TCPR: Dr. Carpenter, you are a member of the DSM-5 work group that is considering risk syndrome for first psychosis, or what is now called “attenuated psychosis syndrome” as a new diagnosis in the manual. Please give us some background on this.
Dr. Carpenter: Whichever side of the debate you are on, I think we can all agree that there is a lot of evidence that attenuated psychotic symptoms are an important phenomenon. What we mean by “attenuated symptoms” is a weaker than usual threshold for, say, schizophreniform disorders. My coauthor on an editorial for The American Journal of Psychiatry, Jim van Os, and I have had many debates on this issue, and each have compelling arguments for including or not including this diagnosis in the new manual. [You can read the editorial in the May 2011 issue of The American Journal of Psychiatry].
TCPR: What is attenuated psychosis syndrome?
Dr. Carpenter: When we first began studying this disorder, we were calling it “risk syndrome for first psychosis,” but actually, it doesn’t make sense to conceptualize it as a “risk.” Rather, it is a disorder unto itself, like angina, for example. So, you need to be able to identify and diagnose angina, and if you are effective in treating it, among other things maybe you will decrease the likelihood of or delay heart attack. But it’s not looked at as though the one true measure of successful angina treatment is not having a heart attack. Keeping the patient comfortable, active, and functional is successful treatment. Either way, angina is a disorder in and of itself that merits clinical attention.
TCPR: How have you gone about studying whether this is a legitimate, or “reliable,” diagnosis?
Dr. Carpenter: The criteria are being field tested, and we’re awaiting data on reliability. ”Field testing” means that we’re seeing how well this diagnosis would work in real practice. To do that, we have a number of psychiatrists who are not experts in this diagnosis see a number of patients, some of whom would meet the criteria for attenuated psychosis syndrome and others who meet some sort of nearby criteria, for example schizotypal personality disorder or a mood disorder. A patient may see two clinicians (or have his or her office visit recorded and viewed by a second clinician) to see if there is agreement on diagnosis.
TCPR: What is the threshold that you are looking for in making this a “reliable” condition?
Dr. Carpenter: Probably in the 0.6 to 0.7 range or higher. That means pretty good agreement among different clinicians as to the presence or absence of the syndrome.
TCPR: Paint for me a portrait of a patient who might end up with the diagnosis of attenuated psychosis syndrome.
Dr. Carpenter: Imagine a young person, perhaps between the ages of 15 and 30, who comes in because either the patient or somebody else in his or her life is worried. The patient will have some psychotic-like symptoms, but in your judgment doesn’t reach sufficient severity to make a psychosis diagnosis. These would be things like suspiciousness, a little paranoia, pulling away from friendships, deterioration in school or work, decline in functioning, maybe sometimes hearing things. So you as the clinician think this person has maintained insight despite some perceptual aberrations. There is also distress and some disability. So you have to figure out: does he or she actually have a disorder?
TCPR: How did you come up with these symptoms as the basis for attenuated psychosis syndrome?
Dr. Carpenter: The criteria are derived from and validated in the seven North American sites funded by NIMH to conduct studies of the prodromal, or “at risk,” mental state. The question is: where do you draw the line between normal non-ill levels of these experiences and an actual illness? One doctor might diagnose schizotypal, and somebody else might just say this is weird adolescence, and somebody else may think it is psychosis NOS. “Care seeking” is another criteria for this diagnosis. [To read all of the criteria for the diagnosis, see http://bit.ly/dXXgBO]
TCPR: Tell us a little about stigma around a psychotic diagnosis, since this is something your group has considered.
Dr. Carpenter: These young people are self-stigmatizing by having abnormal experiences and social interactions. They are referred to doctors for help and receive some diagnosis. It is unclear whether there will be an increase or decrease in stigma by adding this diagnosis. It is, by definition, non-psychotic.
TCPR: Does this diagnosis mean this person is destined for schizophrenia?
Dr. Carpenter: Usually not. A person might always stay in this state; or he or she might get worse and move into a psychotic disorder; or he or she might get better. So if the person has these minor league psychotic-type phenomena for many years, you might think schizotypal personality. If the symptoms started recently and have been exacerbated by a depression, it might be a major mood disorder with mild psychosis. But if the patient doesn’t fit an existing diagnosis, then the use of the attenuated psychosis syndrome would be a correct disorder. There have now been a number of studies that have followed both patients who don’t make a transition to psychosis and those who do. Estimates for a transition to a psychotic condition have varied widely depending on referral source with a range between 10% and 40% (Correll CU, et al, J Child Psychol Psychiatry 2010;51(4):390–431). The most common diagnosis in those who make this transition is schizophrenia, which accounts for about half of this group, but other psychoses, including bipolar and depression with psychotic features have been included. When debating this, people sometimes argue that if a patient doesn’t transition, he or she shouldn’t have this diagnosis. But I always go back to the angina argument—this is a condition on its own that needs to be treated as such, not just as a risk factor for another illness.
TCPR: Tell us more about those people who may not transition into a full blown psychotic disorder.
Dr. Carpenter: There is a tendency for those who don’t transition to actually get better. However, even those who “get better” continue to have functional impairments (Marshall C et al, Shizophrenia Bull 2011;37(suppl 1):272; Addington J et al, Am J Psychiatry 2011;April 15:online ahead of print). So, even though some people might no longer meet criteria for diagnosis, it looks like many of them continue to have impairments that cause distress.
TCPR: What are some of the financial implications of this new diagnosis?
Dr. Carpenter: In most cases, you have to have a codable diagnosis in order to bill insurance and treat a patient in the U.S. Giving these patients a real diagnosis will allow us to keep them in clinical care and monitor them more closely. In the absence of this diagnosis, I speculate that these patients are classified as schizotypical personality because they have features of that diagnosis. Others maybe are considered to have anxiety, depression, or psychosis NOS.
TCPR: Assuming that this is a reliable diagnosis and we begin diagnosing these patients, will antipsychotics be helpful?
Dr. Carpenter: We know antipsychotics have efficacy for these types of symptoms in almost any condition where they occur, so there would be little reason to doubt that they would have it in this. Various randomized controlled clinical trials suggest that antipsychotics would decrease the transition rates (Kelly C et al, Psychiatr Danub 2010;22(suppl 1):S56–62). But the real issue is risk/benefit ratios. I would argue that antipsychotics are not a good place to start, and a number of professional organizations have published guidelines that caution against the early use of antipsychotic drugs.
TCPR: So if not antipsychotics, what is the right treatment for this?
Dr. Carpenter: First, there is probably going to be distress in the family, so you can try to diminish the stressful experiences that they are having. There may well be anxiety and insomnia, which can be treated with medication or psychosocial interventions. The doctor may need to address substance abuse. There are many practical issues to address while monitoring the clinical state to determine if psychosis is emerging.
TCPR: If we do end up turning to an antipsychotic for some of these cases, do you have any thoughts on which would be the best?
Dr. Carpenter: I think any time we use an antipsychotic, almost the only thing we have to go on is what set of adverse effects is most compatible for this person. So I would think that you would want to do something low dose that is benign for dysphoria, EPS, and metabolic features and sort it out from there. You might consider aripiprazole (Abilify) maybe ziprasidone (Geodon), and maybe low doses of lurasidone (Latuda). Generic risperidone may be an acceptable choice, and low to moderate affinity first generation drugs may also be considered. I think you would be eager to stay away from drugs like olanzapine (Zyprexa), clozapine (Clozaril), and haloperidol (Haldol) based on adverse effect profiles.
TCPR: When will a final decision be made on whether this diagnosis makes it into DSM-5?
Dr. Carpenter: We will know the results of field trials late summer 2011. We have to have final text to the publisher in time for the book to come out in May of 2013, so my guess is that fall and winter 2012 will be the crunch of decision making time.
TCPR: Thank you Dr. Carpenter.