While the age of onset for schizophrenia and many other major mental illnesses typically falls into the early twenties, clinicians have long noted the existence of early indicators which act as a warning that a first psychotic episode may be imminent. Usually referred to as prodromal symptoms ( prodrome is a clinical medical term referring to the early symptoms or signs that precede the full-blown illness), research literature has identified behavioural shifts that might indicate impending psychosis (although such symptoms tend only to be recognized in retrospect). Prodromal signs in patients with known psychosis might also signal an impending relapse and mental health workers are trained to recognize the warning signs so that proper intervention may occur. Such symptoms may either be recognized by the patient directly, by clinicians, or by family members. These symptoms might include changes in mood, increasing disinhibition, or bizarre ideas (such as paranoid claims or unusual beliefs). Since delayed treatment for a first psychotic episode can often worsen the outcome, there is a very real need to act on prodromal symptoms as soon as possible. Unfortunately, given that the presence of prodromal signs do not invariably result in psychosis, acting prematurely can often do more harm than good.
Scheduled for publication in May 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-V ) represents the latest attempt at classifying the vast range of different ways in which mental illness can be manifested. Currently in the consultation phase, the DSM-V contains a proposed psychosis risk syndrome diagnosis which has attracted controversy. Also referred to as Attenuated Psychotic Symptoms Syndrome , the suggested diagnostic criteria are:
All six of the following:
a) Characteristic symptoms: at least one of the following in attenuated form with intact reality testing, but of sufficient severity and/or frequency that it is not discounted or ignored
b) Frequency/Currency: symptoms meeting criterion A must be present in the past month and occur at an average frequency of at least once per week in past month c) Progression: symptoms meeting criterion A must have begun in or significantly worsened in the past year; d) Distress/Disability/Treatment Seeking: symptoms meeting criterion A are sufficiently distressing and disabling to the patient and/or parent/guardian to lead them to seek help, e) Symptoms meeting criterion A are not better explained by any DSM-5 diagnosis, including substance-related disorder. f) Clinical criteria for any DSM-V psychotic disorder have never been met
Mental health professionals testing for the diagnosis are advised to assess each dimension on a four-point scale ranging from 0 (Not present) to 4 (Present and severe). Hallucinations and delusions are assessed separately and a separate category for cognitive impairment has also been proposed. In proposing the new diagnosis, the DSM-5 work group has argued that early signs and symptoms of schizophrenia can be identified long before the first psychotic episode and some researchers have even suggested that schizophrenia risk can be predicted in infancy. While acknowledging the potential impact of stigma and negative predictive ability, the proposed diagnosis is currently being evaluated in field trials to determine whether it should be included in the DSM-V as part of the main manual or in the Appendix as worthy of further research. It has also been the subject of considerable attention the clinical literature (both pro and ) as well as the mainstream media.
In a recent article in Harper's Magazine , author Rachel Aviv discussed many of the real-life implications of psychosis risk syndrome. The article (of which the author very kindly provided a reprint) provides interviews with several young adults who were patients at several of the sixty clinics in the United States providing treatment for early psychotic symptoms. Given that these patients are still in the very early stages of their illness, the question of whether the symptoms would procede to full-blown psychosis is very real. She also presents some of the findings of the North American Prodromal Longitudinal Study ( NAPLS ). Made up of eight research centres based in universities and hospital clinics across the U.S. and Canada, the NAPLS consortium was awarded a five-year grant by the National Institute of Mental Health to undertake a prospective, longitudinal study of 720 prodromal patients and 240 matched healthy controls for the purpose of establishing and refining prediction algorithms intended to identify those at greatest risk for developing schizophrenia. While initial studies showed risk of onset to be only 35% using conventional clinical protocols for assessing psychosis risk, the NAPLS algorithms showed significantly improved prediction ability (but moderate sensitivity). The ongoing NAPLS research project will be incorporating neuroimaging, genomic, electrophysiological, hormonal, and psychosocial factors to create a data-set twenty times larger than any other study previously undertaken.
The proposed psychosis risk syndrome diagnosis for the DSM-V is largely based on the preliminary findings of the NAPLS although fundamental questions remain concerning the ethical consequences of false positives as well as how soon biomedical interventions should begin in cases of prodromal psychosis. If prodromal patients never progress to full-blown psychosis , would they be able to live normal lives without the stigma often attached to mental illness in most societies? These are concerns which are only beginning to be addressed.