The DSM-5 proposal for attenuated psychosis syndrome: a history

Abstract

This article narrates a consensus history of the proposal to include diagnostic criteria for a psychosis risk syndrome in the DSM-5, in part, to document what happened, but also to potentially help focus future efforts at clinically useful early detection. The purpose of diagnosing a risk state would be to slow and ideally prevent the development of the full disorder. Concerns about diagnosing a psychosis risk state included a high false positive rate, potentially harmful use of anti-psychotic medication with people who would not transition to psychosis, and stigmatization. Others argued that educating professionals about what ‘risk’ entails could reduce inappropriate treatments. During the revision, the proposal shifted from diagnosing risk to emphasizing current clinical need associated with attenuated psychotic symptoms. Within the community of researchers who studied psychosis risk, people disagreed about whether risk and/or attenuated symptoms should be an official DSM-5 diagnosis. Once it became clear that the DSM-5 field trials did not include enough cases to establish the reliability of the proposed criteria, everyone agreed that the criteria should be put in a section on conditions for further study rather the main section of the DSM-5. We close with recommendations about some practical benchmarks that should be met for including criteria for early detection in the classification system.

Clinical, Brain, and Multilevel Clustering in Early Psychosis and Affective Stages

“…These considerations are important because the study suggests differential preventive approaches 3 that can be personalized; for example, universal neurodevelopmental interventions for brain subgroups 80 vs specific, indicated prevention for clinical subgroups. 3 Within this context, it is important to note that, rather than replacing existing reference frames (eg, CHR-P vs ROP), the results clarify boundaries between health, high risk, and illness [48][49][50] by identifying additional multidimensional targets and subgroups that may enhance care. 3,21 Limitations Attempts to divide individuals in early, minimally treated illness are difficult because the solution will represent a single snapshot at a time of substantial change (eg, for the positive symptoms and depressive subgroups).…”

“…47 Thus, studies are needed to examine the heterogeneity separately prior to combination. Existing studies have also been conducted in chronic cohorts, which does not explore potential premorbid vulnerability and ignores normative variation that is suspected across symptom [48][49][50] and biological 14,44,51 levels. As such, we aimed to further develop a multilevel data-driven technique originally defined in cancer genomics [52][53][54][55] to cluster, compare, and combine clinical and brain clustering solutions (ie, levels) in those with CHR-P, ROP, ROD, and in healthy control groups.…”

What is a mental disorder? An exemplar-focused approach

“…Attenuated psychosis syndrome (APS), which is associated both with evidence of psychobiological dysfunction and potential harm in the case of conversion, was included in DSM-5 as a condition for further study (Tsuang et al, 2013 ). APS elicits concerns about overdiagnosis, mainly due to the possibility that interventions for individuals who meet the criteria may cause harm (Zachar, First, & Kendler, 2020 ). There are some parallels between APS and other risk-syndromes such as hypercholesterolaemia or hypertension.…”

The Mini-SIPS: development of a brief clinical structured interview guide to diagnosing DSM-5 Attenuated Psychosis Syndrome and training outcomes

“…Approximately ten years ago, the American Psychiatric Association DSM-5 Task Force and its Psychotic Disorders Workgroup engaged in an extensive evaluation of the reliability, validity, and utility of the CHR construct and elected to include the most common of the three CHR syndromes [ 12 , 13 ] in the manual as a condition for further study, the Attenuated Psychosis Syndrome (APS) [ 14 ]. Criteria for DSM-5 APS are similar to those for SIPS Attenuated Positive Symptom Syndrome but also require both distress and impairment.…”