Short Report Psychopathology 2014;47:292–296 DOI: 10.1159/000365291
Received: March 24, 2014 Accepted after revision: June 17, 2014 Published online: July 10, 2014
Attenuated Psychosis Syndrome: Don’t Jump the Gun Barnaby Nelson Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Melbourne, Vic., Vic. , Australia
Key Words DSM · Psychosis · Prodrome · High risk
Abstract Attenuated psychosis syndrome (APS) was introduced in DSM-5 as a condition for further study. A number of concerns have been raised regarding APS, including its validity as a clinical entity, issues relating to stigma, the potential that it is an unnecessary diagnosis of what might be a self-limiting phase of attenuated psychotic symptoms, and treatment implications of the diagnosis. The current paper presents a number of conceptual and practical issues that should be addressed in deciding whether APS should be accepted as an official diagnosis in subsequent editions of DSM. These include the problem of transferring the established validity of ‘at-risk’ criteria to APS given some non-trivial differences between the criteria sets, the relationship between attenuated psychotic symptoms and other presenting non-psychotic disorders, the difficulties of operationalising the subthreshold or ‘attenuated’ concept in standard clinical practice, and the likelihood of the diagnosis leading to overprescription of antipsychotic medication for this group of patients. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0254–4962/14/0475–0292$39.50/0 E-Mail
[email protected] www.karger.com/psp
Attenuated psychosis syndrome (APS) was recently introduced in Section 3 (‘Emerging Measures and Models’) of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) [1] as a condition for further study. The decision to include it in Section 3 rather than in the main body of the text was based on inconclusive results from the DSM-5 field trials on the reliability of the diagnosis in clinical settings. The diagnosis was originally formulated as a risk syndrome (psychosis risk syndrome), but was reformulated as a self-contained syndrome requiring diagnosis and clinical care. APS is in its proper place as a condition requiring further research. It would have been premature to include APS as a DSM-5 diagnosis, not just due to the inconclusive results from the field trials. A number of concerns have been raised regarding its inclusion in the main body of DSM. These have included: • Potentially unnecessary unnecessary diagnosis diagnosis and treatment treatment of what might be a self-limiting phase of attenuated psychotic symptoms. • Concerns regarding stigma and discrimination discrimination associated with the diagnosis, particularly given that patients who would receive the diagnosis are subthreshold for psychosis and that their symptoms might resolve without treatment. Dr. Barnaby Nelson Orygen Youth Health Research Centre, Centre for Youth Mental Health University of Melbourne, Melbourne , 35 Poplar Road Parkville, VIC 3052 (Australia) E-Mail nelsonb @ unimelb.edu.au
• The possibility of its inclusion leading to increased prescription of antipsychotic medication for this group, a practice for which there is not good evidence, either as a preventative treatment or as a treatment for existing symptoms. • The validity of APS as a clinical entity. These issues have been thoroughly discussed elsewhere [e.g., 2, 3]. This article will briefly address the following: distress associated with APS; the relationship between attenuated psychotic symptoms and other presenting non-psychotic disorders; operationalising the subthreshold or ‘attenuated’ concept in standard clinical practice, and treatment implications.
Distress Associated with APS
The formulation of the syndrome requires that attenuated psychotic symptoms are the main source of clinical concern, i.e., that they are the source of distress or disability that motivates help-seeking. Criterion D of APS reads: ‘Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention.’ This criterion was partly introduced to guard against the potential problem of overdiagnosis and ‘diagnostic creep’ (the threshold for diagnosis gradually shifting in response to clinical practice, political lobbying and other social forces [4]). The requirement of the attenuated psychotic symptoms being a significant source of distress/ disability is not part of the current ultra-high risk/clinical high risk/prodromal criteria (hereafter, ‘at-risk’ criteria) on which the APS is based. Indeed, attenuated psychotic symptoms are frequently not the main source of distress or disability in this patient population [5]. Data from the PACE Clinic, Melbourne, indicates that attenuated psychotic symptoms were distressing for only 52% of ultrahigh risk patients, with social and other functional difficulties and depressive symptoms rating as the highest sources of distress and reason for help-seeking (78 and 50%, respectively) [6]. (This is why the ‘at-risk’ treatment manuals are deliberately broad in target [7, 8].) This observation is not clinic-specific, with other ‘at-risk’ clinics reporting a similar profile of patients [Fusar-Poli et al., pers. commun., 2014]. Chest pain has been used as an analogy for APS, because, as with chest pain, it is a symptomatic condition associated with a number of possible trajectories [2]. While this would seem to be an apt analogy, the pain often does not correspond to the attenuated psychotic symptoms in the ‘at-risk’ group but rather to other complaints. Attenuated Psychosis Syndrome
This ‘distress issue’ means that the formulation of APS does not map neatly onto the ‘at-risk’ criteria that formed the basis of the proposal in the first place and which are drawn upon as evidence for the validity of APS [9]. The patients who would attract the APS diagnosis are really only a subgroup of the broader ‘at-risk’ group (those who are distressed/disabled/help-seeking due to these symptoms). Validity and reliability should be established for this subgroup via follow-up and group comparison studies rather than relying on the validity and reliability of the broader ‘at-risk’ group established in research studies. Similarly, it is not logical to assume that phenomenological, neurocognitive or neurobiological markers of X (the ‘at-risk’ group), or the results of intervention studies in this group, also apply to ‘subgroup-X’ (APS) [10]. While one might assume that narrowing the diagnosis in this way creates a more nosologically valid clinical entity (and may identify a group at higher risk of transitioning over time from APS to full-threshold psychotic disorder), this needs to be empirically tested. In fact, preliminary data indicates that distress associated with attenuated psychotic symptoms or reason for referral being due to attenuated psychotic symptoms [5] does not correspond to higher risk for transition to psychotic disorder. The findings of Rietdijk et al. [11] are consistent with this. They found that at-risk patients ascertained via a traditional case-recruitment strategy, relying on referral when psychotic symptoms were suspected, resulted in lower transition rates to psychosis than sequential screening of a helpseeking population entering secondary mental health ser vices for non-psychotic problems. The former group corresponds more closely to APS than the latter group, in that the help-seeking/referral of this group was associated with the emerging psychotic symptoms as opposed to these symptoms being detected via screening and not necessarily being a significant source of distress or reason for help-seeking/referral. One possibility for dealing with this ‘distress issue’ is to add a specifier of ‘attenuated psychotic symptoms’ to the diagnosis that more accurately captures the person’s presenting complaint and source of distress. So, for example, a person presenting with clinical depression who also presents with attenuated psychotic symptoms could receive a diagnosis of ‘major depression with attenuated psychotic symptoms’. [The current ‘psychotic symptoms’ specifier refers to frank (or ‘full-threshold’) psychotic symptoms rather than to attenuated symptoms.] Another possibility, as suggested by some researchers [12], would be to revert to the risk syndrome notion but broaden it beyond psychosis to include multiple exit points (the Psychopathology 2014;47:292–296 DOI: 10.1159/000365291
293
‘pluripotential’ model), with treatment corresponding to stage of disorder in line with the clinical staging model [13]. This approach could capture people with a broader range of presenting complaints, with the distress not necessarily associated with the attenuated psychotic symptoms, or at least not to the same degree as other (nonpsychotic) complaints.
The Relationship between Attenuated Psychotic Symptoms and Non-Psychotic Disorders
A similar issue is the point that ‘reality distortions that are concomitant with borderline personality disorder’ [ 1, p. 786] should not contribute to an APS diagnosis. The approach at present in many ‘at-risk’ clinics is to rate presenting symptoms on the relevant assessment instruments purely on their phenomenology rather than on clinical formulation. The rationale for this is that at this very early stage of disorder it is not yet clear whether symptoms are part of the prodromal phase of an emerging disorder, such as a psychotic disorder, or represent an existing disorder, such as borderline personality disorder, or indeed are symptoms of comorbid disorders, such as concurrent psychotic disorder and borderline personality disorder. It is not clear why there should be a change of approach for DSM-5, particularly given data indicating that ‘at-risk’ patients with borderline personality disorder features are just as likely to transition to psychotic disorder as those who do not present with borderline personality disorder features [23]. As with point 1, this specification defines a narrower group than the ‘at-risk’ criteria without providing sufficient validation of this narrower construct.
Criterion E requires that the attenuated psychotic symptoms are not better explained by another mental disorder. The problem with this is that we have not yet achieved an adequate understanding of when attenuated psychotic symptoms occur in the context of non-psychotic disorders (and can therefore be ‘better explained’ by these disorders), as opposed to viewing these attenuated psychotic symptoms as ‘schizophrenia light’ [14]. A body of work indicates that psychotic symptoms are reasonably common in non-psychotic disorders [15–17] and substantial covariation of mood and psychotic symptoms exists in general population samples [18–20]. Wigman et al. [16] report data from a large sample where 27% of people Operationalising the Subthreshold or ‘Attenuated’ with anxiety and depressive disorders displayed one or Concept more psychotic symptom versus 14% in those without these disorders (OR = 2.23). Two community studies reThe operationalisation and implementation of the ported that a large majority of young people who report- subthreshold/attenuated concept presents a challenge reed psychotic symptoms had at least one non-psychotic lated to the issue of ‘diagnostic creep’ [24]. Specifically, axis-1 psychiatric disorder [17], indicating that psychotic how low is too low to be considered an attenuated psysymptoms commonly occur in the context of non-psy- chotic symptom? The current description of APS in chotic (‘neurotic’) conditions. Psychotic symptoms have DSM-5 lacks a clear operationalised definition of ‘attenubeen found to be strong markers of risk for multimorbid ation’. While cut-off points are provided in the research non-psychotic disorders, with their prevalence increasing instruments, such as the CAARMS and the SIPS, the in a dose-response fashion in relation to the number of judgement of the degree of ‘attenuation’ that is allowed axis-1 disorders [17, 21]. Given this body of work, how before an individual is below the APS threshold is a conexactly is a clinician to determine if the presenting at- stant challenge in the ‘at-risk’ clinical and research field. tenuated psychotic symptoms can be accounted for by It is questionable how reliably this decision could be made these other, non-psychotic disorders or are better under- in standard clinical practice, particularly when there may stood as an independent comorbid condition? Certainly be pressure to provide a diagnosis in order to access treatthe concept of basic self-disturbance has shown great ment and gain insurance coverage. promise as a specific phenotype of schizophrenia spectrum disorders and may be a useful concept for identifying when psychotic symptoms are indicative of schizoTreatment Implications phrenia spectrum disorders rather than non-psychotic disorders [22], but further work needs to be done before The concern has been raised that the APS diagnosis this construct (or other phenotypic or endophenotypic would lead to overprescription of antipsychotic medicamarkers) can be incorporated into routine clinical prac- tion in this group, in the absence of good evidence for the tice. effectiveness of antipsychotics, either as a treatment for 294
Psychopathology 2014;47:292–296 DOI: 10.1159/000365291
Nelson
existing symptoms or as a preventative treatment. This would mean exposing this group to the side effects of these medications, such as the potentially serious metabolic side effects, without delivering significant benefits (i.e., an unfavourable risk-benefit ratio). In response to this concern, the point has been made that introducing APS as a diagnosis would be accompanied by education and evidence-based treatment recommendations that may reduce rather than increase antipsychotic medication use in this group [25]. While this may be the case in some sectors it would seem rather optimistic that such education and treatment recommendations are likely to be terribly effective in the face of the substantial current overuse of antipsychotics in this group [26] and the widespread endorsement amongst practitioners that APS should be treated similarly to full-threshold psychosis, including the use of antipsychotic medications [27]. Education and recommendations regarding use of antipsychotics in this group are already conducted in Melbourne, including statements in the clinical practice guidelines for early psychosis [28]. Despite these efforts we are seeing an increase in prescription of antipsychotic medications for this group in primary and secondary care [26], with 27% of ultra-high risk patients now on antipsychotics at the time of referral to the PACE clinic [Thompson A, unpubl. data]. A similar percentage was reported in the North American Prodrome Longitudinal Study [29]. It is instructive to look at other areas of psychiatry in this regard. Clinical guidelines for first episode psychosis recommend regular monitoring of weight gain and metabolic profiles in those prescribed antipsychotic medications. However, despite these guidelines, the level of ‘metabolic monitoring’ is invariably poor in most clinical ser vices [30]. Hetrick et al. [31] report file audit data indicating significant divergence from clinical guidelines in the treatment of depression in young people, with a
References
Attenuated Psychosis Syndrome
marked trend towards overuse of antidepressant medications before other treatments have been trialed. A similar pattern is reported in the US for common mental disorders, where only 14.3% of a sample with mental health diagnoses received care consistent with evidence-based treatment recommendations [32].
Final Comments
In summary, the current formulation of APS differs from existing ‘at-risk’ criteria (the issue of distress, the interpretation of symptoms in the context of borderline personality disorder, etc.) in ways which mean that the established validity and reliability of ‘at-risk’ criteria cannot be automatically transferred to the APS construct. Given accumulating research findings that psychotic and non-psychotic symptoms are far more overlapping and intertwined phenomena than assumed in traditional classification systems, it is certainly not a straightforward clinical decision whether attenuated psychotic symptoms are better explained by ‘another mental disorder’ or not, as in the current formulation. APS also raises concerns about operationalising the ‘attenuated’ concept in clinical practice and the potential for overprescription of antipsychotic medications, which is not easily tackled via education and treatment recommendations. The debate has also lacked sufficient representation by patients and carers of their opinion on the issue. None of the above is to suggest that attenuated psychotic symptoms are not of clinical concern or should not be addressed in treatment or research studies. They should certainly be a treatment target in their own right in help-seeking people and be closely monitored for evolution over time. However, these conceptual and practical issues should be addressed before APS is accepted as an official diagnosis.
1 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 5. Arlington, American Psychiatric Association, 2013. 2 Yung AR, Woods SW, Ruhrmann S, Addington J, Schultze-Lutter F, Cornblatt BA, Amminger GP, Bechdolf A, Birchwood M, Borgwardt S, Cannon TD, de Haan L, French P, Fusar-Poli P, Keshavan M, Klosterkotter J, Kwon JS, McGorry PD, McGuire P, Mizuno M, Morrison AP, Riecher-Rossler A, Salokangas RK, Seidman LJ, Suzuki M, Valmaggia L, van der Gaag M, Wood SJ, McGlashan TH: Whither the attenuated psychosis syndrome? Schizophr Bull 2012; 38:1130–1134.
3 Nelson B, Yung AR: Should a risk syndrome for first episode psychosis be included in the DSM V? Curr Opin Psychiatry 2011; 24:128–133. 4 Yung AR, Nelson B, Thompson AD, Wood SJ: Should a ‘risk syndrome for psychosis’ be included in the DSMV? Schizophr Res 2010; 120: 7–15. 5 Polari A, Nelson B, Yung AR: Does reason for referral to UHR clinics predict transition to psychosis? Early Interv Psychiatry 2010;4: 38– 187. 6 Rapado-Castro M, McGorry PD, Yung AR, Calvo A, Nelson B: Sources of clinical distress in young people at ultra high risk of psychosis. In review 2014.
Psychopathology 2014;47:292–296 DOI: 10.1159/000365291
295
7 The PACE Clinic Manual: A Treatment Approach for Young People at Ultra High Risk of Psychosis. Melbourne, Orygen Youth Health, 2012. 8 Addington J, Francey SM, Morrison AP (eds): Working with People at High Risk of Developing Psychosis. Chichester, Wiley & Sons, 2006. 9 Woods SW, Addington J, Cadenhead KS, Cannon TD, Cornblatt BA, Heinssen R, Perkins DO, Seidman LJ, Tsuang MT, Walker EF, McGlashan TH: Validity of the prodromal risk syndrome for first psychosis: findings from the North American Prodrome Longitudinal Study. Schizophr Bull 2009; 35:894–908. 10 Fusar-Poli P, Carpenter WT, Woods SW, McGlashan TH: Attenuated psychosis syndrome: ready for DSM-5.1? Annu Rev Clin Psychol 2014; 10:155–192. 11 Rietdijk J, Klaassen R, Ising H, Dragt S, Nieman DH, van de Kamp J, Cuijpers P, Linszen D, van der Gaag M: Detection of people at risk of developing a first psychosis: comparison of two recruitment strategies. Acta Psychiatr Scand 2012; 126:21–30. 12 Johannessen JO, McGorry P: DSM-5 and the ‘psychosis risk syndrome’: the need for a broader perspective. Psychosis Psychol Soc Integrative Approaches 2010;2: 93–96. 13 McGorry PD: Issues for DSM-V: clinical staging: a heuristic pathway to valid nosology and safer, more effective treatment in psychiatry. Am J Psychiatry 2007; 164: 859–860. 14 van Os J, Murray RM: Can we identify and treat ‘schizophrenia light’ to prevent true psychotic illness? BMJ 2013; 346:f304. 15 Varghese D, Scott J, Welham J, Bor W, Najman J, O’Callaghan M, Williams G, McGrath J: Psychotic-like experiences in major depression and anxiety disorders: a populationbased survey in young adults. Schizophr Bull 2011; 37: 389–393.
296
16 Wigman JT, van Nierop M, Vollebergh WA, Lieb R, Beesdo-Baum K, Wittchen HU, van Os J: Evidence that psychotic symptoms are prevalent in disorders of anxiety and depression, impacting on illness onset, risk, and se verity – implications for diagnosis and ultrahigh risk research. Schizophr Bull 2012; 38: 247–257. 17 Kelleher I, Keeley H, Corcoran P, Lynch F, Fitzpatrick C, Devlin N, Molloy C, Roddy S, Clarke MC, Harley M, Arseneault L, Wasserman C, Carli V, Sarchiapone M, Hoven C, Wasserman D, Cannon M: Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. Br J Psychiatry 2012; 201: 26–32. 18 Scott J, Martin G, Bor W, Sawyer M, Clark J, McGrath J: The prevalence and correlates of hallucinations in Australian adolescents: results from a national survey. Schizophr Res 2009; 107: 179–185. 19 Yung AR, Buckby JA, Cotton SM, Cosgrave EM, Killackey EJ, Stanford C, Godfrey K, McGorry PD: Psychotic-like experiences in nonpsychotic help-seekers: associations with distress, depression, and disability. Schizophr Bull 2006; 32:352–359. 20 Wigman JT, Vollebergh WA, Raaijmakers QA, Iedema J, van Dorsselaer S, Ormel J, Verhulst FC, van Os J: The structure of the extended psychosis phenotype in early adolescence – a cross-sample replication. Schizophr Bull 2011; 37:850–860. 21 Kelleher I, Devlin N, Wigman JT, Kehoe A, Murtagh A, Fitzpatrick C, Cannon M: Psychotic experiences in a mental health clinic sample: implications for suicidality, multimorbidity and functioning. Psychol Med 2013, Epub ahead of print. 22 Nelson B, Parnas J, Sass LA: Disturbance of minimal self (ipseity) in schizophrenia: clarification and current status. Schizophr Bull 2014; 40: 479–482. 23 Thompson A, Nelson B, Bechdolf A, Chanen AM, Domingues I, McDougall E, Yung AR: Borderline personality features and development of psychosis in an ‘ultra high risk’ (UHR) population: a case control study. Early Interv Psychiatry 2012; 6: 247–255.
Psychopathology 2014;47:292–296 DOI: 10.1159/000365291
24 Ross CA: DSM-5 and the ‘psychosis risk syndrome’: eight reasons to reject it. Psychosis Psychol Soc Integrative Approaches 2010; 2: 107–110. 25 Carpenter WT Jr: Criticism of the DSM-V risk syndrome: a rebuttal. Cogn Neuropsychiatry 2011; 16:101–106. 26 Yung AR: Antipsychotic treatment of UHR (‘prodromal’) individuals. Early Interv Psychiatry 2010; 4:197–199. 27 Jacobs E, Kline E, Schiffman J: Defining treatment as usual for attenuated psychosis syndrome: a survey of community practitioners. Psychiatr Serv 2012; 63:1252–1256. 28 Early Psychosis Guidelines Writing Group: Australian Clinical Guidelines for Early Psychosis. Melbourne, Orygen Youth Health, 2010. 29 Cannon TD, Cadenhead K, Cornblatt B, Woods SW, Addington J, Walker E, Seidman LJ, Perkins D, Tsuang M, McGlashan T, Heinssen R: Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America. Arch Gen Psychiatry 2008; 65: 28–37. 30 Thompson A, Hetrick SE, Alvarez-Jiménez M, Parker AG, Willet M, Hughes F, Gariup M, Gomez DL, McGorry PD: Targeted intervention to improve monitoring of antipsychoticinduced weight gain and metabolic disturbance in first episode psychosis. Aust NZ J Psychiatry 2011; 45:740–748. 31 Hetrick SE, Thompson A, Yuen K, Finch S, Parker AG: Is there a gap between recommended and ‘real world’ practice in the management of depression in young people? A medical file audit of practice. BMC Health Serv Res 2012; 12:178. 32 Wang PS, Berglund P, Kessler RC: Recent care of common mental disorders in the United States: prevalence and conformance with evidence-based recommendations. J Gen Intern Med 2000; 15:284–292.
Nelson
C o p y r i g h t : S . K a r g e r A G , B a s e l 2 0 1 4 . R e p r o d u c e d w i t h t h e p e r m i s s i o n o f S . K a r g e r A G , B a s e l . F u r t h e r r e p r o d u c t i o n o r d i s t r i b u t i o n ( e l e c t r o n i c o r o t h e r w i s e ) i s p r o h i b i t e d w i t h o u t p e r m i s s i o n f r o m t h e c o p y r i g h t h o l d e r .
