ادراکات پزشکان از سندرم روان پریشی ضعیف شده

The “Attenuated Psychosis Syndrome” (APS, sometimes referred to as the “schizophrenia prodrome”) is characterized by subthreshold psychotic-like symptoms and functional decline, and is often associated with significant disability. These symptoms may cause impairment and are of further interest due to their predictive relation to schizophrenia and other psychotic disorders. These symptoms currently are not represented in the diagnostic system for mental health, and it is unclear how they are conceptualized by relevant professionals. The current study surveyed a national sample (n = 303) of clinical psychologists, psychiatrists, and general practitioners regarding their clinical appraisal of APS. Practitioners were asked to respond to vignettes representing three conditions: psychosis, subthreshold psychosis (indicating ‘attenuated’ psychosis symptoms), and no psychotic symptoms. Practitioners' responses suggested that APS is viewed consistently with a DSM-IV-TR defined mental disorder and that most clinicians may diagnose this condition as a full threshold psychotic disorder. Findings tentatively suggest that the inclusion of an attenuated psychosis symptoms category in the forthcoming DSM-5 may be helpful in improving diagnostic reliability and facilitating best practice among community practitioners.

Among those who develop schizophrenia, approximately 70–90% experience attenuated psychotic symptoms prior to meeting diagnostic criteria for the disorder (Yung and McGorry, 1996, Häfner and an der Heiden, 1999 and Compton et al., 2009). Recently, the DSM-5 Psychotic Disorders Workgroup coined the term “Attenuated Psychosis Syndrome” (APS) to characterize subthreshold positive symptoms (e.g., unusual thought content, suspiciousness, perceptual disturbances) that co-occur with distress and/or disability (American Psychiatric Association, 2011). Though APS does not inevitably signal an impending psychotic break, attenuated symptoms may predict psychosis onset and cause functional decline (Yung et al., 2010). A growing body of literature documents the disability often associated with attenuated psychotic symptoms. Researchers have reported average Global Assessment of Functioning (GAF) scores of 60.5, 40, and 37 in samples of those with attenuated psychotic symptoms, indicating notable impairment (Miller et al., 2003 and Yung et al., 2003). In a study comparing quality of life among individuals with psychosis, attenuated psychosis, and no symptoms, Bechdolf (Bechdolf et al., 2005) found that the attenuated psychosis group reported the poorest quality of life. Preda (Preda et al., 2002) found that 90% of individuals meeting criteria for APS had prior treatment history, suggesting high frequency of help-seeking behavior in this population. Recent research efforts (Cannon et al., 2008 and Klosterkötter, 2008) have focused on conceptualizing the period of attenuated symptoms that often precedes psychosis onset. Researchers have developed reliable instruments to identify those at heightened risk for developing psychotic disorders, with rates of psychosis onset ranging from 14% to 54% over a one to two year period among individuals determined to be ‘high risk’ according to various paradigms (Klosterkötter et al., 2001, Miller et al., 2003, Yung et al., 2005, Cannon et al., 2008, Nelson and Yung, 2010 and Ruhrmann et al., 2010). In addition, researchers tested promising treatments for APS that may reduce associated distress and delay or prevent the onset of psychosis (McGlashan et al., 2006, Compton et al., 2007, Morrison et al., 2007, McGorry et al., 2009 and Amminger et al., 2010). Advances in identification and treatment of APS are also important as shorter duration of untreated psychosis (DUP) has been associated with better long-term prognosis in schizophrenia (Marshall et al., 2005). Despite this potential for improved treatments and outcomes, advances in research are not yet incorporated into the diagnostic system for mental disorders. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revision (DSM-IV-TR) ( American Psychiatric Association, 2000) defines the term ‘psychotic’ loosely, referring simply to “the presence of certain symptoms” (i.e., delusions, hallucinations, and disorganization symptoms). The DSM-IV-TR acknowledges the existence of “prodromal” and “residual” periods in which individuals “may express a variety of unusual or odd beliefs; they may have unusual perceptual experiences; their speech may be generally understandable but digressive, vague, or overly abstract or concrete; and their behavior may be peculiar but not grossly disorganized” (2000; p. 302). Though it contains this description of attenuated psychotic symptoms within the section on schizophrenia, the DSM-IV-TR gives clinicians no diagnosis which uniquely captures the construct. Attenuated symptoms are restricted to a subset of personality disorders (e.g., schizotypal personality disorder), which are, by definition, “stable over time.” APS, in contrast, can result in various outcomes, and often precedes further deterioration into psychotic symptoms ( Yung et al., 2010). Despite the evidence that individuals experiencing APS exist and seek treatment in community settings, there is no diagnostic category appropriate for this group. It is unclear how community providers diagnose or conceptualize individuals with APS. Assessment tools for the identification of APS have been employed in tightly controlled research contexts (Miller et al., 2003 and Yung et al., 2005), but little is known about providers' perspectives on such cases in real-world practice. Technically, meeting criteria for APS alone would not warrant a formal diagnosis under the current classification system, yet this syndrome indicates current impairment and implies future risk. As such, in many mental health systems, an individual with APS would not be afforded care or future monitoring. Alternatively, clinicians might lower diagnostic thresholds in order to diagnose someone experiencing APS with a full psychotic disorder. In these cases, treatments would likely be made available, but the recommended treatments might be inappropriate for APS clients. APS creates a predicament for clinicians, who lack a diagnostic label for these clients. Understanding how practitioners approach the current diagnostic dilemma related to APS may contribute to the ongoing debate regarding the potential inclusion of an attenuated psychosis risk category in DSM-5 (Carpenter, 2009, Corcoran et al., 2010 and Yang et al., 2010). The current study examines how providers perceive and diagnose APS. Clinicians were asked to read vignettes depicting individuals with different levels of psychotic-like symptoms and provide diagnostic impressions. Given the impairment associated with APS, it was hypothesized that clinicians would lower the DSM-IV-TR threshold for psychosis to incorporate cases illustrating APS into the schizophrenia spectrum class of disorders.