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Online Discussions

Updated 26 June 2009 E-mail discussion
Printable version

Live Discussion: Is the Risk Syndrome for Psychosis Risky Business?


William T. Carpenter Jr.

Barbara Cornblatt

Howard H. Goldman

Thomas McGlashan

Patrick McGorry

Scott Woods

Alison Yung



Click here to view slidecasts.

SRF Live Discussion Series: Anticipating the DSM-V
Over the next few months, Schizophrenia Research Forum will present a series of live discussions focusing on areas of contention within the evolution of the Diagnostic and Statistical Manual (DSM) psychotic disorders area. You will have an opportunity to view several brief slidecasts that represent differing views within the mental health treatment, research, and policy communities before each discussion. Our goal is to spark commentary, so be sure to view the slidecasts and post your comments…don’t be left out of the debate! While you don’t need to be a member to view the slidecasts, you do have to register in order to leave comments below. (We invite you to join SRF—it’s free and we do not share your membership information with other organizations.)

This past spring, many researchers got together at the International Prodromal Research Network Psychosis Satellite Meeting in San Diego to review and decipher the latest psychosis prodrome data. One topic in particular—whether to include a diagnostic "at-risk" category in DSM-V—was discussed up and down the hallways, both at the satellite meeting and at a Workshop at the ICOSR. Clearly this proposal is controversial, and Schizophrenia Research Forum opened this debate up to you via a series of short slidecasts, the opportunity to provide comments, and a special live discussion on 22 July at 8 p.m. EST.

Read the backgrounder below, prepared by our discussion organizer, William T. Carpenter Jr., director of the Maryland Psychiatric Research Center and leader of the DSM-V psychosis work group. After that, click the link below to view the slidecasts prepared by the invited presenters, and return to this page to submit your comments.

See Draft of DSM-V Criteria.

See also Anticipating DSM-V and Validity of the Prodromal Risk Syndrome.

Click here to view slidecasts.

View Transcript of Live Discussion — Posted 4 October 2009

View Comments By:
Daniel Mathalon — Posted 10 July 2009
Dirk van Kampen — Posted 16 July 2009
Scott Woods — Posted 17 July 2009
Lois Oppenheim — Posted 17 July 2009
Dolores Malaspina — Posted 20 July 2009
Philip Seeman — Posted 20 July 2009
Norman Sartorius — Posted 21 July 2009
Todd Lencz — Posted 21 July 2009
Gary Remington — Posted 21 July 2009
Amresh Shrivastava — Posted 21 July 2009
Helen Stain — Posted 22 July 2009
Amresh Shrivastava — Posted 22 July 2009
Andrew Thompson — Posted 22 July 2009
Ashok Malla — Posted 22 July 2009
Roger Peele — Posted 22 July 2009
Anthony Morrison — Posted 22 July 2009
Paul French — Posted 22 July 2009
Patrick McGorry — Posted 22 July 2009
Cheryl Corcoran — Posted 22 July 2009
Michael Hwang — Posted 24 July 2009
Thomas McGlashan — Posted 27 July 2009
Anthony Grace — Posted 2 August 2009
Joachim Klosterkötter — Posted 24 August 2009
Danny Koren — Posted 10 September 2009
Eileen McGinn — Posted 4 December 2009


Background Text
By William Carpenter, Maryland Psychiatric Research Center
Leader, DSM-V Psychotic Disorders Workgroup

Early detection and intervention is a compelling goal throughout medicine. Has the time come to formally endorse this for psychotic illnesses? Research on this issue has been conducted on a large, international scale during the past decade. It is clear that experts can define risk and that a non-trivial proportion of at-risk individuals convert to a psychotic illness. But, is the evidence sufficient to establish psychosis risk as a diagnostic class within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)? Is enough known about intervention to assure an effective application?

A DSM-V endorsement raises a number of serious concerns. Will false positive diagnoses stigmatize non-ill individuals? Will medications be widely used with more harm than good resulting? Will non-experts, including primary care doctors, be able to make reliable and valid diagnoses? Will the APA be vulnerable to allegations that another category has been created to serve pharmaceutical marketing?

Criteria for diagnoses may include help seeking, distress, and/or disability. A category can be established as a risk syndrome similar to hyperlipidemia of elevated blood pressure, marking the need for clinical care to prevent progression. Text and educational programs can give emphasis to evidence-based therapeutic interventions and reduce risk of harm from unwarranted treatments. Can such procedures reduce stigma and harm?

It seems likely that in the near future we will establish interventions with efficacy for secondary prevention. Should DSM-V be prepared to facilitate broad-based application and the translation of research to clinical practice?

There is a compelling need for clinical attention for individuals meeting psychosis risk syndrome criteria, but much to be debated as to the most effective way to address this need. The Report of the DSM-V Psychotic Disorders Work Group will eventually make a recommendation. Feedback from the field is critically important at this time, and the 22 July SRF Live Discussion provides this opportunity.

Click here to view slidecasts.


Comments on Online Discussion
Comment by:  Daniel Mathalon
Submitted 8 July 2009 Posted 10 July 2009

When diagnoses enter the DSM, they become reified in the minds of most clinicians in psychiatry and allied fields. This raises special concerns for individuals considered to be at risk for psychosis based on current clinical research criteria. Although current estimates of risk for conversion to psychosis among individuals meeting UHR/COPS criteria are around 35 percent over a two year period (Cannon et al., 2008), these estimates are not yet stable across research samples and appear to be decreasing as the criteria get applied to broader, less clinically acute, community samples. No matter what efforts are made to encourage clinician to exercise caution and restraint in their treatment of individuals who meet UHR criteria, it seems inevitable that we will see more of these individuals treated with pharmacological treatments that are associated with medically significant and often stigmatizing side effects (e.g., motor side effects and obesity). Moreover, when pharmacological treatments are initiated, the research literature...  Read more


View all comments by Daniel Mathalon

Comment by:  Dirk van Kampen
Submitted 16 July 2009 Posted 16 July 2009

In my opinion, there are several arguments to not include a diagnostic “at-risk” category for schizophrenia in DSM-V. In the slidecast presented by Drs. McGlashan and Woods, five characteristic symptoms are listed to define this category that, however, can all be regarded to denote psychotic-like or attenuated psychotic symptoms. It seems to me very premature to define the “at risk” syndrome or schizophrenia prodrome merely on the basis of positive symptoms. Moreover, I think the concept of the schizophrenia prodrome itself can be criticized, also making the inclusion of the risk syndrome in DSM-V a risky business. In the following, I will elucidate on these points from the perspective of my own research on the SSQ (Schizotypic Syndrome Questionnaire) model (Van Kampen, 2005; 2006; Van Kampen et al., 2009a; 2009b). Although I basically agree with the comments made by Drs. Cornblatt and Yung on their slidecasts in rejecting the proposal of...  Read more


View all comments by Dirk van Kampen

Comment by:  Scott Woods (Disclosure)
Submitted 17 July 2009 Posted 17 July 2009

The risks of including a risk syndrome for psychosis have been well articulated by Drs. Yung and Cornblatt, and I personally agree with most of their points.

However, here I would like to bring more focus on risks of not continuing to consider a risk syndrome for inclusion in DSM-V.

When I give talks about a risk syndrome, some of the most poignant comments from the audience sound like this: “My son/daughter has been suffering with schizophrenia for a long time now. I only wish something like this had been available years ago, and maybe we could have caught it early and things could have gone much better.” I hear the same comments from parents who bring in their younger children for evaluation when an older child has already developed schizophrenia: “We took our older son/daughter to see several doctors when s/he was becoming ill but no one did anything.” If we stay with DSM-IV, a risk is that most patients who are truly on the course to develop schizophrenia will continue to develop a chronic disabling condition without having their early symptoms...  Read more


View all comments by Scott Woods

Comment by:  Lois Oppenheim
Submitted 17 July 2009 Posted 17 July 2009

Carpenter notes that "It is clear that experts can define risk and that a non-trivial proportion of at-risk individuals convert to a psychotic illness." And he rightly asks if "the evidence [is] sufficient to establish psychosis risk as a diagnostic class within the...DSM-V." Mathalon is concerned about the inevitability of the precipitous use of pharmacology and its stigmatizing side effects. I share that concern, but am also aware of the devastation wrought by schizophrenia in patients and their families where a genetic predisposition was evident from the number of individuals afflicted with schizophrenia and/or related factors. One potential risk factor for conversion that is compelling (at least to some) is marijuana. I say “potential” as it is still debated. Though there have been a number of convincing studies that appear to demonstrate the morbidity of this substance where predisposition is known, there are others who claim the cannabis question is still to be doubted. Nonetheless, I would ask if there might not be a way to make the general public more aware of what is...  Read more


View all comments by Lois Oppenheim

Comment by:  Dolores Malaspina
Submitted 20 July 2009 Posted 20 July 2009

Given the morbidity and difficulty of treating psychotic disorders, including schizophrenia, there has been a move toward identifying and treating adolescents and young adults who appear to be clinically at risk or "prodromal" to psychosis. The field now has greater specificity in identification, with rates of 40-50 percent conversion to frank psychosis within one to two years. There is further evidence that medications and other treatments may have some efficacy for "prodromal" patients, though with variable side effects. However, controversy remains about some of the inherent risks in prodromal research, such as medication exposure and stigma among false-positives. In this paper (Corcoran et al., 2005), we add to this discussion through an analysis of ethics in prodromal research from the more established field of predictive genetic testing. Issues are raised about the effects of information on patients, families, and institutions, as well as future insurability, the limits of confidentiality (as it relies on discretion of...  Read more


View all comments by Dolores Malaspina

Comment by:  Philip Seeman (Disclosure)
Submitted 20 July 2009 Posted 20 July 2009

The psychosis-risk syndrome is worth being recognized by the next DSM because the syndrome is in principle reversible and treatable in its early stages, as shown in animal models of psychotic-like behavior (Shuto et al., 2008; Seeman et al., 2006; 2009). There is, therefore, practical hope for the development of future treatment and desensitization of this syndrome.

References:

Shuto, T., Seeman, P., Kuroiwa, M., Nishi, A. Repeated administration of a dopamine D1 receptor agonist reverses the increased proportions of striatal dopamine D1High and D2High reeptors in methamphetamine-sensitized rats. Eur. J. Neurosci. 27: 2551-2557 (2008). Abstract

Seeman et al. Psychosis pathways converge via D2High dopamine receptors. Synapse 60: 319-346 (2006). Abstract

Seeman, P. Schizophrenia model of elevated D2High receptors: Haloperidol reverses the amphetamine-induced elevation in dopamine D2High. Schizophrenia Res. 91: 191-192 (2009). Abstract

View all comments by Philip Seeman


Comment by:  Norman Sartorius
Submitted 20 July 2009 Posted 21 July 2009

The idea of helping people when they are at high risk for developing an illness is laudable and has proved its worth many times.

The proposal to have an at-risk diagnosis is, of course, applicable to most of the classification of mental disorders. Individuals might be at risk for dementia, for personality disorders, for depression, for dependence on drugs, and so on.

At present, psychiatric treatment interventions are fairly non-specific for risk states. They are specific if the risks are known and can be removed, but this is not always the case. For most at-risk states the interventions will not be specific. Specifically, an at-risk-for-schizophrenia category might not correspond to a specific treatment intervention that is significantly different from an intervention that could be used to avoid the occurrence of other multifactorially caused disorders.

It would be wise to fight for improved access to mental health services, in particular, in cases where availability of services would in fact help individuals who are at risk for becoming mentally ill. This is a...  Read more


View all comments by Norman Sartorius

Comment by:  Todd Lencz
Submitted 21 July 2009 Posted 21 July 2009

While the arguments for and against inclusion of a risk syndrome have been well aired in this forum, less attention has been paid to the potential content of the proposed criteria.

Current research criteria for the risk syndrome were developed and operationalized more than a decade ago. The primary basis for diagnosis was presence of a single attenuated (subpsychotic) positive symptom. However, these original criteria have exhibited a pattern of decreasing predictive value as study populations have expanded over time (Yung et al., 2008; Cannon et al., 2008).

At the same time, numerous studies have demonstrated that predictive validity of these criteria can be enhanced by 1) increasing the threshold of attenuated positive symptoms required at baseline; and 2) addition of attenuated negative symptoms, basic symptoms, and/or functional deficits to the prediction model (Cornblatt et al., 2003; Lencz et al., 2003;   Read more


View all comments by Todd Lencz

Comment by:  Gary Remington
Submitted 21 July 2009 Posted 21 July 2009

I side with Drs. Cornblatt and Yung on this controversy. Substantially more evidence is needed across various domains:

1. Capacity to accurately diagnose those who will convert.

2. Effective strategies for treatment.

3. Evidence that these early interventions produce meaningful and sustained effects over time.

I would not dispute the promising results addressing each of these points—others have alluded to this work. To suggest, though, that the present data substantiate incorporation into DSM-V is simply premature. The elephant in the room seems to be “real world” implications, which I believe would rapidly include further sanctioning (implicit or explicit) of antipsychotics in an age group where such use is already soaring for reasons that are, at best, open to question.

View all comments by Gary Remington


Comment by:  Amresh Shrivastava
Submitted 20 July 2009 Posted 21 July 2009

The “at-risk” state is an interesting clinical condition, and the question of including it as a diagnostic category in the DSM-V requires a critical appraisal of the work in the field of psychiatric research (i.e., ICOSR) accomplished over the past 20 years. It is imperative that we unequivocally make a case that “at-risk” psychosis is a clinical condition, which is aetiopathologically distinct, has its own natural history of course, outcome, response to treatment, and does not overlap with several other syndromes. The fundamental issue is whether it is a clinical syndrome or a phase specific condition in the longitudinal course of psychotic disorders.

As the title “at-risk” suggests, this condition is a precursor to a range of psychotic, non-affective, and affective disorders. There is no convincing evidence that at-risk psychosis is a distinct clinical entity. It is also not clear as to what happens to those who do not convert to major psychosis over time. Remarkable work has been done in this area that has brought some reasonable clarity to understanding the...  Read more


View all comments by Amresh Shrivastava

Comment by:  Helen Stain
Submitted 22 July 2009 Posted 22 July 2009

I agree with the concerns raised by Barbara Cornblatt. The criteria for identification of youth at ultra high risk of developing psychosis are still in the early stages of development, and as noted by Barbara, this identification or classification of ultra high risk can only be confirmed retrospectively. For the young people who are fortunate not to go on and develop a psychosis, “misidentification” of being at ultra being risk for psychosis can cause much trauma for young people and their families. This can be construed as having a similar traumatic impact as that of hospitalization in an adult psychiatric ward of a young person experiencing a first-episode psychosis. There has been much work to prevent this practice for youth, and I argue we should view placing ultra high risk for psychosis in DSM-V classification as being poor practice.

View all comments by Helen Stain


Comment by:  Amresh Shrivastava
Submitted 22 July 2009 Posted 22 July 2009

At this site there are very interesting observations which need to be synthesized. While it appears from a few observations that it may be premature to reject the idea of an at risk syndrome, there are some serious concerns:

1. Is it clarified what exactly will be the benefit of including this condition as a diagnosis in DSM-V?

2. The strongest argument for such inclusion is based upon the “staging model of illness” illustrated by Patrick McGorry. The concept of symptom progression in schizophrenia is neither universally accepted nor popular. It has been mostly “either-or” cases.

3. Is it then on a “severity continuum,” which can be coded independently?

4. There is value in the argument, but to define it as a clinical entity, which is distinct in diagnosis, is premature and non-validated.

5. Most of the objections are on the grounds of the following:
a. Non-specific nature of syndrome
b. Poor validation
c. Low conversion rate
d. High false positive cases
e. Concept of “diagnosis” and “disease”
f. Stigma
g. Inappropriate...  Read more


View all comments by Amresh Shrivastava

Comment by:  Andrew Thompson
Submitted 22 July 2009 Posted 22 July 2009

I agree with Dr. Cornblatt and Professor Yung that it is premature given the current state of the evidence to include a risk syndrome for psychosis in DSM-V. There are a number of points I would like to raise on the issue:

1. The considerably lower rates of transition to a frank psychotic disorder experienced in international clinics other than the NAPLS group, such as the 10-15 percent quoted in recent years from the PACE clinic in Melbourne (Yung et al., 2007). These rates have significantly reduced from previous years and suggest that in such established clinics, perhaps only one in 10 individuals who meet the “at risk syndrome” would be correctly identified as developing a psychotic illness. Indeed, within the group that does make a transition to a psychotic illness, only around 55 percent develop a schizophreniform psychosis (Cannon et al., 2008). The question should be, Can we justify labeling and treating these individuals when using the present criteria if the positive...  Read more


View all comments by Andrew Thompson

Comment by:  Ashok Malla
Submitted 22 July 2009 Posted 22 July 2009

The intention to include the "at risk syndrome for psychosis" in DSM-V may be a noble one but appears to be misguided, not only because there is clearly lack of evidence for its specificity in terms of prediction as well as lack of any specific treatment, but also because of the potential for social harm. Clinicians once given the criteria for yet another ambiguous syndrome will most likely rush to using antipsychotic medications with all the attendant deleterious effects and unnecessary exposure to such harm. In addition, and perhaps more importantly, the real potential of introducing stigma associated more often with psychotic disorders than with depression, anxiety, etc., and possible rejection of future treatment by young people cannot be ignored.

I am bothered by the use of the term "prodromal" repeatedly in the DSM submission. This is at best intellectually reckless as prodrome (something that becomes before) can only be termed as such retrospectively, after the event it is supposed to precede has occurred. It is even more disconcerting when qualifications such as...  Read more


View all comments by Ashok Malla

Comment by:  Roger Peele
Submitted 22 July 2009 Posted 22 July 2009

In addition to echoing Carpenter’s points, I would like to suggest that the “risk syndrome” comprises signs that have not yet differentiated themselves into catatonic, disorganized, or paranoid type. Believers in the risk syndrome could, however, use the present ICD-10 diagnosis of undifferentiated schizophrenia (which has far less focus on deterioration than does DSM-IV’s). This would have the disadvantage of using “schizophrenia,” but would open up the concept of treating people before they differentiate. Restated, the social/occupational dysfunction requirements of DSM-IV are totally arbitrary, and loosening up on that criterion would give “schizophrenia” more of a sense of a disorder, much like the rest of medicine where function doesn’t get confused with diagnosis. Still, this approach would not avoid the issues highlighted by Carpenter.

Additionally, I hope that the DSM-V will not preserve the unfortunate “positive” and “negative” division of schizophrenia. A less problematic division is “florid,” “conative deficits,” and “cognitive deficits.”

View all comments by Roger Peele


Comment by:  Anthony Morrison
Submitted 22 July 2009 Posted 22 July 2009

I am rather skeptical about the benefits of inclusion of an at-risk state in DSM-V, but relatively convinced regarding many of the costs, so am in support of Professors Yung and Cornblatt. With regard to proposed benefits, UHR criteria already exist, so it is unclear why these cannot be utilized to allow more research to be done (focusing on predictive validity, reliability, and treatment, in the same way that they do currently); if these need additional criteria, such as help-seeking, distress, or impairment, then these could be amended. Similarly, if we require international consensus to allow convergence of the slightly different approaches to defining UHR status, an organization like the International Early Psychosis Association would seem more fit for the purpose than the DSM. The argument that such a category would allow access to treatment in an insurance company-led, managed care context is appealing, but since most of these patients meet criteria for another axis-I disorder (for example, see McGorry et al., 2002), these...  Read more


View all comments by Anthony Morrison

Comment by:  Paul French
Submitted 22 July 2009 Posted 22 July 2009

Firstly, it is exciting to see that this debate is even taking place. It is an acknowledgement of the important work that has been undertaken by key researchers to develop strategies to identify and treat this group of individuals. However, despite some potential gains, it would currently be wrong to include an at risk category in the next iteration of the DSM.

As has been discussed in some of the slidecasts, the inclusion of an at risk category would certainly help focus attention on this population, and it would also improve the potential for larger, well-funded trials. But the problems associated with the creation of the at risk category are too great.

Having worked in both research and clinical settings, I have already seen a large numbers of clients who are being prescribed antipsychotic medication due to their being classified as “putatively prodromal.” As suggested, this terminology alone medicalizes these individuals. Additionally, it's problematic that the medication literature given to patients discusses schizophrenia, not risk. For young people in the midst...  Read more


View all comments by Paul French

Comment by:  Patrick McGorry, SRF Advisor
Submitted 22 July 2009 Posted 22 July 2009

The concept of a psychosis risk syndrome based on 15 years of research is a valid one which is breaking new ground in psychiatry. It is congruent with clinical staging approaches as practiced in oncology and other areas of medicine to assist in treatment selection in early stages of illness when the disorder is more susceptible to successful treatment. There is a similar attraction to this approach in psychiatry. Based on our own work in Australia in the early 1990s and with refinement through important subsequent U.S. and other international work, a set of criteria has been developed which not only defines a group of people with an immediate need for non-specific symptom- and needs-based care, but who also carry a greatly enhanced risk of progression over the short term to more severe and often (but not always) more persistent psychotic symptoms, often qualifying for a later diagnosis of schizophrenia or a related illness. The risk is elevated up to 400-fold under certain sampling conditions; however, the false positive rate for psychosis is appreciable, ranging from 60 to 90...  Read more


View all comments by Patrick McGorry

Comment by:  Cheryl Corcoran
Submitted 22 July 2009 Posted 22 July 2009

Let's do a cost-benefit analysis.

In prodromal research, we consider true positives to be those at-risk individuals who develop the disorder, and false positives to be those who do not. In prodromal research, we know that the false positive rate was initially high and that it is increasing further.

However, in considering adding the psychosis risk syndrome to the DSM, we must consider yet another distinction between true and false positives. In this case, true positives are those individuals identified correctly as at risk (with academic centers as the gold standard) and false positives are those who are incorrectly believed to be at risk (incorrect use of the criteria, etc.). We don't have any sense yet what the false positive rates will be in terms of clinicians in the community, but per Michael First in a personal communication, in the best outcomes for previous new DSM diagnoses in field trials, typically this is 65-75 percent.

Putting these false positive rates together—say a 20 percent true positive conversion rate (for the academic prodromal...  Read more


View all comments by Cheryl Corcoran

Comment by:  Michael Hwang
Submitted 24 July 2009 Posted 24 July 2009

Schizophrenic disorder has been known as a psychotic spectrum disorder that encompasses heterogeneous clinical phenomena and diverse neurobiological pathogenesis. This has resulted in a long, ongoing debate as to whether these varied clinical manifestations constitute unique clinical phenomena with distinct neurobiological bases, or alternatively, are part of a broader schizophrenic spectrum process. Modifications to more permissible diagnostic revisions in earlier DSMs and increasing emphasis on the recognition and treatment of specific symptoms in recent years have advanced our understanding and clinical care of schizophrenic patients, as they heightened clinician awareness and research interest. Extensive epidemiological, clinical, and more recently genetic studies, have shown that the currently recognized schizophrenic symptoms often overlap with affective and anxiety disorders such as depressive, obsessive-compulsive, and panic disorders, as well as some impulse control disorders.

While such comorbid schizophrenic patients may constitute a distinct schizophrenic...  Read more


View all comments by Michael Hwang

Comment by:  Thomas McGlashan
Submitted 23 July 2009 Posted 27 July 2009

In 1900 Freud declared dreams to be the royal road to the unconscious and then went on to elaborate psychodynamic psychiatry from that initial observation. Now in 2000 we have the risk syndrome for first psychosis and we can identify it reliably and follow it with scientific precision in ways that it can become our prospective royal road into the machinations of psychosis.

I recognized the power of this perspective the first time I saw Alison Yung's work at the PACE Clinic in 1994, and I have pursued this line of inquiry ever since. I still maintain my initial enthusiasm and I advocate strongly that the ultimate benefit of promoting this perspective far outweighs the risk.

I cannot argue at all with the caution expressed in many, if not most, of the critiques of nosologizing the risk syndrome, but I believe there is an almost exclusive focus here on the risks for the false positive person/patient. Little concern or question has emerged about the true positive person in the risk syndrome discussions. All of the concern centers around the dangers of making a mistaken...  Read more


View all comments by Thomas McGlashan

Comment by:  Anthony Grace, SRF Advisor (Disclosure)
Submitted 30 July 2009 Posted 2 August 2009

There is always a concern about treating individuals at risk for schizophrenia with potent drugs, especially given that the majority of those individuals will not transition to psychosis. On the other hand, there is evidence from Johnstone et al. (2002) that among children at risk for developing psychosis, the ones that show abnormally high stress reactivity are the individuals most likely to convert. We have found that stress can affect the dopamine system (Valenti and Grace, 2008) in a manner analogous to what occurs in our animal models of schizophrenia (Lodge and Grace, 2008). This is consistent with a model we had advanced that, along with others, posits a means by which stress could lead to psychosis in susceptible individuals (Thompson et al., 2004). Based on these data, we examined whether treating the already-present anxiety component could circumvent the onset of psychosis in an animal model. We now have preliminary evidence that...  Read more


View all comments by Anthony Grace

Comment by:  Joachim Klosterkötter
Submitted 24 August 2009 Posted 24 August 2009

During regular periodic revisions of the diagnostic systems, categories are assessed in terms of conformity with the current state of knowledge. In the event that new insights were gained since the last revision, categories are revised and adjusted.

Regarding the abnormalities that occur prior to psychotic episodes, the DSM-III listed eight symptoms and the DSM-III-R listed nine symptoms, of which at least two are needed to be evident in addition to a clear deterioration of performance, in order to fulfill the criteria for a prodromal phase. These symptoms, which at the same time were also utilized for the definition of the residual phase, were basically concordant with the symptoms used to diagnose a "schizotypal personality disorder" in DSM-III, DSM-III-R, and again in DSM-IV and its text revision. Additionally, evidence of these symptoms achieved a positive predictive power between 36 percent and 48 percent in the most thorough retrospective prediction analyses completed at that time (Jackson et al., 1995).

Similar to...  Read more


View all comments by Joachim Klosterkötter

Comment by:  Danny Koren
Submitted 9 September 2009 Posted 10 September 2009

At-risk states can be viewed in one of two ways. Namely, the "glass half full,” which translates into a low stigma, endangered health status; and the "glass half empty," which corresponds to a high stigma, emerging disease status.

The present structure of the DSM is designed to support only the "glass half empty" meaning of the at-risk syndrome.

An important question is whether adoption of the proposed at-risk syndrome into the next edition of the DSM will take place through a process of assimilation in which the syndrome will be pigeon-holed into the current disease oriented Procrustean bed of the DSM. Or, alternatively, will the syndrome be adopted through a process of accommodation in which the DSM will adapt its schema to accommodate both meanings of the at-risk state.

Like professors Cornblatt and Yung, and the many other commentators who share their concerns, I agree that the risks associated with adopting a psychosis risk syndrome into the DSM outweigh its potential benefits.

I believe that such adoption may be less risky if the DSM adapts itself to...  Read more


View all comments by Danny Koren

Comment by:  Eileen McGinn
Submitted 4 December 2009 Posted 4 December 2009

Weighing the benefits and harms of adding a "prodrome" for schizophrenia to the DSM as a separate diagnostic category is important at this time. The comments thus far reveal the values that many of us prioritize and the assumptions we bring to this issue. Early intervention may not always produce improved outcomes. We need to examine more closely under which conditions early interventions are more beneficial than harmful. If the screening, diagnosis, evidence base, and treatment outcomes are not robust, and if there are considerable social and medical harms probable or evident, early intervention may do more harm than good—it cannot be considered good public health policy. Recently, we have seen the controversy around possible and probable benefits and harms of breast and cervical cancer screening, with differing opinions based on competing views of the evidence base and differing values. The evidence base for these interventions is larger and clearer than for any psychiatric diagnoses. Also, long-term outcomes may not be better for early treatment versus delayed...  Read more


View all comments by Eileen McGinn
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