The Risk-Benefit Ratio of the Proposed DSM-5 Attenuated Psychosis Syndrome

To the Editor: We commend Dr. Weiser's editorial on early intervention in patients at risk for schizophrenia in the August 2011 issue of the Journal (1) and in particular his conclusion that current evidence does not support the practice of routinely offering such patients clinical treatment with antipsychotic medication. However, we must take issue with the hypothetical clinical case patient who displays the attenuated positive symptoms used to identify risk. Because the attenuated positive symptoms cause the patient no distress and his sole reason for seeking treatment is unrelated to the specific symptoms, his risk is presumably low.

As Dr. Weiser notes, such a patient might meet research criteria for ultra high risk (2) or a psychosis risk syndrome (3) if the nondistressing attenuated positive symptoms were rated as sufficiently severe to pass threshold, but this hypothetical case would not meet the proposed DSM-5 criteria for attenuated psychosis syndrome. The criteria currently being tested in field trials do not permit such presumably low-risk patients to receive the diagnosis because criterion D requires that the attenuated positive symptoms themselves must be “sufficiently distressing and disabling to the patient and/or parent/guardian to lead them to seek help” (4, 5). The field trials should help determine whether these criteria can be applied with reliability in the clinical setting.