Attenuated Psychosis Syndrome: Not Ready for Prime Time

The DSM-5 Psychotic Disorders Work Group has proposed a new diagnosis called “attenuated psychosis syndrome” (APS) for people with subthreshold psychotic experiences (eg, hallucinations or delusions) if their symptoms do not meet criteria for a threshold psychotic disorder, they are distressed/impaired by these symptoms, and their psychotic experiences cannot be better explained by another disorder. With my coauthor, Mark Zimmerman, MD, I conducted one of the first investigations of the prevalence of APS in a general psychiatric outpatient clinic sample (N = 1,257).¹ Even after excluding those with psychotic disorders based on diagnostic interview, 28% of patients self-reported at least 1 current attenuated psychotic experience, and rates were similar across all major diagnostic categories. Only 1 patient (0.08%) reported attenuated symptoms but did not meet criteria for another current disorder; however, this individual endorsed other nonpsychotic symptoms of greater severity and thus was not a good candidate for APS. Our study demonstrated little, if any, clinical utility for the APS diagnosis when applied to a general psychiatric sample.

The psychosis research community has been deeply divided over the merits of the APS diagnosis for several years. When I began the study, it was not clear whether APS would be included in the DSM main text or in the appendix. Currently, the diagnosis is being considered for the appendix because subsequent field testing could not confirm the reliability of the criteria.² The stated purpose of including new syndromes in the appendix is to stimulate further research. Thus, I do not think that the APS diagnosis is an idea that many clinicians and researchers are motivated to abandon anytime soon. I also think that including APS in the DSM, even in the appendix, might spur some clinicians to use it either explicitly or implicitly to guide their treatment decisions.

There are 2 potential ways that an APS diagnosis could negatively affect patients and their families. First, it would essentially lower the threshold for designating someone as being potentially psychotic (or being at risk for future psychosis). A major concern is that the vast majority of people with attenuated psychosis never develop a threshold psychotic disorder.³ Proponents of recognizing APS in clinical practice state that medication treatment would not be required and might not even be recommended. However, the realities of clinical practice include the lack of resources for behavioral interventions and/or the time and money to pay for them, especially in primary care settings. This dearth of available behavioral interventions would make it likely that many more patients identified as having APS, or even some of the symptoms, would be prescribed antipsychotic medications. Of particular concern is that research suggests that antipsychotics do not have favorable risk-benefit profiles for this group.⁴

In addition, the APS diagnosis could lead to increased stigma and discrimination if more patients are labeled as having a psychotic-spectrum diagnosis. The traditional DSM psychotic disorders apply only to a relatively small percentage of the population. Our study, however, demonstrated that a substantial proportion of patients with common depressive or anxiety disorders could be viewed as having “attenuated” psychotic symptoms, depending on the way the clinician is inclined to interpret them. Thus, if applied in routine clinical practice, the APS diagnosis could lead to an explosion of new people identified as having a psychotic-spectrum disorder, similar to the previous expansion in the rate of bipolar disorder after criteria were modified in previous versions of the DSM. The law of unintended (but predictable) consequences suggests that including APS in the DSM-5 could create a major new public health problem if researchers and clinicians do not proceed with caution.

Financial disclosure:Dr Gaudiano had no relevant personal financial relationships to report.

References

1. Gaudiano B, Zimmerman M. Prevalence of attenuated psychotic symptoms and their relationship with DSM-5 diagnoses in a general psychiatric outpatient clinic [published online ahead of print October 2, 2012]. J Clin Psychiatry. doi:104088/JCP12m07788. Full Text

2. Regier DA, Narrow WE, Clarke DE, et al. DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses [published online ahead of print October 30, 2012]. Am J Psychiatry. doi:10.1176/appi.ajp.2012.12070999. PubMed

3. van Os J, Linscott RJ, Myin-Germeys I, et al. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychol Med. 2009;39(2):179–195. PubMed

4. Carpenter WT, van Os J. Should attenuated psychosis syndrome be a DSM-5 diagnosis? Am J Psychiatry. 2011;168(5):460-463. PubMed