Probably at-risk, but certainly ill — Advocating the introduction of a psychosis spectrum disorder in DSM-V
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.
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2019, European PsychiatryCitation 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.
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Joined first authorship.