Should a Risk Syndrome for First Episode Psychosis be Included in the DSM-5?

Barnaby Nelson; Alison R. Yung


Curr Opin Psychiatry. 2011;24(2):128-133. 

In This Article

Abstract and Introduction


Purpose of review The purpose of this paper is to review recent discussion about the possibility of including a new category in the next version of the DSM (DSM-5) for the 'at risk mental state' or the 'psychosis risk syndrome'.
Recent findings A number of issues have been addressed by commentators in the field, including the issue of early intervention versus the risk of false positives; stigma and discrimination; the use of antipsychotic medication in at-risk individuals; how to manage clinical need; whether the Risk Syndrome is a valid clinical entity; the reliability of assessment of the Risk Syndrome; and where to place the Risk Syndrome in the DSM-5.
Summary There are several issues about which advocates of the different positions (for or against inclusion of the Risk Syndrome category or advocating inclusion of an alternative category) are in agreement. These include that people who meet the 'at risk' criteria are symptomatic and in need of clinical care, that they have a greatly increased risk of developing a psychotic disorder within a brief time frame, and that they need treatment for current problems and to prevent transition to psychotic disorder. However, a source of disagreement between the positions is the relative importance that they afford each of these factors.


In the mid-1990s criteria were introduced in the hope of prospectively identifying people in the prodrome of schizophrenia and other psychotic disorders. These criteria identified individuals with attenuated positive psychotic symptoms, brief self-limiting psychotic symptoms, and those with a family history of psychotic disorder combined with a decline in functioning.[1] The criteria were subsequently used in a number of studies, with rates of onset of psychosis ranging between 20% and 40% over the short term.[2,3] These rates are substantially higher than in the general population and other clinical populations. This field of research has variously been referred to as 'ultra high risk (UHR)',[1,4] 'clinical high risk (CHR)',[2,5] the 'at risk mental state (ARMS)',[6] the 'prodromal stage',[7] and 'prepsychosis'.[8]

Recent discussion has focused on whether the attenuated psychotic symptoms component of the criteria should be included as a diagnostic category in the next version of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5). Different terms have been suggested for this new diagnosis, including 'Psychosis Risk Syndrome', 'Risk Syndrome for First Psychosis', and, most recently, the 'Attenuated Psychotic Symptoms Syndrome' (,[9•,10] see Table 1). The diagnosis would be a 'transitional' diagnosis in that it would be intended to be used for a limited period of time and be supplanted by other DSM diagnoses later, should their criteria be met. In this sense, it would be akin to 'mild cognitive impairment' as a prodromal risk syndrome for dementia.[11] This is a controversial suggestion, and different opinions have been espoused as to its merit. The purpose of the current paper is to review recent publications on this issue.

There are three positions on whether the Risk Syndrome should be included in the DSM-5: it should be included, it should not be included, and a new diagnosis should be added to DSM-5 but that this should be a diagnosis of disorder per se, not risk of disorder. Despite opposing positions, there are features common to the three alternatives.


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