Skip to main content

Advertisement

SpringerLink
Log in

Detecting incipient schizophrenia: a validation of the Azima battery in first episode psychosis

  • Original Paper
  • Published:
Psychiatric Quarterly Aims and scope Submit manuscript

Abstract

Early psychosis intervention aims to accurately detect adolescents and young adults at risk for major mental disorders, particularly schizophrenia, yet early biomedical diagnostic accuracy remains poor. However, phenomenological approaches focusing on eliciting and understanding the subjective experience of help-seeking youth better detect incipient schizophrenia. The Azima Battery is an occupational therapy projective assessment that uses expressive media in a standard setup, in order to phenomenologically elicit and describe the activity performance and narratives of individuals at risk of, or on, the psychotic-spectrum.

The purpose of this study was to estimate the predictive validity of the Azima Battery with youth seeking help for a first episode of psychosis, and identify patterns of performance distinctive of a diagnosis of schizophrenia 1-year later. A mixed methods phenomenological approach was used to calculate the predictive validity of the Azima Battery in detecting incipient schizophrenia, and to qualitatively identify patterns of performance. Study results demonstrate that the diagnostic accuracy of the Azima Battery is greater than psychiatric interviewing for a future diagnosis of schizophrenia (N = 62: 88.7 % vs 42 %). Performance elements and patterns statistically distinctive of schizophrenia are described, and relate to the structure of the created objects. Therefore, the Azima Battery is a valid measure for clinical use by occupational therapists working in early intervention for psychosis as a complement to traditional psychiatric interviewing.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Canadian Institute for Health Information. Canadian Institute for Health Information Health Indicators 2011. Author. 2011. http://www.cihi.ca/. Accessed January 20, 2015.

  2. Mitchell AJ. Early intervention for first episode psychosis ~ Worldwide burden of psychosis is not as severe as suggested [letter]. British Medical Journal. 2004; 329:401.

    Article  PubMed  PubMed Central  Google Scholar 

  3. World Health Organization. The World Health Report, 2001: Mental health: new understanding, New Hope. Geneva: World Health Organization 2001.

  4. Bertolote J, McGorry PD. Early intervention and recovery for young people with early psychosis: consensus statement. British Journal of Psychiatry [Supplement]. 2005;48:s116–9. doi:10.1192/bjp.187.48.s116.

    Article  CAS  Google Scholar 

  5. Ehmann T, Hanson L, Yager J, Dalzell K, Gilbert M. Standards and guidelines for early psychosis intervention (EPI) programs. British Columbia: British Columbia Ministry of Health Services; 2010.

  6. Ministère de la Santé et des Services Sociaux. Plan d’Action en Santé Mentale. La Force des Liens. Quebec: Author; 2005.

  7. Mental Health Evaluation & Community Consultation Unit. Early Psychosis. A Guide for Physicians. In: Mental Health Evaluation & Community Consultation Unit DoPftBCMoH, editor. Vancouver, B.C.: Government of British Columbia; 2000. p. 50.

  8. Chang WC, Chan SSM, Chung DWS. Diagnostic stability of functional psychosis: a systematic review. Hong Kong Journal of Psychiatry. 2009; 19:30–41.

    Google Scholar 

  9. Addington J, Chaves A, Addington D. Diagnostic stability over one year in first-episode psychosis. Schizophrenia research. 2006; 86(1–3):71–5. doi:10.1016/j.schres.2006.04.018.

    Article  PubMed  Google Scholar 

  10. Fraguas D, Castro MJ, Medina O, Parellada M, Moreno D, Graell M et al. Does diagnostic classification of early-onset psychosis change over follow-up? Child Psychiatry and Human Development. 2007; 39(2):137–45. doi:10.1007/s10578-007-0076-3.

    Article  PubMed  Google Scholar 

  11. Rahm C, Cullberg J. Diagnostic stability over 3 years in a total group of first-episode psychosis patients. Nordic Journal of Psychiatry. 2007; 61(3):189–93. doi:10.1080/08039480701352454.

    Article  PubMed  Google Scholar 

  12. Chang WC, Pang SL, Chung DWS, Chan SSM. Five-year stability of ICD-10 diagnoses among Chinese patients presented with first-episode psychosis in Hong Kong. Schizophrenia research. 2009; 115(2–3):351–7. doi:10.1016/j.schres.2009.09.037.

    Article  PubMed  Google Scholar 

  13. Holtzman CW, Larson MK, Addington J, Cadenhead K, Cannon TD, Cornblatt B et al. Sex differences in symptom presentation in individuals at risk for psychosis. Schizophrenia research. 2010; 117(2–3):304–5. doi:10.1016/j.schres.2010.02.508.

    Article  Google Scholar 

  14. Kim JS, Baek JH, Choi JS, Lee D, Kwon JS, Hong KS. Diagnostic stability of first-episode psychosis and predictors of diagnostic shift from non-affective psychosis to bipolar disorder: a retrospective evaluation after recurrence. Psychiatry research. 2011; 188(1):29–33. doi:10.1016/j.psychres.2010.09.017.

    Article  PubMed  Google Scholar 

  15. Amin S, Singh SP, Brewin J, Jones PB, Medley I, Harrison G. Diagnostic stability of first-episode psychosis. Comparison of ICD-10 and DSM-III-R systems. The British Journal of Psychiatry. 1999; 175(6):537–43. doi:10.1192/bjp.175.6.537.

    Article  CAS  PubMed  Google Scholar 

  16. Ramirez N, Arranz B, Salavert J, Alvarez E, Corripio I, Duenas RM et al. Predictors of schizophrenia in patients with a first episode of psychosis. Psychiatry research. 2010; 175(1–2):11–4. doi:10.1016/j.psychres.2009.03.013.

    Article  PubMed  Google Scholar 

  17. Zandi T, Havenaar JM, Laan W, Kahn RS, van den Brink W. Predictive validity of a culturally informed diagnosis of schizophrenia: a 30 month follow-up study with first episode psychosis. Schizophrenia research. 2011; 133(1–3):29–35. doi:10.1016/j.schres.2011.09.024.

    Article  PubMed  Google Scholar 

  18. Ochoa S, Usall J, Cobo J, Labad X, Kulkarni J. Gender differences in schizophrenia and first-episode psychosis: a comprehensive literature review. Schizophrenia research and treatment. 2012; 2012:916198. doi:10.1155/2012/916198.

    PubMed  PubMed Central  Google Scholar 

  19. Corin E, Thara R, Padmavati R. Shadows of culture in psychosis in South India: a methodological exploration and illustration. International Review of Psychiatry. 2005; 17(2):75–81. doi:10.1080/09540260500050016.

    Article  PubMed  Google Scholar 

  20. Parnas J. A disappearing heritage: the clinical core of schizophrenia. Schizophrenia bulletin. 2011; 37(6):1121–30. doi:10.1093/schbul/sbr081.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Stanghellini G. The grammar of the psychiatric interview. A plea for the second-person mode of understanding. Psychopathology. 2007;40(2):69–74. doi:10.1159/000098486.

    Article  PubMed  Google Scholar 

  22. Klosterkötter J, Hellmich M, Steinmeyer EM, Schultze-Lutter F. Diagnosing schizophrenia in the initial prodromal phase. Archives of General Psychiatry. 2001; 58:158–64.

    Article  PubMed  Google Scholar 

  23. Raballo A, Parnas J. Examination of anomalous self-experience: initial study of the structure of self-disorders in schizophrenia spectrum. Journal of Nervous and Mental Disease. 2012; 200(7):577–83.

    Article  PubMed  Google Scholar 

  24. Reynolds F. Expressive media used as assessment in mental health. In: Hemphill-Pearson B, J., editor. Assessments in occupational therapy mental health. An integrative approach. 2nd ed. Thorofare, NJ: Slack Inc; 2008. p. 81–96.

  25. Lilienfeld SO, Wood JM, Garb HN. The scientific status of projective techniques. Psychological Science in the Public Interest. 2000; 1:27–66.

    Article  CAS  PubMed  Google Scholar 

  26. Heidgerd E. Research in drawing techniques. In: Hammer EF, editor. The clinical application of projective drawings. 6th ed. Springfield, IL: Charles C. Thomas Publisher; 1958/1980. p. 483–507.

    Google Scholar 

  27. Burton A, Sjoberg B. The diagnostic validity of human figure drawings in schizophrenia. Journal of Psychology. 1964; 57:3–18.

    Article  CAS  PubMed  Google Scholar 

  28. Zafran H, Tallant BK. “it would be a shame to lose them” ~ A critical historical, scoping, and expert review on the use of projective assessments in occupational therapy. Part II. Occupational Therapy in Mental Health. 2015; 33(4):328–65.

    Article  Google Scholar 

  29. Thompson M, Blair SEE. Creative arts in occupational therapy: ancient history or contemporary practice? Occupational therapy international. 1998; 5(1):48–64.

    Article  Google Scholar 

  30. Woodside H, Krupa T, Pocock K. Early psychosis, activity performance and social participation: a conceptual model to guide rehabilitation and recovery. Psychiatric Rehabilitation Journal. 2007; 31:125–30.

    Article  PubMed  Google Scholar 

  31. Zafran H, Tallant BK. “it would be a shame to lose them” ~ A critical historical, scoping, and expert review on the use of projective assessments in occupational therapy. Part I. Occupational Therapy in Mental Health. 2015; 33(3):187–210. doi:10.1080/0164212X.2015.1065538.

    Article  Google Scholar 

  32. Azima H, Azima FJ. Outline of a dynamic theory of occupational therapy. American Journal of Occupational Therapy. 1959;XIII(5):215–21.

    Google Scholar 

  33. Cramer-Azima FJ. The Azima Battery: An overview. In: Hemphill BJ, editor. The evaluative process in psychiatric occupational therapy. Thorofare, NJ: Slack, Inc; 1982. p. 57–62.

  34. Hammer EF. The prognostic role of drawings in the projective battery. In: Hammer EF, editor. The clinical application of projective drawings. Springfield, ILL: Charles C. Thomas Publisher; 1958/1980. p. 628–34.

    Google Scholar 

  35. Parker S, Lewis S. Identification of young people at risk of psychosis. Advances in Psychiatric Treatment. 2006; 12:249–55.

    Article  Google Scholar 

  36. McGorry PD, Yung AR, Phillips LJ. The “close-in” or ultra high-risk model: a safe and effective strategy for research and clinical intervention in prepsychotic mental disorder. Schizophrenia bulletin. 2003; 29:771–90.

    Article  PubMed  Google Scholar 

  37. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed., text rev.) Washington, DC: American Psychiatric Association; 2000.

  38. Creswell JW. Research design: qualitative, quantitative and mixed methods approaches. CA: Sage.: Thousand Oaks; 2003.

  39. Mayoh J, Onwuegbuzie AJ. Toward a conceptualization of mixed methods phenomenological research. Journal of Mixed Methods Research 2013 doi:10.1177/1558689813505358.

    Google Scholar 

  40. Finlay L. A dance between the reduction and reflexivity: explicating the “phenomenological psychological attitude”. Journal of Phenomenological Psychology. 2008; 39:1–32.

    Article  Google Scholar 

  41. Levesque R. SPSS programming and data management: a guide for SPSS and SAS users. 4th Ed. Ed. Chicago, IL: SPSS Inc.; 2007.

  42. Streiner GR, Norman DL. Health measurement scales, a practical guide to their development and use. 4th ed. Oxford, UK: Oxford University Press; 2008.

  43. Henry LP, Harris MG, Amminger GP, Yuen HP, Harrigan SM, Lambert M et al. Early psychosis prevention and intervention Centre long-term follow-up study of first-episode psychosis: methodology and baseline characteristics. Early intervention in psychiatry. 2007; 1(1):49–60. doi:10.1111/j.1751-7893.2007.00008.x.

    Article  PubMed  Google Scholar 

  44. Møller P. Duration of untreated psychosis: are we ignoring the mode of initial development? An extensive naturalistic case study of phenomenal continuity in first-episode schizophrenia. Psychopathology. 2001; 34:8–14.

    Article  PubMed  Google Scholar 

  45. Nelson B, Yung AR, Bechdolf A, McGorry PD. The phenomenological critique and self-disturbance: implications for ultra-high risk ("prodrome") research. Schizophrenia bulletin. 2008; 34(2):381–92. doi:10.1093/schbul/sbm094.

    Article  PubMed  Google Scholar 

  46. Louet E, Consoli A, Lucanto R, Duplant N, Bailly-Salin MJ, Lemoigne A et al. Psychodynamic-oriented psychological assessment predicts evolution to schizophrenia at 8-year follow-up in adolescents hospitalized for a manic/mixed episode: interest of an overall subjective rating. Journal of physiology, Paris. 2010; 104(5):257–62. doi:10.1016/j.jphysparis.2010.08.004.

    Article  PubMed  Google Scholar 

  47. Kalla O, Wahlström J, Aaltonen J, Holma J, Tuimala P, Mattlar C-E. Rorschach characteristics and comparison of first-episode psychotic patients in Finland and Spain. Rorschachiana. 2004; 26:63–84.

    Article  Google Scholar 

  48. Ilonen T, Taiminen T, Karlsson H, Lauerma H, Leinonen K-M, Wallenius E et al. Diagnostic efficiency of the Rorschach schizophrenia and depression indices in identifying first-episode schizophrenia and severe depression. Psychiatry research. 1999; 87:183–92.

    Article  CAS  PubMed  Google Scholar 

  49. Billig O, editor. Spatial structure in schizophrenic art. 5th International Colloquium of Psychopathology of Expression. Psychiatry and art: Art interpretation and art therapy.; 1969; Los Angeles, CA: Karger.

  50. Amos SP. The diagnostic, prognostic, and therapeutic implications of schizophrenic art. The Arts in Psychotherapy. 1982; 9(2):131–1443.

    Article  Google Scholar 

  51. Small L. Neuropsychodiagnosis in psychotherapy. New York: Brunner/Mazel; 1973.

  52. Harrower MR. The most unpleasant concept test. A graphic projective technique for diagnostic and therapeutic use. In: Hammer EF, editor. The clinical application of projective drawings. 6th ed. Springfield, IL: Charles C. Thomas Publisher; 1958/1980. p. 365–90.

    Google Scholar 

  53. Weiner IB. Psychodiagnosis in schizophrenia. New York, NY: John Wiley; 1966.

  54. Ogdon DO. Psychodiagnosis and personality assessment: a handbook. 2nd ed. Los Angeles, CA: Western Psychological Services; 1977.

  55. Arieti S. Interpretation of schizophrenia. 2nd ed. New York: Basic Books; 1958/1974.

  56. Hammer EF. Recent variations of the projective drawing techniques. In: Hammer EF, editor. The clinical application of projective drawings. 6th ed. Springfield, IL: Charles C. Thomas Publisher; 1958/1980. p. 391–480.

    Google Scholar 

  57. Goodman Evaskus M. The Goodman battery. In: Hemphill BJ, editor. The evaluative process in psychiatric occupational therapy. Tohorfare, NJ: Slack, Inc.; 1982. p. 85–126.

    Google Scholar 

  58. Hammer EF. Projective drawings. In: Rabin AI, editor. Assessment with projective techniques: a concise introduction. New York, NY: Springer; 1981.

  59. Wenck LS. House-tree-person drawings: an illustrated diagnostic handbook. Torrance, CA: Western Psychological Services; 1970.

  60. Rabin AI. Projective methods: a historical introduction. In: Rabin AI, editor. Assessment with projective techniques: a concise introduction. New York, NY: Springer; 1981. p. 1–22.

  61. Slade M. 100 ways to support recovery: a guide for mental health professionals rethink recovery series, vol 1. London: UK: Author; 2009.

Download references

Acknowledgments

We would like to thank Dr. Howard Margolese Associate Professor, Department of Psychiatry, Faculty of Medicine, McGill University, for his contribution in recruiting participants.

Author information

Authors and Affiliations

  1. School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir-William-Osler, Montreal, Quebec, H3G 1Y5, Canada

    Hiba Zafran

  2. Institute of Community and Family Psychiatry, Jewish General Hospital, 4333 Côte St-Catherine Road, Montreal, Quebec, H3T 1E4, Canada

    Hiba Zafran

  3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Jewish Rehabilitation Hospital, 3205 Place Alton Goldbloom, Laval, Quebec, H7V 1R2, Canada

    Barbara Mazer

  4. School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir-William-Osler, Montreal, Quebec, H3G 1Y5, Canada

    Barbara Mazer

  5. School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir-William-Osler, Montreal, Quebec, H3G 1Y5, Canada

    Beverlea Tallant

  6. School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir-William-Osler, Montreal, Quebec, H3G 1Y5, Canada

    Gevorg Chilingaryan

  7. Feil & Oberfeld/ CRIR Research Centre, Centre intégré de santé et de services sociaux de Laval, Hôpital juif de réadaptation, 3205, Place Alton-Goldbloom, Laval, Québec, H7V 1R2, Canada

    Gevorg Chilingaryan

  8. School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir-William-Osler, Montreal, Quebec, H3G 1Y5, Canada

    Isabelle Gelinas

  9. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Jewish Rehabilitation Hospital, 3205 Place Alton Goldbloom, Laval, Quebec, H7V 1R2, Canada

    Isabelle Gelinas

Authors
  1. Hiba Zafran
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Barbara Mazer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Beverlea Tallant
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gevorg Chilingaryan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Isabelle Gelinas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hiba Zafran.

Ethics declarations

Funding

This study was funded by a doctoral grant awarded by the Canadian Occupational Therapy Foundation.

Conflict of interest

The authors declare that they have no conflict of interest

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zafran, H., Mazer, B., Tallant, B. et al. Detecting incipient schizophrenia: a validation of the Azima battery in first episode psychosis. Psychiatr Q 88, 585–602 (2017). https://doi.org/10.1007/s11126-016-9482-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11126-016-9482-7

Keywords

Search

Navigation