\nDSM-5 Status of Psychotic Disorders: 1 Year Prepublication<\/font><\/strong><\/u><\/a>
EDITORIAL<\/font><\/strong>
by Rajiv Tandon and William T. Carpenter, Jr.<\/sup>
Schizophrenia Bulletin<\/font><\/strong>. 2012 38[3]:369–370.
EPub April 13, 2012<\/sup><\/div>\n<\/p>\n
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…<\/p>\n8. 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.<\/sup><\/div>\n<\/blockquote>\n
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 …<\/em><\/font><\/strong>" 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<\/em> [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. <\/div>\nDr. 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<\/em> [formerly the Psychosis Risk Syndrome<\/em>]. 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<\/font><\/strong><\/u><\/a>]. 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.<\/p>\n
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<\/font><\/strong><\/em>." My disagreement with #8. is that I don’t agree that the criteria are established yet. <\/p>\n
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<\/em> published 100 years ago. There was an article in it by Danish psychiatrist, Josef Parnas<\/span>, called A Disappearing Heritage: The Clinical Core of Schizophrenia<\/font><\/strong><\/em><\/u><\/a>. 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:<\/div>\n\n
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…<\/sup><\/div>\n<\/ul>\nI 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. <\/div>\nI 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<\/em>…<\/font><\/a><\/strong><\/u>, 2. from n equals one<\/em>…<\/font><\/a><\/strong><\/u>, 3. from n equals one<\/em>…<\/font><\/a><\/strong><\/u>]. 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<\/em> method is ever going to cut it. <\/p>\n