Controversial New Diagnosis in DSM-5 May Be Faulty

Pam Harrison

October 17, 2012

Attenuated psychosis syndrome (APS), a new and controversial diagnosis for potential inclusion in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is questionable, new research suggests.

A large study conducted by investigators at Brown University, in Providence, Rhode Island, showed that among a large sample of psychiatric outpatients, not a single patient met criteria for the APS diagnosis who did not already meet criteria for another DSM disorder — a finding that calls into question the true need for the new diagnosis, investigators note.

"APS has been a controversial topic because the introduction of this diagnosis would basically lower the threshold for diagnosing someone with a psychotic-type disorder. Making such a diagnosis has serious implications because it could lead to inappropriate treatments, such as antipsychotic medications that could pose more risks than benefits for these patients or increase stigma," lead researcher Brandon Gaudiano, PhD, said in a statement.

The study is published in the October issue of the Journal of Clinical Psychology.

Dr. Gaudiano noted that the diagnosis of APS was developed on the basis of the treatment of patients at specialty clinics, so it was a selective sample. Because of this, the investigators were interested to see how the same criteria would work in a nonspecialty setting.

The study included 1257 treatment-seeking psychiatric outpatients recruited from June 1997 to June 2002 at a single center.

Patients were screened using the Psychiatric Diagnostic Screening Questionnaire, a 125-item self-report measure to screen for psychiatric diagnoses.

Researchers also used the Structured Clinical Interview for DSM-IV (SCID-I) as well as the Structured Interview for DSM-IV Personality (SIDP-IV) to diagnose current DSM-IV Axis I and II disorders, respectively.

Patients diagnosed with a current or past DSM-IV psychotic disorder were excluded from the analysis.

Of the remaining sample (n = 1218), 28.3% (n = 345) endorsed at least 1 psychotic experience over the past 2 weeks.

In contrast, only 2.5% of the sample, or 31 patients, did not endorse any psychotic experiences or meet criteria for any current DSM disorder.

More importantly, only 1 patient endorsed psychotic experiences but did not meet criteria for a current psychiatric disorder, based on the SCID-I or the SIDP-IV.

"If you ask someone if they have been sad over the past few weeks, a lot of people would say, 'yes.' This is similar if you loosen the criteria for psychotic disorder. There are a lot of people in a general psychiatric outpatient population who can relate. So this casts a very wide net, and it's the beginning of a very slippery slope," Dr. Gaudiano told Medscape Medical News.

These findings, he added, suggest that patients who are not psychotic but who are diagnosed with APS could end up being treated unnecessarily with antipsychotic drugs.

"Once a diagnosis gets put into the DSM, it starts getting used," said Dr. Gaudiano.

The rationale for the proposed APS diagnosis was early identification and treatment of high-risk patients with the aim of preventing conversion to full-blown psychosis.

"The problem with that thinking is that the vast majority of patients with attenuated symptoms will never develop a psychotic disorder," said Dr. Gaudiano.

There is also no evidence to suggest that antipsychotic drugs are efficacious in patients with attenuated symptoms of psychosis, he added.

"If you capture many more people who don't have the disorder and never will have the disorder, there is no clinical utility in it. This is just the wrongheaded strategy for trying to prevent schizophrenia."

Jim van Os, MD, from Maastricht University Medical Centre, the Netherlands, told Medscape Medical News that he agreed with the Rhode Island researchers and campaigned against including the APS as a new diagnosis in the DSM-5 because he shared similar concerns.

It appears that this argument may have prevailed because, according to the investigators, the APS diagnosis will likely be included in the appendix of the DSM-5 and not as part of the main text.

Dr. Gaudiano has disclosed no relevant financial relationships. Coinvestigator Dr. Zimmerman reports receiving royalties from the Western Psychological Services for the Psychiatric Diagnostic Screening Questionnaire. Dr. van Os has received speakers' honoraria from a number of pharmaceutical companies.

J Clin Psychiatry. Published October, 2012. Abstract