General News — 21 November 2012
‘Attenuated’ psychosis not a DSM-5 diagnosis

Adding attenuated psychosis syndrome to the upcoming DSM-5 is unnecessary and potentially dangerous, researchers argue.

When Assistant Professor Brandon Gaudiano and colleague Dr Mark Zimmerman heard that attenuated psychosis syndrome or APS was slated to appear in the upcoming DSM-5, they wanted to know what impact it would have.

The diagnosis was created for patients who are “impaired by subthreshold psychotic symptoms that are not better accounted for by another diagnosis” and don’t meet the criteria for a psychotic disorder.

Researchers conducted a post hoc analysis of more than 1200 psychiatric outpatients in the US. While 28% of the patients had at least one psychotic experience in the previous two weeks, only one patient in that group did not meet the criteria for another disorder already in the DSM.

Moreover, that patient had other nonpsychotic symptoms of greater severity, and the authors’ analysis showed that severity of general clinical symptoms predicted endorsement of psychotic experiences.

“We could not identify any patients who clearly met criteria for APS alone in our sample,” the authors concluded.

“Diagnosing APS in the community could result in high rates of false-positives or high rates of APS “comorbidity” with other nonpsychotic disorders, leading to the increased use of antipsychotic medications without clear need.”

Attenuated psychosis syndrome is currently being considered for the appendix of the DSM-5 because field tests could not confirm the reliability of the criteria and the psychosis research community remains deeply divided over its merits, Assistant Professor Gaudiano says.

“Our study demonstrated that a substantial proportion of patients with common depressive or anxiety disorders could be viewed as having ‘attenuated’ psychotic symptoms, depending on the way the clinician was inclined to interpret them,” he adds.

“The stated purpose of including new syndromes in the appendix is to stimulate further research… I think that including APS in the DSM, even in the appendix, might spur some clinicians to use it either explicitly or implicitly to guide their treatment decisions.”

That, he believes, could have some negative ramifications.

“Proponents of APS state that recognising this syndrome in clinical practice would not require medication treatment and it might not even be recommended.

“However, the realities of clinical practice, including the lack of resources for behavioural interventions or time and money to pay for them, especially in primary care settings, would make it a pretty good bet that patients identified as having APS or even some of these symptoms, would be more likely to be prescribed antipsychotic medications. The problem is that research suggests that antipsychotics do not have favourable risk-benefit profiles for this group.”  

As first appeared in Medical Observer, 20 November 2012. Source: J Clin Psychiatry 2012; online 2 Oct

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