1 Boring Old Man

Should Attenuated Psychosis Syndrome Be a DSM-5 Diagnosis?
^{by William T. Carpenter, M.D. and Jim van Os, Ph.D.}
American Journal of Psychiatry 2011 168:460-463.

^{The best hope for secondary prevention of the often devastating course of psychotic disorders resides in early detection and intervention when individuals first develop symptoms. There is sufficient evidence for attenuated psychosis syndrome as a clinical syndrome with predictive validity to establish this diagnostic class. There is much that clinicians can and should do for care-seeking individuals with distress and dysfunction who manifest early psychotic-like psychopathology. A new DSM-5 diagnosis can focus attention on this syndrome and stimulate the creative acquisition of new knowledge that may be life altering for afflicted persons. There is little reason to rely on less specific diagnostic categories, such as anxiety and depression, if we can reliably give patients and their families a more informative picture of their situation.}
^{—William T. Carpenter}

^{The best hope for early intervention in psychotic disorders resides in public health measures for the population as a whole rather than in attempts to diagnose risk in individuals for what will be a low incidence of future psychosis. Making services more accessible, providing general diagnostic training to primary care workers, and creating community awareness will make the filters on the pathway to mental health treatment more permeable for people with early psychotic symptoms in need of care. Individual treatment should be initiated early but when it is indicated, as when criteria are first met for psychotic disorder not otherwise specified. Creating a diagnostic class that does not unambiguously define a specific group, treatment, or outcome does not add value for patients and their families.}
^{—Jim van Os}

^{The DSM-5 Psychosis Work Group, of which we are both members, is considering attenuated psychosis syndrome as a new diagnostic category. The proposed category reflects the clinical observation that many adolescents and young adults who eventually develop psychotic disorders such as schizophrenia first manifest less severe but still troubling psychotic symptoms in a several-year prodrome before the onset of more severe illness. Although not all individuals with these attenuated symptoms will develop a lifelong psychotic illness, the presence of such symptoms appears to confer a higher risk. An axiom of most medical practice is that early detection and treatment constitute an essential strategy to prevent more serious consequences of illness. However, there is as yet no consensus that this new diagnosis will be helpful in that regard. In this brief commentary we note some of the more controversial points…}

Field Testing Attenuated Psychosis Syndrome Criteria
^{by Judith Rietdijk, M.Sc., Don Linszen, M.D., Ph.D., Mark van der Gaag, Ph.D.}
American Journal of Psychiatry 2011 168:1221-1221.

^{To the Editor: Attenuated psychotic symptoms that manifest before the first psychotic episode of schizophrenia are an important and challenging subject in the field of psychosis. In a commentary in the May 2011 edition of the Journal, Dr. William Carpenter and Dr. Jim van Os discussed whether or not attenuated psychosis syndrome should be a DSM-5 diagnosis. At issue is that the proposed diagnosis has been made only in research settings attracting ill individuals at rates disproportionate to the overall population; it is not clear whether field testing outside these settings would result in the same conversion rates.}

^{At Parnassia Psychiatric Institute in The Hague, we recently completed a multicenter study on the implementation of a screening method for at-risk mental states in all consecutive help-seeking patients accessing community mental health services for nonpsychotic mental disorders…}

^{Of 3,671 consecutive patients, we identified 52 [1.4%] with psychotic symptoms and 147 [4.0%] with at-risk mental states in whom the nontrained community mental health caretakers managing their care recognized neither psychotic states nor attenuated psychotic symptoms. Thus, these patients went undetected by the community caregivers who should in fact be among the important referrers to specialized clinical research settings. In short, these patients are missed in the traditional referral process.}

^{On the other hand, our screening detected patients who later developed other severe psychopathology. This suggests that the at-risk group may develop multiple severe illnesses besides psychotic disorders, and it offered us the opportunity to destigmatize mental illness for them. We tell our at-risk patients that they rightly sought help because of a risk for developing severe mental illness in the future. We never mention psychosis because we have found the at-risk group to be very sensitive to the notion of psychotic syndromes. In therapy we explain how dopamine sensitization affects perception, cognitive biases, and affect, and we find that patients are less distressed by their symptoms after receiving this information.}

^{In the future, we should develop reliable screening and detection methods with greater sensitivity and specificity in order to detect at-risk mental state populations with higher true incidences of severe illness. We recommend the nonstigmatizing name “pluripotent dopamine sensitization risk syndrome.”}

^{The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition to the Disorder…}

^{Because the DSM-III is generally atheoretical with regard to etiology, it attempts to describe what the manifestations of the mental disorders are…}

^{This approach can be said to be "descriptive" in that the definitions of the disorders generally consist of descriptions of the clinical features of the disorders…}

Why is DSM being revised?
DSM has been periodically reviewed and significantly revised since the publication of DSM-I in 1952. Particularly over the past two decades, there has been a wealth of new information in neurology, genetics and the behavioral sciences that dramatically expands our understanding of mental illness. Researchers have generated a wealth of knowledge about the prevalence of mental disorders, how the brain functions, the physiology of the brain and the lifelong influences of genes and environment on a person’s health and behavior.  Moreover, the introduction of scientific technologies, ranging from brain imaging techniques to sophisticated new methods for mathematically analyzing research data, have given us new tools to better understand these illnesses.

Back in 1980, the DSM-III was intended to be something like a compass. It was meant to point the way away from ideology to descriptive science, and I expect Dr. Spitzer and friends thought that it would iterate towards a mutually acceptable base, similar to the medical classification of diseases – something that would knit psychiatrists of different ilks and other mental health disciplines into a cohesive unit in the treatment of mental illnesses. It has certainly not succeeded. Now we hear about advances in neuroscience, implications for the future, impacts on the family, and fictitious explanations – but not much about signs and symptoms of disease. When Dr. Frances first began to write about the DSM-5 in Distress, he was accused of being stuck on his version and being territorial. Frankly, it initially seemed a reasonable claim. But as time has passed, he has been beyond vindicated on that charge. We’re in his debt for alerting up to how far off the beam the whole enterprise was.