A much anticipated addition to the revised Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) is questionable according to research findings. The newly revised DSM-5, the first alterations since it was last revised in 1994, includes attenuated psychosis syndrome (APS), a new diagnosis that would identify those impaired by preliminary psychotic symptoms that do not meet the threshold for an existing diagnosis as having a psychotic disorder. In an effort to understand the impact this new diagnosis would have in a real clinical setting, researchers at Butler Hospital, Brown University and Rhode Island Hospital studied how APS applied in an outpatient clinic, and found reasons for concern. The findings are published in the October issue of Journal of Clinical Psychiatry.
Published by the American Psychiatric Association, the DSM provides standard criteria for the diagnosis of mental disorders and is used by clinicians and other key mental healthcare professionals across the U.S. "Including APS as a new diagnosis in the DSM-5 has been an issue of debate since its first consideration because of the negative impact it could have on patients and their families," said Brandon Gaudiano, PhD, a research psychologist at Butler Hospital and an Assistant Professor of Psychiatry & Human Behavior at the Alpert Medical School of Brown University. One of the original rationales for APS was to help identify patients who are at high risk for transition to a psychotic disorder in the near future but do not currently meet the criteria for one of the existing DSM-4 psychotic disorder diagnoses. In the study of over 1,200 patients, the researchers did not identify a single patient who met the criteria for APS who did not already meet the criteria for another existing DSM disorder, thus calling into question the true need for the new diagnosis.
The study also found that 28 percent of clinic patients reported these attenuated psychotic symptoms in addition to their other common psychiatric symptoms. The researchers believe that these attenuated symptoms are better explained by the patients' existing conditions, such as depression and anxiety in most cases, and are unlikely to represent true psychotic symptoms. However, if included in the new DSM-5, the fear is that many clinicians could simply give APS as an additional diagnosis, thus causing many more patients to be inappropriately labeled as potentially "psychotic." "APS has been a controversial topic because the introduction of this diagnosis would basically lower the threshold for diagnosing someone with a psychotic-type disorder. Making such a diagnosis has serious implications because it could lead to inappropriate treatments such as antipsychotic medications that could pose more risks than benefits for these patients or increased stigma," said Gaudiano.
Researchers and clinicians anticipate APS to be included in the appendix of the revised DSM-5 coming out in 2013, not the main text. As Gaudiano explains, this would not officially recognize the syndrome as an accepted diagnosis, but rather open the door for discussion of its utility and allow for further studies of if and how APS may be made more useful and less problematic.