Probably at-risk, but certainly ill — Advocating the introduction of a psychosis spectrum disorder in DSM-V

https://doi.org/10.1016/j.schres.2010.03.015Get rights and content

Abstract

Current criteria for an increased risk of developing first-episode psychosis are associated with conversion rates many times higher than the general incidence of psychosis. Yet, non-conversions still outnumber conversions, and conversion rates across and within centres vary considerably, fueling the ongoing debate about clinical and ethical justification of indicated prevention. This debate, however, almost exclusively focuses on the predictive validity of at-risk criteria, thereby widely disregarding the main general finding: persons meeting at-risk criteria already suffer from multiple mental and functional disturbances for those they seek help. Moreover, they exhibit various psychological and cognitive deficits along with morphological and functional cerebral changes. Thereby, the majority of help-seeking at-risk persons fulfils DSM-IV's general criteria for mental disorders (defined as a clinically significant behavioural or psychological syndrome associated with disability and/or severe distress) and clearly have to be considered as ‘ill’, i.e., as ‘patients’ with a need and right for treatment.

Hence, the clinical picture defined by current at-risk criteria should be more adequately perceived as not only a still insufficient attempt to define the psychotic prodrome but a psychosis spectrum disorder in its own right – akin to ICD-10's schizotypal disorder – with conversion to psychosis just being one of several outcomes. Such a disorder, whose criteria are proposed and discussed, should initially be part of DSM-V research criteria. Following from this shift in the perception of current at-risk criteria, access to standard medical care would have to be granted, and diagnosis- or symptom- rather than conversion-related interventions would have to be developed.

Section snippets

Prevention of psychoses — rationale and concept

Although treatment of psychoses has much advanced over the last decades, a significant number of patients, especially with schizophrenia, continue to take an unfavourable chronic course (Häfner and an der Heiden, 2008, Harrison et al., 2001). This makes schizophrenia the leading single cause for permanent occupational disability among the less than 40 year olds in Germany, and, worldwide, the 8th most common cause for disability adjusted life years among the 15- to 44-year olds, despite its low

Prediction does not equal early diagnosis

The probabilistic approach of indicated prevention implicates that the early signs and symptoms cannot be considered early diagnostic symptoms of an indubitably evolving illness but indicators of an increased risk of developing this illness at anytime in the future. As such, each symptom brings about a certain error probability. An early detection has therefore to be regarded as early risk probability estimation rather than early diagnosis. For psychoses, this risk estimation is currently based

The risk approach within the framework of DSM and ICD

Neither in DSM-IV-TR nor in Chapter V (F) of the ICD-10 diagnostic categories or syndromes are considered solely for their predictive value (APA, 2000, WHO, 1992). Other chapters of the ICD-10 have included diagnostic entities, which do not represent diseases. For example, hypertension and hypercholesterolemia – unless severe – remain clinically asymptomatic, thus their pathologic denotation primarily originate in their contribution to the development of cardio- and cerebrovascular disorders (

Validity of at-risk criteria

One question is central in the discussion about the introduction of a risk syndrome category into the DSM: Do current clinical at-risk criteria possess sufficient validity to justify such an important, probably ground-breaking step?

Risk syndrome or psychosis spectrum disorder?

In light of the significantly increased incidence of psychosis in at-risk samples, the hazards associated with the onset of psychosis and especially of schizophrenia have to be weighed against those associated with a false-positive prediction. This inevitably leads to a complex, mainly ethically driven debate that might not be concluded in the near future (Corcoran et al., 2005, Klosterkötter and Schultze-Lutter, in press). However, as this debate over-emphasises aspects of prediction and

Criteria of a Psychototypal Disorder

When relating to current at-risk criteria and to StD as an exemplary disorder concept, some difficulties in the choice of symptoms for inclusion in a Psychototypal Disorder category and their operationalization occur (for an exemplary operationalization see Appendix).

First, UHR criteria include three different risk syndromes that have rarely been evaluated separately. APS, however, were repeatedly reported to account for the vast majority of inclusions (about 80%), resemble four of the nine StD

Role of funding source

No funding was provided for the preparing this manuscript.

Contributors

Stephan Ruhrmann wrote the first draft of the manuscript, Frauke Schultze-Lutter revised and extended it carefully, both authors developed the proposed criteria together. All authors contributed to and have approved the final manuscript.

Conflict of interest

Within three years of beginning the work submitted Stephan Ruhrmann, MD, received speaker's honoraria from Janssen-Cilag, Bristol Myers-Squibb, AstraZeneca.

Frauke Schultze-Lutter, PhD, has nothing to disclose.

Joachim Klosterkötter, MD, received a research grant and speakers honoraria from Bristol Myers Squibb as well as speaker's honoraria from Janssen-Cilag.

Acknowledgements

There are no special acknowledgements.

References (115)

  • F. Schultze-Lutter et al.

    Early detection of psychosis — establishing a service for persons at risk

    Eur. Psychiatry

    (2009)
  • A.E. Simon et al.

    High remission rates from an initial ultra-high risk state for psychosis

    Schizophr. Res.

    (2010)
  • A.E. Simon et al.

    Defining subjects at risk for psychosis: a comparison of two approaches

    Schizophr. Res.

    (2006)
  • T. Svirskis et al.

    Axis-I disorders and vulnerability to psychosis

    Schizophr. Res.

    (2005)
  • J. Addington et al.

    Decline in social functioning for those with an “at risk mental state”

    Schizophr. Res.

    (2004)
  • J. Addington et al.

    North American Prodrome Longitudinal Study: a collaborative multisite approach to prodromal schizophrenia research

    Schizophr. Bull.

    (2007)
  • G. Amminger et al.

    Omega-3 fatty acids reduce the risk of early transition to psychosis in ultra-high risk individuals: a doubleblind randomized, placebocontrolled treatment study

    Schizophr. Bull.

    (2007)
  • APA

    Diagnostic and Statistical Manual of Mental Disorders

    (2000)
  • D.M. Barch et al.

    Anticipating DSM-V: opportunities and challenges for cognition and psychosis

    Schizophr. Bull.

    (2010)
  • R.Q. Bell

    Multiple-risk cohorts and segmenting risk as solutions to the problem of false positives in risk for the major psychoses

    Psychiatry

    (1992)
  • M. Besthehorn et al.

    Repräsentative Studie zur Verteilung schizophrener Patienten auf medizinische Versorgungseinrichtungen in Deutschland

    Fortschr. Neurol. Psychiatr.

    (1999)
  • BMG, 2007. gesundheitsziele.de - Maßnahmen des Bundesministeriums für Gesundheit zur Umsetzung nationaler...
  • E. Bora et al.

    Cognitive impairment in schizophrenia and affective psychoses: implications for DSM-V criteria and beyond

    Schizophr. Bull.

    (2010)
  • S.J. Borgwardt et al.

    Structural brain abnormalities in individuals with an at-risk mental state who later develop psychosis

    Br. J. Psychiatry Suppl.

    (2007)
  • D.E. Cameron

    Early schizophrenia

    Am. J. Psychiatry

    (1938)
  • T.D. Cannon et al.

    Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America

    Arch. Gen. Psychiatry

    (2008)
  • V. Carr et al.

    A risk factor screening and assessment protocol for schizophrenia and related psychosis

    Aust. N. Z. J. Psychiatry

    (2000)
  • CDHAC

    Promotion, Prevention and Early Intervention for Mental Health—a Monograph

    (2000)
  • J. Clouth

    Costs of early retirement — the case of schizophrenia

    Psychiatr. Prax.

    (2004)
  • B.A. Cornblatt et al.

    The schizophrenia prodrome revisited: a neurodevelopmental perspective

    Schizophr. Bull.

    (2003)
  • B.A. Cornblatt et al.

    Preliminary findings for two new measures of social and role functioning in the prodromal phase of schizophrenia

    Schizophr. Bull.

    (2007)
  • G. De Backer et al.

    European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts)

    Eur. J. Cardiovasc. Prev. Rehabil.

    (2003)
  • A. Demjaha et al.

    Combining dimensional and categorical representation of psychosis: the way forward for DSM-V and ICD-11?

    Psychol. Med.

    (2009)
  • EC

    Green Paper — Improving Mental Health of the Population: Towards a Strategy on Mental Health for the European Union

    (2005)
  • H.H. Goldman et al.

    Revising axis V for DSM-IV: a review of measures of social functioning

    Am. J. Psychiatry

    (1992)
  • R.S. Gordon

    An operational classification of disease prevention

    Public Health Rep.

    (1983)
  • P. Gourzis et al.

    Symptomatology of the initial prodromal phase in schizophrenia

    Schizophr. Bull.

    (2002)
  • J. Gutiérrez-Maldonado et al.

    Burden of care and general health in families of patients with schizophrenia

    Soc. Psychiatry Psychiatr. Epidemiol.

    (2005)
  • G. Guyatt et al.

    Users' Guides to the Medical Literature: a Manual for Evidence-based Clinical Practice

    (2008)
  • H. Häfner et al.

    Course and outcome

  • H. Häfner et al.

    The influence of age and sex on the onset and early course of schizophrenia

    Br. J. Psychiatry

    (1993)
  • H. Häfner et al.

    The ABC Schizophrenia Study: a preliminary overview of the results

    Soc. Psychiatry Psychiatr. Epidemiol.

    (1998)
  • H. Häfner et al.

    Modeling the early course of schizophrenia

    Schizophr. Bull.

    (2003)
  • N. Haroun et al.

    Risk and protection in prodromal schizophrenia: ethical implications for clinical practice and future research

    Schizophr. Bull.

    (2006)
  • G. Harrison et al.

    Recovery from psychotic illness: a 15- and 25-year international follow-up study

    Br. J. Psychiatry

    (2001)
  • C.H. Hennekens et al.

    Epidemiology in Medicine

    (1987)
  • G. Huber

    Reine Defektsyndrome und Basisstadien endogener Psychosen

    Fortschr. Neurol. Psychiatr.

    (1966)
  • G. Huber et al.

    Schizophrenie. Verlaufs- und sozialpsychiatrische Langzeituntersuchungen an den 1945–1959 in Bonn hospitalisierten schizophrenen Kranken

    (1979)
  • S.N. Iyer et al.

    Signs and symptoms in the pre-psychotic phase: description and implications for diagnostic trajectories

    Psychol. Med.

    (2008)
  • E. Kahn

    Schizoid und Schizophrenie im Erbgang

  • Cited by (137)

    • Subjective disturbances in emerging psychosis: basic symptoms and self-disturbances

      2020, Risk Factors for Psychosis: Paradigms, Mechanisms, and Prevention
    • Associations of psychosis-risk symptoms with quality of life and self-rated health in the Community

      2019, European Psychiatry
      Citation Excerpt :

      The most noteworthy result, however, is that CHR symptoms, even when they occur rather infrequently and below the threshold for psychosis-risk criteria, have a negative effect on both SRH and QoL in the community, which is independent of the effect of non-psychotic mental disorders. This emphasises their clinical relevance and the need to address these symptoms not only in specialized services, but in all mental health care [34,69]. The finding of differential effects of delusional ideas on SRH emphasizes the need to address the differential effects of perceptive and non-perceptive psychosis-risk phenomena.

    View all citing articles on Scopus
    1

    Joined first authorship.

    View full text