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News Brief: Attenuated Psychosis Syndrome Left Out of DSM-5 Main Text

20 June 2012. The American Psychiatric Association (APA) has announced that the main text of the revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will likely not include attenuated psychosis syndrome as a formal diagnosis. Instead, the controversial syndrome is slated to appear in the appendix, along with other categories that the APA deems in need of further study (read the full announcement on their website). The decision is based on the recommendation of the APA’s Psychotic Disorders workgroup, which has been considering if and how attenuated psychosis syndrome should appear in the DSM-5, due to be published in May of 2013, for the past several years.

Attenuated psychosis syndrome (APS) is characterized by mild psychotic symptoms that don’t meet the diagnostic criteria for a full-blown psychotic disorder, as well as significant distress and disability that bring the individual to clinical attention. Individuals with these symptoms are at an increased risk of later developing a psychotic disorder, with transition risks of 18 percent at six months and about 40 percent after three years (Fusar-Poli et al., 2012). Nearly three-quarters of those who do transition receive a diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder (Fusar-Poli et al., 2012).

The question of whether or not DSM-5 should include an APS diagnosis has sparked a lively debate (see SRF Live Discussion), with scores of researchers and clinicians on both sides of the issue. Although APS has been widely studied (see SRF related news story) and several interventions have been proposed to reduce conversion rates (Preti and Cella, 2010), the Psychotic Disorders workgroup has decided that more information is needed before the diagnosis can be included in the main text. In particular, the high comorbidity of APS with other psychiatric illnesses, such as depression and anxiety, is one reason cited for the workgroup’s decision. The APA cautions that more data are needed to determine if APS is a distinct illness or merely a subtype of the comorbid disorders, and if the distress and disability experienced with APS may be due to these other illnesses. In addition, in a preliminary study, the workgroup found that physicians may not be able to reliably identify APS based on the current diagnostic criteria.

For more information about the community’s reaction to the APA announcement, check out a recent Nature News article.—Allison A. Curley.

Comments on News and Primary Papers
Comment by:  William Carpenter, SRF Advisor (Disclosure)
Submitted 27 June 2012 Posted 27 June 2012

Debating APS is interesting, and reasonable people will disagree on key issues. Clarity on a couple of points would reduce confusion and help make the debate more substantive:

1. Attenuated psychotic symptoms and attenuated psychosis syndrome are not at all the same. The latter is under consideration by DSM-5; the former is not. APS, if referring to the syndrome, is a putative disorder class with criteria requiring distress, disability, dysfunction, and help seeking. It encompasses a clinical cohort where, by definition, another DSM-5 disorder class is not a better fit. When low-level psychotic-like phenomena are observed in non-ill populations, it is interesting, but by definition these are not disease symptoms, and they have no known relationship to the disorder concept captured by APS as defined in the DSM-5 considerations.

2. Anxiety and depression are ubiquitous in persons developing a number of disorders. This is clearly the case in persons developing psychotic disorders. The diagnostic significance of anxiety and depression experiences is often clear in...  Read more

View all comments by William Carpenter

Comment by:  Allen Frances
Submitted 28 June 2012 Posted 28 June 2012

Among all the problematic DSM-5 suggestions, this was the most premature and the riskiest. The three strikes against it are: 1) an unacceptably high false positive rate (over 90 percent in the most recent study; Morrison et al., 2012); 2) no intervention has been proven effective; and 3) the likelihood it would result in inappropriate use of harmful antipsychotic medication.


Morrison AP, French P, Stewart SL, Birchwood M, Fowler D, Gumley AI, Jones PB, Bentall RP, Lewis SW, Murray GK, Patterson P, Brunet K, Conroy J, Parker S, Reilly T, Byrne R, Davies LM, Dunn G. Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial. BMJ . 2012 ; 344():e2233. Abstract

View all comments by Allen Frances

Comment by:  Frauke Schultze-LutterStephan RuhrmannJoachim Klosterkötter
Submitted 6 July 2012 Posted 6 July 2012

Inclusion of the attenuated psychosis syndrome in Section III of DSM-5—Chance or Defeat?
The heated, often assuming scientific and public debate of the past three years over the introduction of an attenuated psychosis syndrome in DSM-5 has recently come to a conclusion for the time being, with the DSM committee deciding not to include it in the main section but rather the appendix, i.e., Section III. With this, attenuated psychotic symptoms (APS), one of the five main single criteria developed and examined within the context of preventive efforts to psychosis (Fusar-Poli et al., 2012), will continue to be the subject of further research for some time. However, in comparison to other at-risk criteria such as the remaining two ultra-high-risk criteria (Yung and McGorry, 1996) or the basic symptoms criteria (Schultze-Lutter et al., 2007), it will be considered not mainly as a predictor...  Read more

View all comments by Frauke Schultze-Lutter
View all comments by Stephan Ruhrmann
View all comments by Joachim Klosterkötter

Comment by:  Patrick McGorry, SRF Advisor
Submitted 17 July 2012 Posted 17 July 2012

Diagnosis in psychiatry is struggling to deliver. Its main function should be to guide clinicians to select the right treatment approaches. However, we have too many categories that overlap and have low utility for treatment planning and prediction of outcome.

Diagnostic inflation (more “splitting” with micro-categories) is not the answer. We need a simpler but more practical approach. This will involve “lumping,” with categories only included if they are justified by differential treatment needs.

I have argued that we need to import the clinical staging idea from general medicine (McGorry et al., 2006). The purpose would be to help with more accurate treatment selection and to allow early diagnosis of potentially serious illness in a safe and non-stigmatizing way, ensuring that benefits always outweigh risks. Of course, this means breaking the nexus in the U.S. that drug treatment is the main or only form of intervention for patients—a nexus reinforced by the hard neurobiological reductionism that took over...  Read more

View all comments by Patrick McGorry
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