Werbeloff et al. make a valuable contribution with an epidemiological cohort that permits estimates of self-reported attenuated psychosis-like experiences as a risk factor for a future psychotic disorder in the non-ill population. The possibility that attenuated psychosis syndrome would be included in DSM-5 has created an intense and interesting debate. Jim van Os and I, both members of the responsible DSM-5 Work Group, provided an update on the controversy last year (Carpenter and van Os, 2011), and I have offered a rebuttal to some of the objections elsewhere (Carpenter, 2011). As this is a work in progress, I will briefly state where we are, at the moment, in the DSM-5 process.

• Criteria are developed and reliability data are presently being tested and evaluated. We know that experts with structured interviews have good reliability, but we need to determine whether non-expert clinicians have sufficient reliability to consider placing in the main text listing disorders rather than in the appendix.
• Persons meeting criteria would have a disorder not better classified elsewhere in DSM-5 [by definition], and the presence of "disorder" would be based on distress, dysfunction, disability, and help seeking (hence, very different from the population-based studies such as reported by Werbeloff). This would more closely represent cohorts established in special study centers dependent on clinical referrals. In the latter, a meta-analysis of transition to psychosis estimates 18 percent after six months, 22 percent after one year, and 36 percent after three years (Fusar-Poli et al., 2012).
• The potential importance of the category is not based on transition to psychosis, for this is secondary prevention in persons already manifesting a disorder. Reports from several groups of follow-up on cases that do not transition to psychosis document continued impairment in many cases with full remission in some. Incidentally, all of the expert centers reporting transition rates and course of the disorder are making observations of treated subjects, so natural course is not yet documented.
• If reliability is not satisfactory, it is very likely that the Work Group will recommend placement in the DSM-5 Appendix for more study. If reliability is okay, the issue will be hotly debated with much uncertainty as to the final recommendation.
• Either recommendation will be reviewed by a Scientific Review Committee and a Clinical and Public Health Committee, and the DSM-5 Task Force will afterwards determine what recommendation to make to the APA Board of Trustees.
• Work on this issue will be completed later this year, as the expected publication of DSM-5 is May 2013.

References:

Carpenter WT and van Os J. Should Attenuated Psychosis Syndrome Be a DSM-5 Diagnosis? Am J Psychiatry 2011 168: 460-463. Abstract

Carpenter Jr. WT. Criticism of the DSM-V risk syndrome: A rebuttal. Cognitive Neuropsychiatry, 16(2):101-106, 2011. Abstract

Fusar-Poli P, Bonoldi I, Yung AR, Borgwardt S, Kempton MJ, Valmaggia L, Barale F, Caverzasi E, McGuire P. Predicting Psychosis: Meta-analysis of Transition Outcomes in Individuals at High Clinical Risk. Arch Gen Psychiatry. 2012; 69(3);220-229. Abstract

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Editor's note: This is an addendum to Will Carpenter's previous comment above.

Jim van Os and colleagues now report on transition to psychosis from a non-clinical population sample. Transition rates are elevated for those with psychotic-like experiences, and persistence of these experiences increases risk for transition. Rates are substantially higher than the representative population without psychotic experiences, but much lower than clinical referral populations reported in studies to date.

References:

Kaymaz N, Drukker M, Lieb R, Wittchen HU, Werbeloff N, Weiser M, Lataster T, van Os J. Do subthreshold psychotic experiences predict clinical outcomes in unselected non-help-seeking population-based samples? A systematic review and meta-analysis, enriched with new results. Psychol Med. 2012 Jan 20;1-15. Abstract

View all comments by William Carpenter