Attenuated Psychosis Syndrome Was Not Actually Removed from DSM-5
What’s in a name? That which we call a diagnosis by any other name would be just as codable.
Those following the DSM-5 controversies will remember the infamous “Psychosis Risk Syndrome,” considered to be the most controversial proposal for the new diagnostic manual. The idea behind the “disorder” category was to capture subthreshold psychotic symptoms before they develop into a full psychotic disorder like schizophrenia. The problem? A false positive rate of 60-90 percent. The vast majority of people diagnosed would never go on to develop a full psychotic disorder.
DSM-5’s “Psychosis Risk Syndrome” proposal was met with heated backlash from all corners of the mental health world. Allen Frances, chair of the DSM-IV Task Force, wrote that the proposal is a “risky, scientifically unsupported idea,” an “ill–conceived and potentially harmful” suggestion that “could turn into a public health nightmare.” Even researchers who dedicated their professional lives to studying psychosis risk, like Patrick McGorry, felt that its inclusion in the DSM was premature: “We want to provide help, but we don’t want to turn everyone into a brain disease.”
In response to the hullabaloo, the DSM-5 Task Force first changed the name of the proposed diagnosis to “Attenuated Psychosis Syndrome.” But the diagnostic criteria remained the same, and researchers weren’t appeased. In the words of Allen Frances, “The suggestion remains just as dangerous and stigmatizing, whatever it is called.”
In May 2012, the DSM-5 Task Force dropped the proposal, relegating it to “Section III” of the manual, reserved for diagnostic categories that require further research before consecration as “official” mental disorders. The decision was received with a great deal of fanfare in the major media and the mental health community. Headlines announced “Psychiatry Manual Drafters Back Down on Diagnoses” (New York Times), “Psychosis risk syndrome excluded from DSM-5” (Nature), and “Wonderful News: DSM-5 Finally Begins Its Belated And Necessary Retreat” (Psychiatric Times).
Later, when criticized for the their ideas in the New York Times, the American Psychiatric Association (APA) was quick to clarify that Psychosis Risk was no longer under consideration for DSM-5: “Updated draft proposals for Attenuated Psychosis Syndrome and Mixed Anxiety Depression have been proposed for inclusion in Section 3 of DSM-5, the area designated for conditions that require further study before they can be considered disorders.”
Consensus had it: Psychosis Risk/Attenuated Psychosis Syndrome was “not ready for prime time.”
Unfortunately, consensus had been misinformed. Attenuated Psychosis Syndrome actually DOES appear as a diagnostic category in DSM-5. It appears in the research appendix (Section III), starting on page 783, but it also appears in the main body of the text, in the section on Schizophrenia Spectrum and Other Psychotic Disorders, page 122. There, it is featured as a specific type of the official, codable diagnosis “Other Specified Schizophrenia Spectrum Disorder”/ “Other Psychotic Disorder.”
The purpose of this brief post is simply to point out that, contrary to popular belief, the “Attenuated Psychosis Syndrome” (psychosis risk) diagnosis is official and codable in DSM-5. I’ll leave it to others to deliberate what it’s doing there, why the APA was announced that it wasn’t, and what the implications are. For now, it seems that even if psychosis risk isn’t ready for prime time, it already made the official lineup — just under a different stage name.