The Psychosis Work Group, of which the authors are members, will complete work in 2012. Final recommendations must be reviewed and approved in order for full text to go to publisher by January 1, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) will appear in print in May, 2013. Much remains to be done…
8. Attenuated psychosis syndrome is a controversial consideration for a new disorder. Whereas the validity of the condition is fairly established and the criteria require distress, disability, dysfunction, and help seeking, the reliability of the category in clinical practice has not yet been established and there is concern that the boundaries of the definition may be broader in application than in criteria. Referral to the appendix may be the optimal outcome, but much discussion and analysis of field trial data remains before a recommendation is made.
I may be over-reading this, but "… the reliability of the category in clinical practice has not yet been established and there is concern that the boundaries of the definition may be broader in application than in criteria. Referral to the appendix may be the optimal outcome …" perked up my mood considerably. For the last three or four days, I’ve been rereading the studies by the various groups that are working on the detection of preSchizophrenia [my term] and I can’t find a mind-set that helps me understand why the Attenuated Psychosis Syndrome is still under consideration as a diagnostic category for the DSM-5. Reading these studies and thinking about my own experience, I applaud the effort, but I don’t think they’re there yet. They do reasonably well in their small pilot studies, but as soon as they try to go large with a multi-center clinical trial, they have a flop. It happened to Dr. McGorry’s Group in Australia and recently to Dr. Morrison’s Group in Manchester UK.
Dr. Carpenter, one of the authors of that Editorial published on-line last week, is the head of the DSM-5 Workgroup considering the diagnosis of the Attenuated Psychosis Syndrome [formerly the Psychosis Risk Syndrome]. I’ve been worried that they were on such a one-track trajectory that they wouldn’t put on the brakes even in the face of these recent failed studies. Recall that it was a conversation between Dr. Carpenter and Dr. Allen Frances about this diagnosis that brought Dr. Frances out of retirement to challenge the whole DSM-5 enterprise [Wired: Inside the Battle to Define Mental Illness]. And this issue has been at the center of a much larger debate, the over-medication of psychiatric patients – a debate that has continued in one form or another since the medications started becoming available half a century ago.
While I disagree a bit with #8. in that it implies that the criteria are established, but the problem is that they may well be overused, I agree [with enthusiasm] with keeping it out of the DSM-5 as a criteria and putting it somewhere else – appendix, research, etc. And I’m glad to see it in print that Dr. Carpenter sees that as the "optimal outcome." My disagreement with #8. is that I don’t agree that the criteria are established yet.
In my Internet wanderings while I was reading the studies, I ran across a Schizophrenia Bulletin that memorialized Bleuler’s
Dementia Praecox and the Group of Schizophrenias published 100 years ago. There was an article in it by Danish psychiatrist,
Josef Parnas, called
A Disappearing Heritage: The Clinical Core of Schizophrenia. If you read it, you might think something like, "Oh lordy, lordy. That guy is nuts!" Or even, "Oh lordy, lordy. 1boringoldman is nuts!" for even recommending it. But I actually think it suggests a possible explanation for why this line of research has gone so oddly. The people who are working on this are experienced clinicians and they’re convinced that Schizophrenia is predictable. And so they do a pilot study and have some fairly decent success. Then they plan a big study involving lots of centers, design research proposals, and come up with a dry run. And the more people get interested in the topic, the less the overall success. There’s even speculation that the incidence of transition is falling. In a recent meta-analysis by Paolo Fusar-Poli et al, they said:
Our analysis of the potentially confounding effect of publication year revealed a small but significant decrease in the reported transition risks over time. This is in line with the recent suggestion that transition risks to psychosis in HR samples may be decreasing.31 One possible explanation is that more recent studies are recruiting individuals who would have made a transition to a psychotic disorder had it not been for the effect of clinical engagement…
I would offer an alternative explanation. The experienced clinicians are in on the ground floor and are diagnosing these patients intuitively [more than they know] based on long experience with Schizophrenic people. As more [and less experienced] clinicians get involved in the studies and the protocols become increasingly objective, the intuitive factor falls out of the equation and their success rate falls with the change. So the old guys are sure it can be predicted and have early successes but they can’t take the show on the road. They can’t pass on their intuition.
I base this impression on three things. First, I’m an old guy and I think I could do it too. Second, I had a case. I wrote about her before. She wouldn’t have fit any version of the criteria listed but I knew what was coming, and it did [1. from n equals one…, 2. from n equals one…, 3. from n equals one…]. The third thing is that I grew up with a guy, and lost track of him after elementary school. He reappeared in my medical school in the class behind me and lived in the same place I did. A few months after he started, I was on the phone to my home town calling his Dad to come quickly because he had a flagrant Schizophrenic Break that seemed to come up in the course of two days. Everyone in the fraternity house was stunned – but I wasn’t. There had always been something wrong, and it wasn’t in those criteria either. I’m not suggesting "old guys" as screeners, but I do think these researchers are going to have to apply a lot more creativity in their attempts to further their research – figuring out how to quantify what’s essential in this diagnosis. I don’t personally think the simple symptom list method is ever going to cut it.
My speculations aside, I really hope that editorial by Dr. Carpenter expresses the way this diagnosis is going to go. Even someone like me who thinks that someday Schizophrenia will be predictable is opposed to including it.
Dr. Allen Frances is correct to worry about inappropriate medication and I’m glad he rose to the challenge –
Frances didn’t want to be “a crusader for the world,” he says. But the idea of more “kids getting unneeded antipsychotics that would make them gain 12 pounds in 12 weeks hit me in the gut. It was uniquely my job and my duty to protect them. If not me to correct it, who? I was stuck without an excuse to convince myself.”
– but there’s more reason than that to oppose the inclusion of this category. They just are not there…
Re your med school classmate, I am wondering if you noticed behaviors in elementary school that seemed (in hindsight) to be predictive of future difficulty. If that’s the case, what sorts of behaviors did you notice?
He was formal, unpredictable. He had temper outbursts that were frightening. But there was a sense of unconnectedness that you could feel. He wasn’t “odd” as in “off beat,” but he was nonetheless odd. Back then, I knew nothing, had never heard of Schizophrenia, but I gave him a wide berth. He had plenty of acquaintances, but I don’t recall him having “pals.” It was the same way later in Med School. Over the years, I periodically asked myself the same question you’re asking, “What was it about him?”
Many years later, before I actually started psychiatric training, I was reading something about the history of psychiatry and read that the early psychiatrists were called “alienists.” I immediately thought of him – something like “That’s it. He felt alien.” Even later, I remembered him when I read about the “praecox feeling ” that I mentioned [A Disappearing Heritage: The Clinical Core of Schizophrenia] which is the subjective experience that goes with these inadequate words.
I don’t think of it as mystical. I think of it as a not easily explained dysjunctive non-verbal metacommunication – like listening to a singer who is a quarter tone off singing in a minor key. The emotional communication doesn’t fit – is eerie and disquieting.
how come an official statement by DSM 5 officials is published in a proprietary journal and not open access on the American Psychiatric Association DSM 5 website?
Jazmo,
Excellent point. I have no idea. I didn’t find it from a reference either. I entered Carpenter W in pubmed because I was curious what he’d published. It said:
Re: intuition and the “old guys” Intuitiveness in the helping professions is more the ability to use integrated, subconscious assessments which appear almost spontaneous and uncanny. That level of expertise gets developed with extensive patient contact which involves much more than brief rudimentary “symptom assessment”. How will the 15 minuters ever develop the “old guy” intuitiveness?
I don’t think they will, and furthermore, I think that a lot of physicians across practice domains, are rapidly losing that growth and development of wisdom and expertise. Patients are surely losers, along with the loss of the sense of professional wisdom.
Errrr…. if criteria are “well established” but do not have clinical validity, doesn’t that make them theoretical? There are endless numbers of pre-emergence psychiatric syndromes we may posit in theory. Ultimately, everyone has one.
It’s starting to look like antidepressants have created an entirely new class of bipolar disorders that are rapid cycling, with treatment resistant depressions. The possiblity that the preventive use of anti-psychotics and anti-depressants might make psychosis worse and harder to treat should not be taken lightly.