Short Report

Psychopathology 2014;47:292296
DOI: 10.1159/000365291

Received: March 24, 2014

Accepted after revision: June 17, 2014
Published online: July 10, 2014

Attenuated Psychosis Syndrome:

Dont Jump the Gun
Barnaby Nelson
Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne,
Melbourne, Vic., Australia

Key Words
DSM Psychosis Prodrome High risk

Abstract
Attenuated psychosis syndrome (APS) was introduced in
DSM-5 as a condition for further study. A number of concerns
have been raised regarding APS, including its validity as a
clinical entity, issues relating to stigma, the potential that it
is an unnecessary diagnosis of what might be a self-limiting
phase of attenuated psychotic symptoms, and treatment implications of the diagnosis. The current paper presents a
number of conceptual and practical issues that should be
addressed in deciding whether APS should be accepted as
an official diagnosis in subsequent editions of DSM. These
include the problem of transferring the established validity
of at-risk criteria to APS given some non-trivial differences
between the criteria sets, the relationship between attenuated psychotic symptoms and other presenting non-psychotic disorders, the difficulties of operationalising the
subthreshold or attenuated concept in standard clinical
practice, and the likelihood of the diagnosis leading to overprescription of antipsychotic medication for this group of
patients.
2014 S. Karger AG, Basel

2014 S. Karger AG, Basel

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Attenuated psychosis syndrome (APS) was recently

introduced in Section 3 (Emerging Measures and Models) of the Diagnostic and Statistical Manual of Mental
Disorders, fifth edition (DSM-5) [1] as a condition for
further study. The decision to include it in Section 3 rather than in the main body of the text was based on inconclusive results from the DSM-5 field trials on the reliability of the diagnosis in clinical settings. The diagnosis was
originally formulated as a risk syndrome (psychosis risk
syndrome), but was reformulated as a self-contained syndrome requiring diagnosis and clinical care.
APS is in its proper place as a condition requiring further research. It would have been premature to include
APS as a DSM-5 diagnosis, not just due to the inconclusive results from the field trials. A number of concerns
have been raised regarding its inclusion in the main body
of DSM. These have included:
Potentially unnecessary diagnosis and treatment of
what might be a self-limiting phase of attenuated psychotic symptoms.
Concerns regarding stigma and discrimination associated with the diagnosis, particularly given that patients
who would receive the diagnosis are subthreshold for
psychosis and that their symptoms might resolve without treatment.
Dr. Barnaby Nelson
Orygen Youth Health Research Centre, Centre for Youth Mental Health
University of Melbourne, 35 Poplar Road
Parkville, VIC 3052 (Australia)
E-Mail nelsonb@unimelb.edu.au

 The possibility of its inclusion leading to increased

prescription of antipsychotic medication for this
group, a practice for which there is not good evidence,
either as a preventative treatment or as a treatment for
existing symptoms.
The validity of APS as a clinical entity.
These issues have been thoroughly discussed elsewhere [e.g., 2, 3]. This article will briefly address the following: distress associated with APS; the relationship
between attenuated psychotic symptoms and other presenting non-psychotic disorders; operationalising the
subthreshold or attenuated concept in standard clinical
practice, and treatment implications.

Distress Associated with APS

The formulation of the syndrome requires that attenuated psychotic symptoms are the main source of clinical
concern, i.e., that they are the source of distress or disability that motivates help-seeking. Criterion D of APS
reads: Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention.
This criterion was partly introduced to guard against the
potential problem of overdiagnosis and diagnostic creep
(the threshold for diagnosis gradually shifting in response to clinical practice, political lobbying and other
social forces [4]). The requirement of the attenuated psychotic symptoms being a significant source of distress/
disability is not part of the current ultra-high risk/clinical
high risk/prodromal criteria (hereafter, at-risk criteria)
on which the APS is based. Indeed, attenuated psychotic
symptoms are frequently not the main source of distress
or disability in this patient population [5]. Data from the
PACE Clinic, Melbourne, indicates that attenuated psychotic symptoms were distressing for only 52% of ultrahigh risk patients, with social and other functional difficulties and depressive symptoms rating as the highest
sources of distress and reason for help-seeking (78 and
50%, respectively) [6]. (This is why the at-risk treatment
manuals are deliberately broad in target [7, 8].) This observation is not clinic-specific, with other at-risk clinics
reporting a similar profile of patients [Fusar-Poli et al.,
pers. commun., 2014]. Chest pain has been used as an
analogy for APS, because, as with chest pain, it is a symptomatic condition associated with a number of possible
trajectories [2]. While this would seem to be an apt analogy, the pain often does not correspond to the attenuated
psychotic symptoms in the at-risk group but rather to
other complaints.
Attenuated Psychosis Syndrome

This distress issue means that the formulation of APS

does not map neatly onto the at-risk criteria that formed
the basis of the proposal in the first place and which are
drawn upon as evidence for the validity of APS [9]. The
patients who would attract the APS diagnosis are really
only a subgroup of the broader at-risk group (those who
are distressed/disabled/help-seeking due to these symptoms). Validity and reliability should be established for
this subgroup via follow-up and group comparison studies rather than relying on the validity and reliability of the
broader at-risk group established in research studies.
Similarly, it is not logical to assume that phenomenological, neurocognitive or neurobiological markers of X (the
at-risk group), or the results of intervention studies in
this group, also apply to subgroup-X (APS) [10]. While
one might assume that narrowing the diagnosis in this
way creates a more nosologically valid clinical entity (and
may identify a group at higher risk of transitioning over
time from APS to full-threshold psychotic disorder), this
needs to be empirically tested. In fact, preliminary data
indicates that distress associated with attenuated psychotic symptoms or reason for referral being due to attenuated psychotic symptoms [5] does not correspond to
higher risk for transition to psychotic disorder. The findings of Rietdijk et al. [11] are consistent with this. They
found that at-risk patients ascertained via a traditional
case-recruitment strategy, relying on referral when psychotic symptoms were suspected, resulted in lower transition rates to psychosis than sequential screening of a helpseeking population entering secondary mental health services for non-psychotic problems. The former group
corresponds more closely to APS than the latter group, in
that the help-seeking/referral of this group was associated
with the emerging psychotic symptoms as opposed to
these symptoms being detected via screening and not
necessarily being a significant source of distress or reason
for help-seeking/referral.
One possibility for dealing with this distress issue is
to add a specifier of attenuated psychotic symptoms to
the diagnosis that more accurately captures the persons
presenting complaint and source of distress. So, for example, a person presenting with clinical depression who
also presents with attenuated psychotic symptoms could
receive a diagnosis of major depression with attenuated
psychotic symptoms. [The current psychotic symptoms
specifier refers to frank (or full-threshold) psychotic
symptoms rather than to attenuated symptoms.] Another
possibility, as suggested by some researchers [12], would
be to revert to the risk syndrome notion but broaden it
beyond psychosis to include multiple exit points (the
Psychopathology 2014;47:292296
DOI: 10.1159/000365291

293

pluripotential model), with treatment corresponding to

stage of disorder in line with the clinical staging model
[13]. This approach could capture people with a broader
range of presenting complaints, with the distress not necessarily associated with the attenuated psychotic symptoms, or at least not to the same degree as other (nonpsychotic) complaints.

The Relationship between Attenuated Psychotic

Symptoms and Non-Psychotic Disorders

Criterion E requires that the attenuated psychotic

symptoms are not better explained by another mental disorder. The problem with this is that we have not yet
achieved an adequate understanding of when attenuated
psychotic symptoms occur in the context of non-psychotic disorders (and can therefore be better explained by
these disorders), as opposed to viewing these attenuated
psychotic symptoms as schizophrenia light [14]. A body
of work indicates that psychotic symptoms are reasonably
common in non-psychotic disorders [1517] and substantial covariation of mood and psychotic symptoms exists in general population samples [1820]. Wigman et al.
[16] report data from a large sample where 27% of people
with anxiety and depressive disorders displayed one or
more psychotic symptom versus 14% in those without
these disorders (OR = 2.23). Two community studies reported that a large majority of young people who reported psychotic symptoms had at least one non-psychotic
axis-1 psychiatric disorder [17], indicating that psychotic
symptoms commonly occur in the context of non-psychotic (neurotic) conditions. Psychotic symptoms have
been found to be strong markers of risk for multimorbid
non-psychotic disorders, with their prevalence increasing
in a dose-response fashion in relation to the number of
axis-1 disorders [17, 21]. Given this body of work, how
exactly is a clinician to determine if the presenting attenuated psychotic symptoms can be accounted for by
these other, non-psychotic disorders or are better understood as an independent comorbid condition? Certainly
the concept of basic self-disturbance has shown great
promise as a specific phenotype of schizophrenia spectrum disorders and may be a useful concept for identifying when psychotic symptoms are indicative of schizophrenia spectrum disorders rather than non-psychotic
disorders [22], but further work needs to be done before
this construct (or other phenotypic or endophenotypic
markers) can be incorporated into routine clinical practice.
294

Psychopathology 2014;47:292296
DOI: 10.1159/000365291

A similar issue is the point that reality distortions that

are concomitant with borderline personality disorder [1,
p. 786] should not contribute to an APS diagnosis. The
approach at present in many at-risk clinics is to rate presenting symptoms on the relevant assessment instruments purely on their phenomenology rather than on
clinical formulation. The rationale for this is that at this
very early stage of disorder it is not yet clear whether
symptoms are part of the prodromal phase of an emerging disorder, such as a psychotic disorder, or represent an
existing disorder, such as borderline personality disorder,
or indeed are symptoms of comorbid disorders, such as
concurrent psychotic disorder and borderline personality
disorder. It is not clear why there should be a change of
approach for DSM-5, particularly given data indicating
that at-risk patients with borderline personality disorder
features are just as likely to transition to psychotic disorder as those who do not present with borderline personality disorder features [23]. As with point 1, this specification defines a narrower group than the at-risk criteria
without providing sufficient validation of this narrower
construct.

Operationalising the Subthreshold or Attenuated

Concept

The operationalisation and implementation of the

subthreshold/attenuated concept presents a challenge related to the issue of diagnostic creep [24]. Specifically,
how low is too low to be considered an attenuated psychotic symptom? The current description of APS in
DSM-5 lacks a clear operationalised definition of attenuation. While cut-off points are provided in the research
instruments, such as the CAARMS and the SIPS, the
judgement of the degree of attenuation that is allowed
before an individual is below the APS threshold is a constant challenge in the at-risk clinical and research field.
It is questionable how reliably this decision could be made
in standard clinical practice, particularly when there may
be pressure to provide a diagnosis in order to access treatment and gain insurance coverage.

Treatment Implications

The concern has been raised that the APS diagnosis

would lead to overprescription of antipsychotic medication in this group, in the absence of good evidence for the
effectiveness of antipsychotics, either as a treatment for
Nelson

existing symptoms or as a preventative treatment. This

would mean exposing this group to the side effects of
these medications, such as the potentially serious metabolic side effects, without delivering significant benefits
(i.e., an unfavourable risk-benefit ratio). In response to
this concern, the point has been made that introducing
APS as a diagnosis would be accompanied by education
and evidence-based treatment recommendations that
may reduce rather than increase antipsychotic medication use in this group [25]. While this may be the case in
some sectors it would seem rather optimistic that such
education and treatment recommendations are likely to
be terribly effective in the face of the substantial current
overuse of antipsychotics in this group [26] and the widespread endorsement amongst practitioners that APS
should be treated similarly to full-threshold psychosis, including the use of antipsychotic medications [27]. Education and recommendations regarding use of antipsychotics in this group are already conducted in Melbourne, including statements in the clinical practice guidelines for
early psychosis [28]. Despite these efforts we are seeing an
increase in prescription of antipsychotic medications for
this group in primary and secondary care [26], with 27%
of ultra-high risk patients now on antipsychotics at the
time of referral to the PACE clinic [Thompson A, unpubl.
data]. A similar percentage was reported in the North
American Prodrome Longitudinal Study [29].
It is instructive to look at other areas of psychiatry in
this regard. Clinical guidelines for first episode psychosis
recommend regular monitoring of weight gain and metabolic profiles in those prescribed antipsychotic medications. However, despite these guidelines, the level of metabolic monitoring is invariably poor in most clinical services [30]. Hetrick et al. [31] report file audit data
indicating significant divergence from clinical guidelines
in the treatment of depression in young people, with a

References

Attenuated Psychosis Syndrome

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treatment recommendations [32].

Final Comments

In summary, the current formulation of APS differs

from existing at-risk criteria (the issue of distress, the
interpretation of symptoms in the context of borderline
personality disorder, etc.) in ways which mean that the
established validity and reliability of at-risk criteria cannot be automatically transferred to the APS construct.
Given accumulating research findings that psychotic and
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intertwined phenomena than assumed in traditional classification systems, it is certainly not a straightforward
clinical decision whether attenuated psychotic symptoms
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as in the current formulation. APS also raises concerns
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also lacked sufficient representation by patients and carers of their opinion on the issue. None of the above is to
suggest that attenuated psychotic symptoms are not of
clinical concern or should not be addressed in treatment
or research studies. They should certainly be a treatment
target in their own right in help-seeking people and be
closely monitored for evolution over time. However,
these conceptual and practical issues should be addressed
before APS is accepted as an official diagnosis.

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