Prodromal Questionnaire : translation , adaptation to Portuguese and preliminary results in ultra-high risk individuals and first episode psychosis

Objective: The Prodromal Questionnaire (PQ) is a 92-item self-report screening tool for individuals at ultra-high risk (UHR) to develop psychosis. This study aims to present the translation to Portuguese and preliminary results in UHR and first episode (FE) psychosis in a Portuguese sample. Methods: The PQ was translated from English to Portuguese by two bilingual researchers from the research program on early psychosis of the Instituto de Psiquiatria HCFMUSP, São Paulo, Brazil (ASAS – “Evaluation and Follow up of Adolescents and Young Adults in São Paulo”) and back translated by two other researchers. The study participants (n = 11 ) were evaluated through the Portuguese version of the Prodromal Questionnaire (PQ) and SIPS. Results: The individuals at UHR (n = 7) presented a lower score than first episode patients (n = 4). The UHR mean scores and standard deviation on Portuguese version of the PQ were: 13.0 ± 10.0 points on positive symptoms subscale, and FE patients: 33.0 ± 10.0. Conclusion: The UHR and FE patients’ of this study presented PQ scores similar to the ones found in the literature; what suggests that it is possible to use the PQ in Brazilian help-seeking individuals as a screening tool.


INTRODUCTION
The past twenty years have seen increasingly rapid advances in the field of early intervention [1][2][3] ; not only due to the relevance of the issue but also because studies showed its positive impact and cost-effectiveness 4,5 .Early intervention aims to investigate early stages of psychosis also known as prodromal phase.In clinical medicine, the prodromal phase is defined by the presence early symptoms or signs that determine if the diseases will occur 1 .In psychiatry, the focus are on individuals at ultra-high risk (UHR) to develop psychosis 1,2 , as they may be experiencing prodromal phase, in which it is observed a gradual development of symptoms and an increa se on its frequency before a full-blow of psychosis 1 .
UHR are individuals at risk to develop psychosis who present the following symptoms at least two weeks most of the days: suspiciousness, perceptual distortions, poor or decline functioning, social withdrawal, hallucinations, disorganized thinking/speech, ideas of reference, depression, anxiety, sleep disturbance, difficulties in concentration that might indicate a risk of conversion to psychosis 1,3,6 and cognitive impairments 7,8 .
The UHR individuals are usually classified according operational criteria derived from the application of Structured Interviews such as the Structured Interview for Prodromal Symptoms (SIPS) 9 in one of the following Psychosis-Risk Syndromes: 1) attenuated positive symptoms (APS), patient who present attenuated psychotic symptoms in the last year; 2) Brief intermittent psychotic symptoms (BLIPS), patient that experience frank episode of psychosis which did not last more than a week and have spontaneously disappeared; and 3) Genetic risk and Functional Deterioration Syndrome, decline in social functioning in the last year and a first-degree relative with psychotic disorder or schizotypal personality 6,10 .
The SIPS 9 and the Comprehensive Assessment of At Risk Mental States (CAARMS) 11 are frequently used to classify individuals at UHR for academic purposes in specialized research centers, even though the UHR diagnosis remains clinical.The SIPS and the CAARMS are golden standard interview-based instruments conducted by experts, able to classify the experiences reported by the potential UHR individuals 12 ; but require long staff training and time, and can result on patient burden 10,12 .
Simple screening self-rating scales could play an important role in widespread evaluation of potential UHR individuals as they do not required trained staff; in contrast to interview-based instruments, self-reported instruments have less sensitivity and a higher risk of a false positive screening leading to harmful consequences 13 .Loewy et al. 10 developed the Prodromal Questionnaire (PQ).The PQ is a 92-item self-report screening tool for individuals at UHR to develop psychosis, the items are answered "true" or "false" and it takes approximately 20 minutes to complete it.It has four major subscales: positive (45 items), negative (19 items), disorganized (13 items) and general symptoms (15 items) and has good validity when compared to the SIPS 10 .
An instrument similar to PQ is the Self-screen-Prodrome, a short screening tool used to distinguish between healthy individuals, individuals with psychosis or an at-risk mental state for psychosis and patients with other ICD-10 diagnoses 14 .The PRO screen, a 21 item screening instrument, is another instrument; similar to PQ and developed according to SIPS 15 .
The implementation of screening tools in non-English--speaking countries is necessary to facilitate the identification of UHR worldwide; the PQ has already been translated to Chinese 16 and to Finnish 12 ; in both studies 12,16 the findings are in line with Loewy et al. 10 .
To the best of our knowledge there are not screening tools for at UHR available in Portuguese in spite of the growing research field in Brazil.
The aim of this study is to present the Portuguese Version of the Prodromal Questionnaire and preliminary results in UHR and first episode psychosis in a Brazilian sample.

METHODS
The Evaluation and Follow up of Adolescents and Young Adults in São Paulo (ASAS) is an outpatient clinic and a resear ch program on early psychosis of the Institute of Psychiatry (IPq), Clínicas Hospital, Medical School, University of São Paulo (FMUSP).ASAS focus on the identification and follow up of UHR individuals and consequently FE patients.All the included participants were from ASAS and they provided written informed consent and the research program was approved by the Ethics Committee.
The included participants were individuals between 14-30 years old living in São Paulo, who contacted ASAS by phone or email.They met the UHR phone screening criteria based on McGorry 2 and Miller et al. 9 (check list of symptoms for at least two weeks: changes from the usual behavior, social withdrawal, odd thoughts, strange or unreal sensations, preoccupation with particular ideas or thoughts, unusual experiences such as seeing or hearing things that are not there, J Bras Psiquiatr.2012;61(2):96-101.
isolation, poor performance at school or work) and came to a personal interview, when a thorough evaluation including: the Portuguese version of the PQ, SIPS or Positive and Negative Syndrome Scale (PANSS) was performed.
The PQ was first translated from English to Portuguese by two bilingual researchers (a psychiatrist and a psychologist) from ASAS with the permission of the author, afterwards it was back translated from Portuguese to English by other two bilingual researchers (a psychiatrist and a psychologist) from ASAS.The original and the back translated English versions were compared, a few changes were made in the Portuguese version of the PQ, and the back translation was reviewed by R. Loewy.The final Portuguese version of PQ is included in the Appendix 1.

Statistical analysis
We performed a descriptive analyses of the groups (UHR and FE) and the Mann-Whitney test to compare the PQ subscale scores (total, positive, negative, disorganized, general symptoms) between the groups; all the analyses were performed using The Statistical Package for the Social Sciences (SPSS) version 14.

RESULTS
The Portuguese version of the PQ is presented in the appendix.Socio demographic data is presented in Table 1.The UHR group is slightly older (20 years against 17); with better educational background (25% against 0% with only elementary school) and consists only of unemployed individuals (whereas 43 of the first episode group is employed).The gender distribution is similar (25-28% female).Seven UHR individuals (5 male and 2 female), aged 16-26 (mean: 20.3 ± 3.4 years) who contacted ASAS fulfilled the Portuguese version of the PQ.Their positive symptoms scale mean was 13.0 ± 10.0 points, negative symptoms scale was 10.1 ± 4.6 points, disorganized symptoms scale was 5.3 ± 3.2 points and general symptoms scale was 7.6 ± 1.9 points (Table 2).
There were four first episode (FE) patients (3 male and 1 female), aged 13-20 (mean: 17.0 ± 2.9 years) who contacted ASAS also fulfilled the Portuguese version of the PQ.Their positive symptoms scale mean was 33.0 ± 10.0 points, negative symptoms scale was 12.5 ± 3.78 points, disorganized symptoms scale was 8.5 ± 1.3 points and general symptoms scale was 10.25 ± 1.9 points (Table 1).
The total PQ score (p = .004),the positive subscale score (p = .011),the disorganized symptoms subscale (p = .029)and general symptoms subscale (p = .031)were significantly different between the groups (UHR and FE) however we did not find differences on negative symptoms subscale (p = .394)(Table 2).

DISCUSSION
Significant differences between UHR and FE patients' on the total PQ score and on the positive, disorganized and general subscales were observed; however no differences were found on negative symptoms scale.The lack of difference between UHR and FE in the negative subscale of the PQ may in part be related to the fact that "positive symptoms" are the keystone in the definition of psychosis and UHR subjects and the scale is mainly designed to detect these symptoms.The course of the negative symptoms along the prodromal phase is more insidious so that less difference would be expected between UHR and FE patients 17 .
Loewy et al. 10 consider that a cutoff point of the positive subscale of 14.0 points (71% sensitivity and 81% specificity) indicates that the subject is at UHR for psychosis.Chiu et al. 16 translated the PQ to Chinese and applied it in 3 groups: UHR, psychosis and healthy subjects and observed that the PQ positive subscale scores were: 12.9 ± 7.0 points, 21.9 ± 7.0 points and 5.4 ± 5.1 points respectively (Table 2).Their findings are similar to ours, what might suggest that the Portuguese version of PQ is able to detect UHR subjects and might also differentiate patients already with an established FE psychosis.Loewy et al. 12 translated the PQ to Finnish and their findings suggest that PQ results are similar in clinic referred and general mental health individuals.
The use of the PQ in different countries and populations showed consistently that the main difference between UHR and FE subjects was on the positive symptoms subscale.
It must be also considered that our results are preliminary, our sample size is small and we did not evaluate a control group.Although the results of this study are preliminary, the availability of a version in Portuguese of PQ could potentially contribute to research in the field in Brazil.
It is important to highlight that the PQ is a screening tool; and should be only used in clinical setting due to the high probability of false-positive if applied in other contexts (i.e.school and community) 10 .As a false positive screening it could be harmful due to the emotional burden and stigma towards the possibility of having a psychiatric disorder 13 .Nonetheless the early recognition of UHR subjects might reduce their duration of untreated psychosis, reduce the risk of suicide and improve their outcome 17,18 .Would these benefits overcome the risk of stigmatization of a false positive screening?Further studies are necessary to answer this question.

CONCLUSION
Brazilian UHR subjects and FE patients presented PQ scores similar to the ones found in the literature 10,12,16 .These results support the possibility that the PQ may be used as a screening tool in Brazilian help-seeking individuals before they are referred to a specialized evaluation.

Table 2 .
Ultra High Risk and First Episode median and mean scores of the Portuguese version of the Prodromal Questionnaire (PQ)Data are presented as mean and standard deviation; UHR: ultra-high risk; FE: first episode; p-value was calculated for each subscale through Mann-Whitney test; *p < .05.

Table 1 .
Ultra-high risk and first episode socio-demographic characteristics