The heterogeneity of attenuated and brief limited psychotic symptoms: association of contents with age, sex, country, religion, comorbidities, and functioning

Christian Theisen*, Marlene Rosen, Eva Meisenzahl, Nikolaos Koutsouleris, Theresa Lichtenstein, Stephan Ruhrmann, Joseph Kambeitz, Lana Kambeitz-Ilankovic, Anita Riecher-Rössler, Katharine Chisholm, Rachel Upthegrove, Linda A. Antonucci, Alessandro Bertolino, Alessandro Pigoni, Raimo K. R. Salokangas, Christos Pantelis, Stephen J. Wood, Rebekka Lencer, Peter Falkai, Jarmo HietalaPaolo Brambilla, André Schmidt, Christina Andreou, Stefan Borgwardt, Naweed Osman, Frauke Schultze-Lutter

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Introduction: The Attenuated Psychosis Symptoms (APS) syndrome mostly represents the ultra-high-risk state of psychosis but, as does the Brief Intermittent Psychotic Symptoms (BIPS) syndrome, shows a large variance in conversion rates. This may be due to the heterogeneity of APS/BIPS that may be related to the effects of culture, sex, age, and other psychiatric morbidities. Thus, we investigated the different thematic contents of APS and their association with sex, age, country, religion, comorbidity, and functioning to gain a better understanding of the psychosis-risk syndrome.
Method: A sample of 232 clinical high-risk subjects according to the ultra-high risk and basic symptom criteria was recruited as part of a European study conducted in Germany, Italy, Switzerland, and Finland. Case vignettes, originally used for supervision of inclusion criteria, were investigated for APS/BIPS contents, which were compared for sex, age, country, religion, functioning, and comorbidities using chi-squared tests and regression analyses.
Result: We extracted 109 different contents, mainly of APS (96.8%): 63 delusional, 29 hallucinatory, and 17 speech-disorganized contents. Only 20 contents (18.3%) were present in at least 5% of the sample, with paranoid and referential ideas being the most frequent. Thirty-one (28.5%) contents, in particular, bizarre ideas and perceptual abnormalities, demonstrated an association with age, country, comorbidity, or functioning, with regression models of country and obsessive-compulsive disorders explaining most of the variance: 55.8 and 38.3%, respectively. Contents did not differ between religious groups.
Conclusion: Psychosis-risk patients report a wide range of different contents of APS/BIPS, underlining the psychopathological heterogeneity of this group but also revealing a potential core set of contents. Compared to earlier reports on North-American samples, our maximum prevalence rates of contents were considerably lower; this likely being related to a stricter rating of APS/BIPS and cultural influences, in particular, higher schizotypy reported in North-America. The various associations of some APS/BIPS contents with country, age, comorbidities, and functioning might moderate their clinical severity and, consequently, the related risk for psychosis and/or persistent functional disability.
Original languageEnglish
Article number1209485
Number of pages24
JournalFrontiers in Psychiatry
Early online date7 Jul 2023
Publication statusPublished - 2023

Bibliographical note

Copyright © 2023 Theisen, Rosen, Meisenzahl, Koutsouleris, Lichtenstein, Ruhrmann, Kambeitz, Kambeitz-Ilankovic, Riecher-Rössler, Chisholm, Upthegrove, Antonucci, Bertolino, Pigoni, Salokangas, Pantelis, Wood, Lencer, Falkai, Hietala, Brambilla, Schmidt, Andreou, Borgwardt, Osman and Schultze-Lutter. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.


  • Attenuated Psychotic Symptoms
  • hallucinatory experiences
  • clinical-high risk for psychosis
  • disorganized communication
  • delusional ideas


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