Attenuated Psychosis Syndrome DSM-5 298.8 (F28)
DSM-5 Category Other Specified
Schizophrenia Spectrum and Other Psychotic Disorder
Attenuated Psychosis Syndrome is a new and somewhat controversial diagnosis in DSM-5. It is a set of symptoms that cause clinically significant distress or impairment in social, occupational, or other life areas (American Psychiatric Association, 2013). These symptoms are very similar to the symptoms seen in schizophrenia, but do
not reach the clinical level of severity to be considered to fit any of the disorders in the schizophrenia spectrum or other psychotic disorder. This new diagnosis is designed to be used by clinicians to describe the specific reasons a patient may not belong in the more serious disorder. Symptoms shown by patients in this diagnosis do not reach the level to be considered a full-blown psychosis. The symptoms are less severe, are more likely to come and go to an extent, and reality is maintained at least partially. At least a part of the controversy behind the inclusion of this diagnosis in DSM-5 has to do with concerns among some professionals that clinicians will use this diagnosis to begin treatment for schizophrenia, especially medications, early which will lead to possibly inappropriate treatments and open the profession up to criticism
(Maxmen, 2012). Other professionals argue its inclusion will enable early treatment of a very difficult disorder.
Those patients suffering from Attenuated Psychosis Syndrome exhibit psychotic symptoms that do not reach the level required for full-blown psychosis. These symptoms may be of shorter duration or lesser severity than those of psychoses (Schizophrenia Research Forum, 2012). There is accompanying significant distress and lowered
functioning in some area of life. Some research (Fosar-Poli, et al., 2012) that suggests individuals with this diagnosis have a significant likelihood of developing full-blown psychoses within six months to three years. They may develop schizophrenia, schizoaffective disorder, or schizophreniform disorder.
The primary psychotic symptoms seen in this disorder are hallucinations, delusions, or disorganized speech (Cornblatt & Correll, 2010). Although these symptoms are present, the patient’s reality testing appears to be relatively intact. This likely leads to the distress felt by the patient. Being aware of the unusual nature of the symptoms being experienced is distressing.
One of the early symptoms of attenuated psychosis may be the tendency to withdraw for short periods of time or a desire to isolate oneself. A low level of suspiciousness may be present, also. Some difficulty in thinking or concentrating at a higher frequency than usual is another possible indication of the disorder.
Many patients who are later diagnosed with attenuated psychosis syndrome present to their medical practitioners with complaints of depression and/or anxiety. Mood disorders seem to be the most common related disorders reported, with rates between 40-61% ((Algon, et al., 2012). Anxiety disorders are also reported, with rates between 16% and 46%. Some risk of suicide has been reported in patients presenting with these disorders (Tandon, et al., 2012).
In addition to careful examination of a patient’s history and family history, there are some more formal test instruments that may be of help. The Bonn Scale for the Assessment of Basic Symptoms (BSABS) can help diagnose early symptoms and identify those who may convert to schizophrenia in five years. The Comprehensive Assessment of ‘At-Risk Mental States’ (CAARMS) and the Structured Interview for Prodromal Symptoms (SIPS) are used to identify individuals with late prodromal symptoms who may convert to schizophrenia in 1-2 years.
Possibly the most reliable risk factor for developing any type of psychosis is a family history of this type of disorder (Krucik, 2014). Twin studies have shows a high concordance rate in the case of identical twins. If one of a set of twins develops a psychotic disorder, there is a 50% chance of the other twin developing a psychotic disorder as well. If brain development is detrimentally affected during periods of significant physical development surrounding pregnancy and birth, the possibility of psychotic disorders developing increases (Heckers, 2009).
Other risk factors associated with the possibility of psychosis may play a part in diagnosing attenuated psychosis syndrome. Some of these factors are environmental, including advanced paternal age, maternal infections and malnutrition during pregnancy, late winter/early spring birth, and cannabis abuse (Tandon, et al., 2012).
Little information is available regarding the onset of Attenuated Psychosis Syndrome. However, clinical experience suggests many of the patients developing this disorder will be adolescents (Carpenter & van Os, 2011). This seems likely since adolescence and early adulthood are two of the most likely times for psychotic
symptoms that emerge at a clinical level first appear.
There continues to be significant controversy regarding treatment of patients diagnosed with Attenuated Psychosis Syndrome. A large number of clinicians see the benefits of early intervention to forestall or prevent progression to full-blown psychosis (Algon, et al., 2012). A part of the argument for this early intervention also
has to do with the fact that this is a largely neglected aspect of mental health treatment (Maxmen, 2012).
On the other hand, a similarly large number of clinicians see significant problems in early intervention for patients with this diagnosis. Issues exist with the lack of
proven treatment approaches for this population (Carpenter & van Os, 2011). And, early interventions with this population may have no long-lasting effect. Add to this the finding that a large number of patients diagnosed with attenuated psychosis syndrome do not go on to develop psychoses (Tandon, et al., 2012). Many professionals also cite the increased possibility of stigma as a reason not to intervene early with this population. These factors suggest treatment for this population may not be appropriate.
If treatment is determined to be needed, as may be the perception of many clinicians (Jacobs, et al., 2011), medication does not appear to be the first line of treatment recommendations. One reason for this is the side effects of this type of medication (Maxmen, 2012). Involuntary movement disorders and sometimes large weight gain are the two that typically manifest with anti-psychotic medications. The development of these side effects combined with what appears to be less than optimal efficacy of medications for this population will potentially lead to lessened compliance with treatment regimens should psychosis develop later. The criticism has been made that prescribers in the community may utilize antipsychotic medications at too high a frequency with patients who are diagnosed with attenuated psychosis syndrome (Jacobs, et al., 2011).
What might be some beneficial treatment approaches for this population? Cognitive therapies, like Cognitive Behavioral Therapy (CBT), have been a focus in research. CBT has been effective in a number of studies (Algon, et al., 2012). In one study, CBT lessened the likelihood of early symptoms converting to psychosis in young adults. Another study of adolescents and young adults showed both supportive therapy and CBT to be effective in improving depression, anxiety, and positive psychotic symptoms.
Risperidone combined with CBT showed promise as a treatment approach compared to a need-based group (McGorry, et al., 2002). Conversion to psychosis occurred three times as often in the need-based group as in the combined risperidone and CBT group. Full adherence to the risperidone regimen was necessary for these results to hold for 12 months. Omega-3 polyunsaturated fatty acid compared with placebo in adolescents and young adults suggested a positive effect in keeping conversion to psychosis under control.
Clear indications of benefits being greater than risk in the use of antipsychotics in treating patient diagnosed with attenuated psychosis syndrome have not been seen to this date.
The majority of patients presenting at treatment facilities and later diagnosed with attenuated psychosis syndrome initially show one or more comorbid conditions (Tsuang, et al., 2013). Depression, anxiety, or substance abuse are the most frequently seen comorbid conditions. These patients require treatment for the presenting
disorders, particularly when the threat of suicide is present. In the process of diagnosing and treating these disorders, a thorough history may reveal the presence of the more significant symptoms that would suggest the diagnosis of attenuated psychosis syndrome.
While clinical experience shows a range of patients with attenuated psychosis syndrome do progress to full-blown psychosis, a large number do not. The actual numbers of patients who convert to psychosis is not clear. Some research suggests a 40% risk of conversion after three years (Fusar-Poli, et al., 2012). Other research
suggests a 70% risk of conversion after ten years (Tandon, et al., 2012). Perhaps the risk of conversion can be lessened by some type of intervention at the time the symptoms of attenuated psychosis syndrome are seen by a professional. That is subject to further research.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Arlington, VA: American Psychiatric Publishing.
Algon, S., et al. (2012). Evaluation and treatment of children and adolescents with psychotic symptoms. Curr Psychiatry Rep. 14(2): 101-110.
Carpenter, W. (2011). This month’s expert: Attenuated psychosis syndrome. Retrieved from http://pro.psychcentral.com/this-monts-expert-attenuated-psychosis-syndrome-by-william-carpenter.
Carpenter, W.T., & van Os, J. (2011). Should attenuated psychosis syndrome be a DSM-5 diagnosis? Am J Psychiatry. 168: 460-463.
Cornblatt, B.A. & Correll, C.U. (2010). A new diagnostic entity in DSM-5? Retrieved from http://www.medscape.com/viewarticle/727682.
Fusar-Poli, P. et al. (2012). Predicting psychosis: Meta-analysis of transition outcomes in individuals at high clinical risk. Arch Gen Psychiatry. 69(3): 220-229.
Heckers, S. (2009). Who is at risk for a psychotic disorder? Schizophr Bull. 35(5): 847-850.
Jacobs, E. et al. (2011). Practitioner perceptions of attenuated psychosis syndrome. Schizophr Res. 131(0): 24-30.
Krucick, G. (2014). Psychosis. Retrieved from http://www.healthline.com/health/psychosis.
Maxmen, A. (2012). Psychosis risk syndrome excluded from DSM-5. Retrieved from http://www.nature.com/news/psychosis-risk-syndrome-excluded-from-dsm-5-1.10610.
Tandon, N. et al. (2012). Attenuated psychosis and the schizophrenia prodrome: Current status of risk identification and psychosis prevention. Neuropsychiatry (London). 2(4): 345-353.
Tsuang, M.T. et al. (2013). Attenuated psychosis syndrome in DSM-5. Schizophrenia Research. 150(1): 31-35.
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