Cognitive behavioural therapy for worry in young individuals with At-Risk-Mental State: a preliminary investigation
Abstract
Cognitive behavioural therapy (CBT) is the first-line strategy in reducing or delaying risk of transition to psychosis among young individuals with At-Risk-Mental State (ARMS). However, there is poor knowledge about its effects on other outcomes associated with ARMS. No study on CBT for ARMS assessed changes in worry, a relevant process associated with this condition. The present study investigated changes at immediate post-treatment and 14-month follow up in worry after CBT for young individuals with ARMS seeking psychiatric care at mental health ser-vices. Thirty-seven young individuals (mean age= 26 years, SD= 6.07; 22.20% females) seeking psychiatric care at mental health services and classified as reporting ARMS through the Compre-hensive Assessment of At-Risk-Mental States were included. The Positive And Negative Syn-drome Scales and the Penn State Worry Questionnaire (PSWQ) were administered at baseline, post-treatment, and follow-up. CBT consisted of 30 individual weekly one-hour sessions based on a validated CBT manual for ARMS, which was enriched with components targeting worry [psychoeducation, problem-solving, (meta)cognitive restructuring, behavioural experiments]. Seven participants (18.91%) at follow-up cumulatively made transition to psychosis. Repeated measures ANOVA with post-hoc pairwise comparisons showed significant changes in PSWQ scores from baseline to post-treatment and from baseline to follow-up; PSWQ scores remained stable from post-treatment to follow-up. This is the first study investigating changes in worry af-ter CBT for ARMS, which appears to be a promising strategy also for this outcome. Future re-search with larger sample and control group may allow understanding whether changes in worry are also associated with reduced transition risk.
Keywords: cognitive behavioural therapy; early intervention; psychosis; schizophrenia; worry; young people.
Learning objectives
To understand evidence and procedures of CBT for young individuals with ARMS To reflect on the current limitations in the literature on CBT for ARMS
To understand importance and clinical implication of assessing worry in ARMS To focus on changes of worry as outcome after CBT for ARMS
To reflect on future research directions on the role of worry in CBT for ARMS
Introduction
At-Risk-Mental State and cognitive behavioural therapy
During the last two decades, interest of researchers and clinicians has increased on early identifi-cation of and intervention on young individuals experiencing the first stages of psychosis (Yung et al., 2005; Schultze-Lutter et al., 2015; McHugh et al., 2018). Accumulating evidence from prospective studies showed that a subgroup of those young patients who report first-episode psy-chosis, seek psychiatric care before the onset of the full disorder, because they experience a pro-dromal state (Häfner et al., 2013). This clinical picture, characterised by attenuated and/or inter-mittent psychotic symptoms associated with significant impairment in psychosocial functioning, was defined as At-Risk-Mental State (ARMS; Yung et al., 2005). Ultra-High-Risk criteria (UHR) identified three subgroups of young individuals with ARMS: (a) attenuated psychotic symptoms (APS); (b) brief limited intermittent psychotic episodes (BLIPs) below duration crite-ria for brief psychotic episode; (c) genetic vulnerability (familiarity with a first-degree relative
having psychosis or schizotypal personality disorder combined with functioning decline during last year) (Yung et al., 2005). Young and colleagues (2005) described subclinical positive symp-toms defining ARMS as Unusual Content of Thoughts, Non-Bizarre Ideas, Perceptual Distur-bance, and Disorganized Speech. A relevant point related to ARMS research is that about two third of the young individuals who are classified as UHR, do not experience the transition to a first episode psychosis within 3 years, as transition risk was 18% at 6-, 22% at 12-, 29% at 24-, and 36% at 36-month follow-up in a meta-analysis of prospective studies (Fusar-Poli et al., 2012). However, these non-converters may continue having functional impairment, subclinical psychotic symptoms, anxiety, and depressive symptoms (Fusar-Poli et al., 2012; Lin et al., 2015).
The CBT model assumes that pathway from ARMS to psychosis is reinforced by catastrophic misinterpretations of psychotic-like symptoms, exacerbated by high emotional arousal (van der Gaag et al., 2013a). The main goal of CBT for ARMS is providing the young individual with
ef-fective skills to reduce distress triggered by subclinical psychotic experiences. By analysing CBT trials for ARMS, Thompson and colleagues (2015) identified the following key components demonstrated to be effective in reducing transition risk: Assessment, Engagement, Case formula-tion, Psychoeducaformula-tion, CBT strategies, Treatment of depression-anxiety, Social skills. In a meta-analysis of five randomised trials, Van der Gaag and colleagues (2013b) concluded that CBT is
promising and pointed out that limitations of the current literature was focus on psychosis pre-vention. The authors highlighted that additional outcomes should be evaluated. Okuzawa and colleagues (2014) conducted a systematic review of six studies assessing CBT as a core element for ARMS. Three trials showed a significant effect. The researchers concluded that CBT may be beneficial in delaying or preventing psychosis, but effect sizes appeared small and further trials were needed (Okuzawa et al., 2014). Later, Schmidt and colleagues (2015) produced a guidance paper through meta-analysis of five CBT trials (mean treatment duration= 6.87 months, mean
follow-up= 16.67), stating that CBT should be considered the first-line psychological strategy for psychosis prevention in ARMS populations.
Worry in ARMS
Worry is a long-studied construct, which was defined as a process involving a chain of thoughts and mental images, negatively affect-laden and relatively uncontrollable (Borkovec et al., 1983). It was hypothesized to represent an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes (Borkovec & Inz, 1990). While worry was long investigated as a maintenance factor of anxiety disorders (e.g, Wells, 1995), recently researchers yielded empirical support for its association with full psychotic symptoms, particularly paranoid thinking, in people diagnosed with schizophrenia (Startup et al., 2016). Worry was found to be a potential maintenance factor of psychotic symptoms, including delusional thinking and hallucinations (Hartley et al., 2014). The role of worry in ARMS is a research area increasingly drawing the attention of investigators and clinicians. Young individuals with ARMS often are worried about their psychotic-like expe-riences: worry may be engaged as a mental coping strategy to manage the distress associated with such experiences (Fresán et al., 2015). Young individuals with ARMS can fear getting crazy and losing control over their minds (Meneghelli et al., 2016). Recent investigations showed that young individuals with ARMS reported higher levels of anticipatory worry than healthy controls and to similar extent as patients with schizophrenia (Fresán et al., 2015). Worry resulted the strongest predictor of subclinical paranoid thinking in epidemiological research con-ducted in community samples (Freeman et al., 2012). Indeed, in a recent systematic review and meta-analysis (Cotter et al., 2017), metacognitive beliefs, a maintenance factor of worry, were found to be higher among individuals with ARMS than among healthy controls and as high as among patients with schizophrenia.
In light of these considerations, worry may be hypothesized to be a target of the psychological intervention for ARMS, as in CBT for schizophrenia (e.g, Freeaman et al., 2015). CBT has the usefulness of providing the patient with a clear, tailored case formulation describing cognitive and behavioural mechanisms reinforcing ARMS. Receiving such an exploratory model of dis-tressing psychotic-like experiences and learning that there is an adequate treatment is a comfort-ing message, that may attenuate repetitive thinkcomfort-ing engaged to cope with such distress (van der Gaag et al., 2013a). In addition, CBT can provide effective psychoeducation on the nature of
worry, useful skills and techniques to manage it, such as metacognitive restructuring and be-havioural experiments.
Rationale and objectives
While CBT was demonstrated to be an effective strategy for reducing or delaying risk of transition to psychosis in young individuals suffering from ARMS, there is poor knowledge on its effects on other outcomes associated with ARMS. According to three systematic reviews (van der Gaag et al., 2013b; Okuzawa et al., 2014; Schmidt et al., 2015), CBT should be assessed on
further outcomes associated with ARMS, not only on prevention of first psychosis episode. No study assessed CBT specifically on worry. The current study aimed at investigating changes at immediate post-treatment and 14-month follow up in worry intensity after CBT in a group of young individuals with ARMS seeking psychiatric care at mental health services.
Methods
Eligibility criteria
Participants were young individuals seeking psychiatric care at mental health services, who were included if being 16-35 year-old and meeting ARMS criteria at the Comprehensive Assessment of At Risk Mental States (CAARMS; Yung et al., 2005). Participants were excluded if diagnosed
with (a) mental retardation, (b) neurological disorders, (c) developmental disorders, (d) current/past psychotic/bipolar disorder, (e) suicidal intent, (f) had undergone prior CBT, (g) be-ing on concurrent psychotherapy or antipsychotics. Concomitant antidepressants were allowed if stable during the study. Exit/discontinuation criteria were (a) voluntary discontinuation by the participant, (b) safety reasons judged by the investigator (ie, the participant met psychosis crite-ria or developed suicidality). Participants who developed a first episode of psychosis entered into routine psychiatric care.
Recruitment was made by leaflets/e-mails to private and public mental health professionals and workshops to provide information on ARMS and encourage referrals. Help-seeking individuals at mental health services with suspicion of ARMS referred by professionals were assessed through the CAARMS.
Baseline measures
Baseline Axis I disorders were assessed through the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I; First et al., 1997; SCID-I Italian; Mazzi et al., 2000). The psy-chosis module was administered at post-treatment and follow-up. Personality disorders were in-vestigated through the Structured Clinical Interview for DSM-IV-TR Personality Disorders (SCID-II; First et al., 1997; SCID-II Italian; Maffei et al., 1997).
Onset of first psychotic episode
The diagnosis of a first psychotic episode at post-treatment or follow-up, including also any psy-chotic/bipolar disorders according to DSM-IV-TR (American Psychiatric Association, 2000), was assessed through the SCID-I. Development of first psychotic episode was assessed at 6-month post-treatment and 14-6-month follow-up or at the moment the psychologist conducting treatment, informed the researchers that transition had (probably) occurred. The Positive And
Negative Syndrome Scales (PANSS; Kay et al., 1989) was used to further support the diagnosis of psychosis at post-treatment or follow-up.
Primary outcome
The Penn State Worry Questionnaire (PSWQ; Meyer et al., 1990) was used as a measure of trait worry and its characteristics of intensity, frequency, persistence and uncontrollability. The PSWQ is a self-report tool composed by 16 items on a five-point Likert scale (“Not at all typical of me”= 1, “Vey typical of me”= 5). High scores indicate severe worry. The Italian version (Morani, Pricci, & Sanavio, 1999) showed good internal consistency. In the current study, inter-nal consistency was good (Cronbach’s alpha= 0.84).
Diagnostic reliability
The CAARMS, the SCID-I and the SCID-II were administered by two independent assessors, trained by internships in the administration of the instruments. All diagnoses were reached by in-ter-rater consensus through staff meetings during the enrolment of participants.
Treatment fidelity
CBT was delivered by psychologists with 4-year training in CBT for ARMS. Training included reading of CBT manuals for ARMS, workshops with international experts, and role-playing. Psychologists delivering CBT were on supervision by one expert with 30-year experience in CBT. Treatment fidelity was assessed by a random selection of sessions, audiotaped and subse-quently rated by two psychologists trained in CBT not involved in the study. Cohen’s kappa esti-mates of fidelity were all equal or higher than 0.70, suggesting satisfactory inter-rate agreement (Cohen, 1968).
Procedure
Participation was voluntary and uncompensated. All participants were offered antidepressants/anxiolytics according to needs. Prescription and management of medication was responsibility of the medical staff who was in contact with, but not involved in, the study. All the included participants were asked to provide written informed consent to participate after receiving a description of the aims and having the possibility to withdraw consent at any time without consequence for their treatment. Individuals under 18 years old required informed consent from both parents. Participants’ identities remained anonymous. Materials containing personal information about participants were kept on electronic supports protected by passwords. The research according to the Helsinki Declaration was approved by the Institutional Ethics Committee.
CBT protocol
The CBT protocol consisted of 30 individual weekly one-hour sessions for a duration of six months overall. The protocol was based on a manual of CBT for young individuals at UHR for psychosis (van der Gaag et al., 2013a), whose efficacy was already demonstrated (Riedtijk et al.,
2010; Ising et al., 2016). The goal of the intervention is to reduce distress provoked by psy-chotic-like experiences (van der Gaag et al., 2013a). In the present study, the therapeutic
compo-nents of van der Gaag et al. (2013a) were adapted to follow the recent recommendations provided
by Thompson and colleagues (2015), who identified the following core components in ran-domised controlled trials of CBT for ARMS: Assessment, Engagement, Individualized case for-mulation, Psychoeducation, Cognitive behavioural strategies, Treatment of comorbid conditions (depression, anxiety), Improvement of social skills. The intervention developed by van der Gaag and colleagues (2013a) was further enriched with additional components based on Wells (2011),
ad-vantages and its dangerous effects, behavioural experiments challenging worry). The protocol was divided in different phases including specific therapeutic components: (1) introduction, (2) assessment, (3) engagement and goal setting, (4) normalization of psychotic-like experiences, (5) cognitive restructuring and metacognitive intervention, (6) skills of emotions management, (7) intervention on depression, (8) intervention on worry, (9) intervention on social anxiety and so-cial skills, (10) relapse prevention, (11) booster sessions. A detailed description of the protocol is provided in Table 1. During the Introduction phase, the therapeutic path is presented including sessions agenda and techniques used. During the Assessment phase, collaborative functional analysis aimed at identified trigger situations; Activating events – Beliefs – Consequences (ABC) diaries are completed by the participant and the therapist during the session; symptom monitor-ing is facilitated; automatic thoughts, intermediate and basic assumptions are analysed. Subse-quently, in the Engagement phase, working together, the therapist and the participant develop a shared hierarchy of goals for the therapeutic intervention. The therapeutic model is based on the hypothesis that the final common pathway from ARMS to psychosis is largely caused by cata-strophic misinterpretations of psychotic-like symptoms which are then exacerbated by a high level of emotional arousal (Riedijk et al., 2010).
During the fifth phase, psychoeducation on psychotic-like experiences is offered. The subsequent phase, Cognitive restructuring and metacognitive intervention, aims to increase the awareness of the individual of the effects of cognitive distortions on emotional experience, physiological re-sponses and behaviours. The intervention aims to enhance monitoring by the young individual of the effects of distortions and help him/her to modify them and their impact on thought, emotions and behaviours. The ABC (activating events, beliefs, consequences) model is provided and is used to help the individual to discover the connection between emotions, thoughts and behav-iours. The aim here is learning how activating events can induce beliefs, which can cause re-sponse in terms of emotions, somatic signals and behaviours (van der Gaag et al., 2013a).
Cogni-tive interventions, such as cogniCogni-tive restructuring and behavioural experiments are designed to challenge and test dysfunctional beliefs. Those interventions are also developed in order to help the individual stopping avoidance of trigger situations and safety behaviours; in addition, expo-sure to trigger stimuli is scheduled.
The subsequent three modules, Intervention on depression, Intervention on worry, Intervention on
social anxiety and social skills are conceived to target comorbid conditions which are often present
among UHR individuals. Intervention on depression starts with completing mood charts, analysing
pleasant activities for the young individual, scheduling pleasant activities that are assigned using a self-monitoring diary. In this diary, the individual had to indicate and schedule activities that he/she will perform during the subsequent days, to report emotions and thoughts he/she have and to measure the intensity of these emotions. The rationale for this is to enhance greater awareness of positive emotions and the intensity associated to them, to enhance self-efficacy in the manage-ment of daily living, thus reducing experience of anxiety and depressive symptoms. Such activi-ties are conceived as behavioural experiments, aimed to challenge catastrophic beliefs about ca-pacity to get pleasure from daily activities (“My days always are unemotional”, “I never feel emotions”). Different from the protocol of van der Gaag and colleagues (2013a), a module on
worry is added, introducing psychoeducation on worry, exploring and correcting metacognitive maladaptive assumptions about worry (positive and negative cognitions about worry) and CBT strategies to manage worry (exposures, problem solving, behavioural experiments). Intervention on social anxiety integrates principles of assertiveness training, targets self-esteem by role-play-ing and in-session and out-session exposure. Trigger situations are identified first. Then, dis-torted beliefs about self, others and the world are analysed with restructuring strategies. Finally,
to optimize flexibility of the intervention, the participant and the therapist can expose themselves together in the real-life context of the young UHR individual out of the office. Subsequently, the participant is encouraged to face such situations on his/her own in order to enhance generaliz-ability of the therapeutic process. At the end of the therapeutic course, a relapse prevention mod-ule is dedicated to the identification of early warning signs of relapse. Between-session home-work tasks are planned during all the treatment course. At the end of each session, the therapist asks the participant for feedback (e,g, how he/she did feel during the session, potential encoun-tered difficulties, usefulness of the session content). Together, they develop key take-home mes-sages.
Table 1 about here.
Data analysis
Statistical analyses were conducted by using SPSS 21.00. The proportion was calculated for par-ticipants reporting a baseline PSWQ score higher than the cut-off based on the normative sample in the validation study of the instrument (Morani et al., 1999). Participants lost to post-treatment or 14-month follow-up were coded conservatively as non-converters. Data at post-treatment and 14-month follow-up on PSWQ scores were analysed using intention to treat analysis with last observation carry-forward. Analyses on this outcome were conducted on the non-converters by performing a repeated measures ANOVA inserting Time-point (baseline, post-treatment, 14-month follow-up) as within-subject factor. Mean differences were calculated and post-hoc pair-wise comparisons were made by conducting Bonferroni test. Statistical significance was at a 0.05 p-value.
Socio-demographics and clinical characteristics
The Flowchart is provided in Figure 1 according to the Strengthening in Reporting Observational Studies in Epidemiology statement (STROBE; von Elm, 2007). Thirty-seven participants were included (Table 2). Mean age was 26 years, 8 (22.20%) were females. All the participants showed APS for intensity/frequency, 3 (8.10%) had BLIPS and 17 (45.90%) had familiarity or schizotypal personality disorder. Twenty-two (59.50%) reported a baseline PSWQ score higher than the cut-off based on the normative sample (Morani et al., 1999). Four participants (10.80%) dropped out from treatment before post-treatment assessment and none was lost at 14-month fol-low-up.
Figure 1 and Table 2 about here.
Transition to psychosis
Four participants (10.81%) at post-treatment and 7 (18.91%) at 14-month follow-up cumula-tively made transition to psychosis. The cumulative number of converters at 14-month follow-up was 7 (18.90%). All patients transitioned at post-treatment or 14-month follow-up met psychosis criteria on the PANSS. Three participants (8.10%) reported a first episode of psychosis, 2 (5.40%) schizoaffective disorder, 1 (2.70%) bipolar disorder with psychotic features.
Changes in worry at post-treatment and follow-up
The results of Repeated measures ANOVA conducted on non-converters showed a significant multivariate test (Table 3). Bonferroni post-hoc pairwise comparisons showed significant mean differences between baseline PSWQ and post-treatment PSWQ scores and between baseline PSWQ and 14-month follow-up PSWQ scores. Mean difference was not significant between post-treatment PSWQ and 14-month follow-up PSWQ scores. These results suggested that there
were significant changes in PSWQ scores from baseline to post-treatment and from baseline to 14-month follow-up; PSWQ scores remained stable from post-treatment to 14-month follow-up.
Table 3 about here.
Discussion
CBT was found to be an effective treatment in reducing or delaying the risk of transition to psychosis in young individuals with ARMS (Schmidt et al., 2015). However, some researchers highlighted the importance of investigating CBT benefits also on other outcomes than transition, particularly in the population of non-converters, as they can report significant distress and symptomatic impairment despite non fulfilling the criteria for psychosis (van der Gaag et al., 2013b). Worry was found to be a significant process associated with ARMS (Fresán et al., 2015):
young individuals reporting ARMS may fear getting crazy and losing control over their mind due to unexplained psychotic-like experiences. The present study was the first one in the international literature investigating changes in worry after CBT for ARMS in a group of non-converters seeking psychiatric care at mental health services. Thirty-seven young participants self-referred or referred by mental health professionals to psychiatric services were classified as ARMS and were included. All of them reported APS and a small subgroup, about 8%, reported also BLIPs; almost half of the total group, about 45%, was also classified as genetic vulnerability subgroup. Overall, these findings seemed in line with the percentages found in previous studies on CBT for ARMS (e.g, Stain et al., 2016), supporting further that APS represents the majority of cases in the ARMS population and that the genetic vulnerability picture is present in about one third of them.
consistent with the evidence of some previous studies on CBT for ARMS, where transition rate ranged from 8 to 16% (Addington et al., 2011; Bechdolf et al., 2012; van der Gaag et al., 2012; McGorry et al., 2013). The present transition rate seemed slightly lower than that reported in the meta-analysis by Fusar-Poli and colleagues (2012) on longitudinal studies, where it was 22% at 12-month follow-up.
A large subgroup, representing about 60%, reported significant baseline worry levels, as shown by a PSWQ score higher than the cut-off reported in the validation study of the instrument (Morani et al., 1999). This evidence supported the notion that worry may be a relevant strategy used by young individuals with ARMS and expanded previous research reporting that worry was significantly associated with ARMS (Fresán et al., 2015; Meneghelli et al., 2016). The proportion of ARMS participants reporting a PSWQ scores higher than the cut-off was over two-fold higher than that found among university students (Ruscio, 2002).
The main result of the study was that there were significant reductions in worry levels after CBT from baseline to post-treatment and from baseline to 14-month follow-up. This suggested that CBT may be able to significantly reduce worry tendencies. An explanation of this result may be related to the fact that the protocol contained a module specifically targeting worry based on Wells (2011), which included some key components such as psychoeducation on worry, cognitive and metacognitive restructuring, behavioural experiments. It may be hypothesized that reductions in worry were enhanced by reductions in cognitive biases specific to young individuals experiencing psychotic-like symptoms, such as attention for threat bias and jumping to conclusions, which play as maintenance factors of worry (Pozza & Dèttore, 2017). However, as such biases were not measured in the present investigation, these explanation may not be verified and warrants future research. Dismantling designs may allow clarifying which CBT components can reduce worry in ARMS. Alternatively, in a broader sense it may be that the protocol as a whole worked and all CBT skills provided helped the individuals leaving worry as
coping strategy to manage distress and replace it with more functional strategies, such as relaxation techniques. Another interesting result was that changes in worry achieved at 6-month post-treatment seemed to remain stable at 14-month follow-up; this supported that the therapeutic gains achieved during CBT course may be reliable over time and enduring also after the end of treatment.
Some limitations should be considered. The lack of a control group did not allow excluding that the changes in worry may be attributed to other factors than CBT, including maturation or extra-therapeutic events (finding a job or a partner, social support). Future research should compare the effects of CBT for ARMS on worry with treatment as usual by using a randomised controlled trial in order to control for these potential biases. In addition, a larger sample size is required. This may allow investigating potential moderators of changes in worry, such as gender or comor-bid anxiety/depressive disorders. Future research should also examine whether changes in worry may moderate transition to psychosis: higher changes in worry may be associated with reduced transition risk. Finally, an interesting point might be investigating whether changes in worry may be associated with changes in some subclinical psychotic symptoms, particularly paranoid think-ing. This may support further the role of worry in ARMS as a mechanism of change, in the same manner as for worry in CBT for full psychosis (Freeman et al., 2015).
Conclusions
The present preliminary study was the first contribution in the literature investigating changes in worry after CBT for a young cohort with ARMS at immediate post-treatment and long-term follow-up. The current results supported that CBT for ARMS may be promising in reducing worry and that treatment gains may be stable over time up to 14 months. Future research with a larger sample and a control group randomly assigned to treatment as usual may also help understanding whether changes in worry are associated with reduced risk of transition to
psychosis.
Acknowledgements
The authors have no acknowledgement to declare.
Ethical statements
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the American Psychological Association. Institutional Ethical Approval was obtained by the Ethics Committee.
Conflict of interest
AP, SD, and DD have no conflict of interest with respect to this publication.
Author contributions
AP designed the study, collected the data, conducted the literature searches, conducted the sta-tistical analysis, wrote the first draft of the paper. SD designed the study, collected the data, wrote the first draft of the paper. DD designed the study, reviewed the first draft of the paper, supervised the clinicians, checked the editing of the final version of the paper. All authors have approved the final manuscript.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
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Fresán A, León-Ortiz P, Robles-García R, Azcárraga M, Guizar D, Reyes-Madrigal F, ... de la Fuente-Sandoval C (2015). Personality features in ultra-high risk for psychosis: a comparative study with schizophrenia and control subjects using the Temperament and Character Inventory-Revised (TCI-R). Journal of Psychiatric Research 61, 168-173.
Van der Gaag M, Nieman D, Van den Berg D. (2013). CBT for Those at Risk of a First Episode Psychosis: Evidence-based Psychotherapy for People with an “at Risk Mental State”. New York, NY: Routledge.
van der Gaag M, Smit F, Bechdolf A, French P, Linszen DH, Yung AR, ... Cuijpers P. (2013b). Preventing a first episode of psychosis: meta-analysis of randomized controlled
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References
Addington J, Epstein I, Liu L, French P, Boydell KM, Zipursky RB (2011). A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophrenia Research 125, 54-61.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association Publishing.
Bechdolf A, Wagner M, Ruhrmann S, Harrigan S, Putzfeld V, Pukrop R, ... Bottlender R (2012). Preventing progression to first-episode psychosis in early initial prodromal states. The British Journal of Psychiatry 200, 22-29.
Borkovec TD, Inz J (1990). The nature of worry in generalized anxiety disorder: A predominance of thought activity. Behaviour Research and Therapy 28, 153-158.
Borkovec TD, Robinson E, Pruzinsky T, DePree JA (1983). Preliminary exploration of worry: Some characteristics and processes. Behaviour Research and Therapy 21, 9-16. Cohen J (1968). Weighted kappa: Nominal scale agreement provision for scaled disagreement
Cotter J, Yung AR, Carney R, Drake RJ (2017). Metacognitive beliefs in the at-risk mental state: a systematic review and meta-analysis. Behaviour Research and Therapy 90, 25-31. Cowan HR, McAdams DP, Mittal VA (2018). Core beliefs in healthy youth and youth at ultra
high-risk for psychosis: Dimensionality and links to depression, anxiety, and attenuated psychotic symptoms. Development and Psychopathology 30, 1-14.
First M, Spitzer R, Gibbon M, Williams J (1997). Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Firenze: Giunti OS.
First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS (1997). Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID-II). Washington, DC: American Psychiatric Press.
Freeman D, Dunn G, Startup H, Pugh K, Cordwell J, Mander H, ... Kingdon D (2015). Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis. The Lancet Psychiatry 2, 305-313.
Freeman D, Stahl D, McManus S, Meltzer H, Brugha T, Wiles N, Bebbington P (2012). Insomnia, worry, anxiety and depression as predictors of the occurrence and persistence of paranoid thinking. Social Psychiatry and Psychiatric Epidemiology 47, 1195-1203.
Fresán A, León-Ortiz P, Robles-García R, Azcárraga M, Guizar D, Reyes-Madrigal F, ... de la Fuente-Sandoval C (2015). Personality features in ultra-high risk for psychosis: a comparative study with schizophrenia and control subjects using the Temperament and Character Inventory-Revised (TCI-R). Journal of Psychiatric Research 61, 168-173.
Fusar-Poli P, Bonoldi I, Yung AR, Borgwardt S, Kempton MJ, Valmaggia L, ... McGuire P (2012). Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Archives of General Psychiatry 69, 220-229.
results since 1996. Social Psychiatry and Psychiatric Epidemiology 48, 1021-1031.
Hartley S, Haddock G, e Sa, DV, Emsley R, Barrowclough C (2014). An experience sampling study of worry and rumination in psychosis. Psychological Medicine 44, 1605-1614. Ising HK, Kraan TC, Rietdijk J, Dragt S, Klaassen RM, Boonstra N, ... Wunderink L (2016). Four-year follow-up of cognitive behavioral therapy in persons at ultra-high risk for developing psychosis: the Dutch early detection intervention evaluation (EDIE-NL) trial. Schizophrenia Bulletin 42, 1243-1252.
Kay SR, Opler LA, Lindenmayer JP (1989). The Positive and Negative Syndrome Scale (PANSS): rationale and standardisation. British Journal of Psychiatry 155, 59-65.
Lin A, Wood SJ, Nelson B, Beavan A, McGorry P, Yung AR (2015). Outcomes of nontransitioned cases in a sample at ultra-high risk for psychosis. American Journal of Psychiatry 172, 249-258.
Maffei C, Fossati A, Agostoni I, Barraco A, Bagnato M, Donati D, Namia C, Novella L, Petrachi M (1997). Interrater Reliability and Internal Consistency of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), Version 2.0. Journal of Personality Disorders 11, 279-284.
Mazzi F, Morosini P, De Girolamo G, Lussetti M, Guaraldi GP (2000). SCID-I—Structured Clinical Interview for DSM-IV Axis I Disorders (Italian Edition). Firenze: Giunti OS.
McGorry PD, Nelson B, Phillips LJ, Yuen HP, Francey SM, Thampi A, ... Thompson AD (2013). Randomized controlled trial of interventions for young people at ultra-high risk of psychosis: twelve-month outcome. The Journal of Clinical Psychiatry 74, 349-356.
McHugh MJ, McGorry PD, Yuen HP, Hickie IB, Thompson A, de Haan L, ... Schloegelhofer M (2018). The Ultra-High-Risk for psychosis groups: Evidence to maintain the status quo. Schizophrenia Research 195, 543-548.
Cognitive Concerns be early warning signs of Psychosis? Evidence from the Anxiety Sensitivity in the first stages of Psychosis study (ASP study). Early Intervention in Psychiatry 10, 229-229.
Meyer TJ, Miller ML, Metzger RL, Borkovec TD (1990). Development and validation of the penn state worry questionnaire. Behaviour Research and Therapy 28, 487-495.
Morani S, Pricci D, Sanavio E (1999). Penn State Worry Questionnaire e Worry Domains Questionnaire. Presentazione delle versioni italiane ed analisi della fedeltà. Psicoterapia Cognitiva e Comportamentale 5, 13-34.
Morrison AP, French P, Stewart SL, Birchwood M, Fowler D, Gumley AI, ... Patterson P (2012). Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial. BMJ 344, e2233.
Morrison AP, French P, Walford L, Lewis SW, Kilcommons A, Green J, ... Bentall RP (2004). Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial. The British Journal of Psychiatry 185, 291-297.
Okuzawa N, Kline E, Fuertes J, Negi S, Reeves G, Himelhoch S, Schiffman J (2014). Psychotherapy for adolescents and young adults at high risk for psychosis: a systematic review. Early Intervention in Psychiatry 8, 307-322.
Pozza A, Dèttore D (2017). The CBQ-p: A confirmatory study on factor structure and convergent validity with psychotic-like experiences and cognitions in adolescents and young adults. BPA-Applied Psychology Bulletin (Bollettino di Psicologia Applicata) 65, 58-69. Rietdijk J, Dragt S, Klaassen R, Ising H, Nieman D, Wunderink L, ... van der Gaag M
(2010). A single blind randomized controlled trial of cognitive behavioural therapy in a help-seeking population with an At Risk Mental State for psychosis: the Dutch Early Detection and Intervention Evaluation (EDIE-NL) trial. Trials 11, 1-9.
high worriers with and without GAD. Journal of Anxiety Disorders 16, 377-400.
Schmidt SJ, Schultze-Lutter F, Schimmelmann BG, Maric NP, Salokangas RKR, Riecher-Rössler A, ... Morrison A (2015). EPA guidance on the early intervention in clinical high risk states of psychoses. European Psychiatry 30, 388-404.
Schultze-Lutter F, Michel C, Schmidt SJ, Schimmelmann BG, Maric NP, Salokangas RKR, ... Meneghelli A (2015). EPA guidance on the early detection of clinical high risk states of psychoses. European Psychiatry 30, 405-416.
Stain HJ, Bucci S, Baker AL, Carr V, Emsley R, Halpin S, ... Startup M (2016). A randomised controlled trial of cognitive behaviour therapy versus non-directive reflective listening for young people at ultra high risk of developing psychosis: The detection and evaluation of psychological therapy (DEPTh) trial. Schizophrenia Research 176, 212-219. Startup H, Pugh K, Dunn G, Cordwell J, Mander H, Černis E, ... Freeman D (2016). Worry
processes in patients with persecutory delusions. British Journal of Clinical Psychology 55, 387-400.
van der Gaag M, Nieman DH, Rietdijk J, Dragt S, Ising HK, Klaassen RM, ... Linszen DH (2012). Cognitive behavioral therapy for subjects at ultrahigh risk for developing psychosis: a randomized controlled clinical trial. Schizophrenia Bulletin 38, 1180-1188.
van der Gaag M, Nieman D, Van den Berg D (2013a). CBT for Those at Risk of a First
Episode Psychosis: Evidence-based Psychotherapy for People with an “at Risk Mental State”. New York, NY: Routledge.
van der Gaag M, Smit F, Bechdolf A, French P, Linszen DH, Yung AR, ... Cuijpers P (2013b). Preventing a first episode of psychosis: meta-analysis of randomized controlled
prevention trials of 12 month and longer-term follow-ups. Schizophrenia Research 149, 56-62.
STROBE Initiative (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370, 1453–1457.
Yung AR, Yung AR, Pan Yuen H, Mcgorry PD, Phillips LJ, Kelly D, ... Stanford C (2005). Mapping the onset of psychosis: the comprehensive assessment of at-risk mental states. Australian and New Zealand Journal of Psychiatry 39, 964-971.
Wells A (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy 23, 301-320.
Wells A (2011). Metacognitive therapy for anxiety and depression. New York, NY: Guilford press.
