeking subjects at ultra-high risk for psychosis help-seeking? Psychiatry
Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.018i
7
Funding
IF was supported by was supported by the G.A. Lienert Founda-
tion, the Adolf-Schmidtmann-Foundation, FAZIT-Foundation and
the German Academic Exchange Service (DAAD).
Acknowledgements
Our special thanks go to the staff and service users of OASIS.
Appendix A. Supporting information
Supplementary data associated with this article can be found in
the online version at http://dx.doi.org/10.1016/j.psychres.2015.05.
018.
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