Despite advances in the treatment of schizophrenia over the past half-century, the illness is frequently associated with a poor outcome. This is principally related to the late identification and intervention in the course of the illness by which time patients have experienced a substantial amount of socio-occupational decline that can be difficult to reverse. The emphasis has therefore shifted to defining psychosis-risk syndromes and evaluating treatments that can prevent transition to psychosis in these ultra-high risk groups. To consider the appropriateness of adding psychosis risk syndrome to our diagnostic nomenclature, the psychotic disorders work group extensively reviewed all available data, consulted a range of experts, and carefully considered the variety of expert and public comments on the topic. It was clear that reliable methods were available to define a syndrome characterized by sub-threshold psychotic symptoms (in severity or duration) and which was associated with a very significant increase in the risk of development of a full-fledged psychotic disorder (schizophrenia spectrum, psychotic mood disorder, and other psychotic disorders) within the next year. At the same time, the majority of individuals with “attenuated psychotic symptoms” had one or more other current psychiatric comorbid conditions (usually mood or anxiety disorders, substance use disorder; Fusar-Poli 2012) and exhibited a range of psychiatric outcomes other than conversion to psychosis (significant proportions either fully recover or develop some other psychiatric disorder, with a minority developing a psychotic disorder). Although the reliability of the diagnosis is well established in academic and research settings, it was found to be less so in community and other clinical settings. Furthermore, the nosological relationship of attenuated psychosis syndrome (APS) to schizotypal personality disorder and other psychiatric conditions was unclear. Further study will hopefully resolve these questions. The work group decided to recommend the inclusion of attenuated psychosis syndrome as a category in the appendix (Section 3) of DSM-5 as a condition for further study.
Despite therapeutic advances over the past half-century, schizophrenia continues to be a debilitating disorder with profound lifelong impairments in social and vocational functioning for most of those with the condition (Cornblatt et al. 2007). Much of the decline occurs early in the course of the illness, and overall outcome is directly correlated with functional ability prior to onset of psychosis and inversely correlated with duration of untreated psychosis (Carpenter, 2009, Woods et al., 2010 and Boonstra et al., 2012). These facts have provided the impetus to early intervention efforts. Reducing treatment delay from the onset of the initial psychotic episode by early diagnosis and effective treatment has yielded only modest improvements in outcome for individuals with schizophrenia, however, leading to interest in possibilities for intervention even earlier in the course of the illness (i.e., before onset of psychosis; Fusar-Poli et al., 2013). This knowledge has led to interest from several centers, including the North American Prodromal Longitudinal Study (NAPLS, Cannon et al., 2007 and Addington et al., 2007), in developing early psychosis detection, intervention, and treatment programs.
In order to address this need and in light of improvements in outcome observed in various early psychosis intervention programs, the psychotic disorders work group considered the addition in DSM-5 of a new category of “psychosis risk syndrome” or “attenuated psychosis syndrome” to describe a condition with recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability. These patients also are at significantly increased risk of conversion to a full-blown psychotic disorder (Fusar-Poli et al., 2012a, Fusar-Poli et al., 2012b, Fusar-Poli et al., 2012c, Fusar-Poli et al., 2012d and Fusar-Poli et al., 2012e). Based on a review of the data relatively early in the process, it was realized that it may be premature to recommend a new category primarily based on future risk (i.e., “psychosis risk syndrome”) and not on current clinical need (Carpenter and van Os, 2011 and Tandon and Carpenter, 2012). Data revealed that a majority of individuals with this condition did not go on to develop a psychotic disorder and that most individuals with this condition had additional relevant clinical needs other than the risk of conversion to psychosis. Consequently, a condition that described current clinical need – attenuated psychosis syndrome (APS) – was considered instead. In contrast to “psychosis risk syndrome,” APS describes a currently relevant clinical condition leading to help seeking, with many more clinical outcomes other than conversion to psychosis. The main considerations with respect to APS involved matters of reliability of diagnosis in routine clinical settings and whether it had more validity and provided greater clinical utility than current classification systems ( Woods et al., 2009, Carpenter and van Os, 2011 and Tandon and Carpenter, 2012). The relationship of APS to related diagnostic categories such as schizotypal personality disorder was also evaluated. In addition to reviewing all available data, the psychotic disorders work group consulted a range of experts and considered a variety of public and expert comments on the topic.
