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Criteria for the Risk Syndrome for First Psychosis
All six of the following:
A.
Characteristic Symptoms: At least one of the first three A criteria symptoms for
Schizophrenia (delusions, hallucinations, disorganized speech) is present in
attenuated form (attenuated positive symptoms). The symptom must be of sufficient
severity and frequency as to be beyond the usual normal variation. Reality testing
must be retained, however, and the symptom must not interfere substantially with
thinking, social relations, or other behavior.
B.
Frequency/Currency: The symptom or symptoms meeting criteria A must be present
in the past month and occur at an average frequency of at least once per week in the
past month.
C.
Progression: The symptom or symptoms meeting criteria A must have begun or
worsened in the past year.
D.
Distress/Disability/Treatment Seeking: The characteristic symptoms are sufficiently
distressing and/or disabling to the patient and/or others to lead to help-seeking.
E.
Characteristic attenuated positive symptoms are not better explained by other DSM-V
diagnoses.
F.
Clinical criteria for any DSM-V frank psychotic disorder have never been met.
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Text for the Risk Syndrome for First Psychosis
Psychotic disorders are commonly preceded by positive psychotic-like symptoms of
recognizable clinical significance even though reality-testing is maintained. During this
period of time, patients are commonly described as being in a prodromal or ultra high risk
state. Persons manifesting such a syndrome are often treatment seeking because of these
symptoms, social withdrawal, and attendant disabilities. They are also at high risk for
becoming worse, ie, developing frank psychosis within the next few weeks, months, or years.
It is known that mild psychotic experiences which are not compromising or distressing occur
not infrequently in persons in the community, and that such phenomena do not necessarily
confer increased risk for a psychotic disorder. The collection of symptoms and disabilities
described here, however, constitute a syndrome of current and future clinical significance,
and individuals who experience them are often help seeking. Further research is needed to
determine the difference between psychotic phenomena that do and do not reach the clinical
realm described here.
There may be other clinical syndromes that are also risk syndromes for first psychosis.
These include, for example, recent onset psychotic episodes that are brief and intermittent, or
a dramatic functional deterioration of recent onset in a person with high "genetic loading"
(eg, family history) for psychosis. In research thus far, such syndromes are very uncommon
compared to the one described here which focuses upon the recent emergence of positive
symptoms that qualitatively mimic those of psychosis yet are attenuated in their frequency
and intensity. Schizotypal personality disorder, when diagnosed in adolescence or young
adulthood, may also be associated with elevated risk to develop frank psychosis.
The risk syndrome for first psychosis is distinguished from risk factors, which are stable,
often demographic, characteristics that can confer a heightened lifetime risk for psychosis,
such as male gender or family history of psychosis. Risk factors differ from the risk
syndrome for psychosis in that they are in and of themselves not associated with current
symptoms or clinical impairment.
Because the attenuated positive symptom syndrome described here may also be a near-term
precursor to psychosis, one of the most important tasks in the diagnostic process is actually
ruling out that psychosis is not already present. Psychosis is present if any of the
characteristic attenuated positive symptoms are rated as being or having recently been at a
psychotic level of intensity, e.g. associated with loss of reality testing, full delusional
conviction, and/or substantial interference with functioning. If any of these have been
present, then the diagnosis is drawn from one of the frankly psychotic disorders in the
psychosis or affective disorders section.
Characteristic Symptoms and Progression
The diagnosis of a risk syndrome for first psychosis, like the diagnosis of psychosis proper, is
made on the basis of positive symptoms. One or more of the following positive symptom
domains detailed below must be present. Symptom severity in the prodromal range can vary
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from mild to severe. In general the mild level of severity is distinguished from normal by the
unanticipated intrusion of new, unusual, seemingly unwilled thoughts, feelings, and
perceptual experiences upon one’s everyday mental palette, resulting in varying levels of
associated puzzlement, distress or dysfunction. At the severe level these thoughts and
experiences are persistent, anticipated, compelling, and organized into symptomatic
expressions that mimic the delusions, hallucinations, or disorganized communications of
frank psychosis except that reality testing and organized communication is preserved or can
be elicited in the diagnostic interview. Please note that a risk syndrome for psychosis cannot
be diagnosed if frank psychosis has ever been present. Patients who have partly recovered
from frank psychosis may have attenuated symptoms similar to those described here, but they
are in a residual phase of illness and cannot be considered at risk for first psychosis.
Attenuated Delusions
Attenuated delusions in the risk syndrome for psychosis may include any of the following:
Feeling perplexed, confused or strange, thinking that the self, the world, and time has
changed (often in ways that cannot be described), having ideas of reference that are not
perceived as directly threatening to the individual, unusual ideas (about the body, guilt,
nihilism), overvalued beliefs (about philosophy, religion, magic), or feeling loss of control
over mental events (eg. thought insertion, broadcasting). When mildly prodromal in
intensity, such experiences are novel and strange but easily dismissed. The persistence of
such experiences may become irritating or worrisome. When severe in prodromal intensity,
such experiences may be very compelling and seem to influence (but not control) will and
attention. They usually affect functioning and may seem real but doubt can still be induced
by contrary evidence and others' opinions.
Attenuated delusions may have suspiciousness/persecutory ideation content including
persecutory ideas of reference, suspiciousness, or paranoid thinking. The patient may present
with a guarded or even an openly distrustful attitude that intrudes on the interview or directs
behavior. When mild in severity the person harbors notions that people are untrustworthy.
They may be hypervigilant or convey a sense that people are saying negative things about
them. Rapport with the interviewer may take some time to establish. When severe but still
within the prodromal range the person entertains loosely organized beliefs about danger or
hostile intention. Guarded behavior in the interview can interfere with the ability to gather
information. Reality testing and perspective can be elicited with non-confirming evidence or
opinion, but the propensity for viewing the world as hostile and dangerous remains strong.
Attenuated delusions may have grandiose content. Grandiose ideas in the risk syndrome for
psychosis present as a high opinion of oneself and as an unrealistic sense of superior
capacity. The person may be verbally expansive or boastful and pursue goals that are
inflated relative to their talents and/or resources. When mild the person harbors notions of
being gifted, influential, or special. He or she may promote unrealistic plans but usually can
be reoriented by others. When severe the person has persistent beliefs of superiority that
often alienate friends and worries relatives. Thoughts of being special may lead to unrealistic
plans and investments, yet skepticism about these attitudes can be elicited with persistent
questioning and confrontation.
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Attenuated Hallucinations
This domain in the risk syndrome for psychosis includes alterations in sensory perceptions,
usually auditory and/or visual. When mild the sounds and images are often unformed (eg,
shadows, trails, halos, murmurs, rumbling). They are usually experienced as unusual, seldom
as worrisome. When severe these experiences become more vivid and frequent, ie, recurring
illusions or hallucinations that capture attention and affect thinking and concentration. At
such a level these perceptual abnormalities may also disrupt behavior, but skepticism about
their reality can still be induced.
Disorganized Communication
Disorganized communication in the risk syndrome for psychosis may present as odd speech
(vague, metaphorical, over-elaborate, stereotyped), unfocused speech (confused, muddled,
too fast or too slow, wrong words, irrelevant context, off track), or meandering speech
(circumstantial, tangential). When mild the patient frequently gets into irrelevant topics but
responds easily to occasional clarifying questions. Speech may be odd but understandable.
At the moderate level speech becomes meandering and circumstantial and when severe it
fails to get to the point without external guidance (tangential). At the severe level thought
blocking and/or loose associations may occur infrequently, especially under pressure, but
reorienting questions quickly return structure and organization to the conversation.
Associated Features
Persons meeting prodrome criteria also commonly display psychiatric symptoms from other
domains of psychopathology. Negative symptoms are prominent and expressed as social
anhedonia, avolition, blunted expression of emotion, diminished subjective experience of
emotions, truncated ideational richness, and poor occupational functioning. Personal
disorganization is often apparent in the form of odd behavior and/or appearance, bizarre
thinking, trouble with focus and attention, and impairment in personal hygiene. A degree of
attentional and/or cognitive impairment, often symptomatic, is also common. Finally,
general symptoms of distress often emerge in the form of sleep disturbances, and impaired
tolerance to normal (daily) stress.
Associated Disorders
A substantial number of patients meeting prodrome criteria will also meet DSM-V criteria
for one or more other disorders. Common examples include major depression, social anxiety
disorder, or a substance abuse disorder. These other disorders should be diagnosed as
comorbid conditions, unless they are believed etiologically to account for the symptoms that
would otherwise qualify as meeting risk syndrome criteria, in which case criterion E is not
met and the risk syndrome for psychosis should not be diagnosed.
Prognostic Features for Psychosis Onset
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Several prognostic factors have been proposed that may heighten the risk for progression to
frank psychosis among patients with a risk syndrome. These include poor current
functioning, more severe attenuated positive symptoms, substance abuse comorbidity, family
history of psychosis, comorbid schizotypal personality disorder, significant decline in
functioning in the past year, and more severe cognitive impairment.
Differential Diagnosis
Depression. Symptoms of reality distortion to a nonpsychotic degree are common in major
depression (such as an unrealistically negative self worth appraisal). Such common and
mood-congruent reality distortions do not qualify as characteristic symptoms for a psychosis
risk syndrome. However, depression-like symptoms that may sometimes qualify for a
syndromal DSM-V diagnosis are common in patients who do meet risk syndrome criteria
based on characteristic symptoms as described above. When risk syndrome criteria are met
in the context of prominent depressive symptoms, both diagnoses may be given, unless the
otherwise characteristic qualifying symptoms are clearly due to the major depression, in
which case criterion E is not met and a diagnosis of depression with psychotic features may
be preferred. When major depression and the psychosis risk syndrome co-occur, either
syndrome may be given as the principal diagnosis, based on severity and need for care.
Mania. Symptoms of reality distortion to a nonpsychotic degree are also common in mania
and hypomania (such as an unrealistically positive self worth appraisal). Such common and
mood-congruent reality distortions do not qualify as characteristic symptoms for a psychosis
risk syndrome. Mania-like symptoms have not been particularly common in patients who do
meet risk syndrome criteria based on characteristic symptoms as described above. When risk
syndrome criteria A are met in the context of prominent manic symptoms, usually only the
manic diagnosis is given, unless the characteristic qualifying symptoms are clearly not due to
the mania.
Affective disorder with psychotic features. Distinction between the risk syndrome for
psychosis and affective disorder with psychotic features is made difficult by issues similar to
those discussed for Schizophrenia and Schizoaffective Disorder. In Major Depressive
Disorder with Psychotic Features, the psychotic features complicate a major depression
whose intensity is usually in the very severe range, and the psychotic features are usually
mood congruent. In a risk syndrome patient with comorbid major depression, by contrast,
the attenuated psychotic features occur in the context of depressive symptoms whose severity
is usually in the mild or moderate range, and the psychotic features are usually mood
incongruent.
Substance-induced psychosis. Substance use is common among patients meeting risk
syndrome criteria, and abuse and dependence can be seen as well. When otherwise
qualifying characteristic symptoms are strongly temporally related to substance use episodes,
the patient may not meet criterion E, and a diagnosis of substance-induced psychosis may be
preferred.
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Schizotypal personality. Generally, more symptoms are required for a schizotypal
personality disorder diagnosis than for a risk syndrome diagnosis, and a risk syndrome
diagnosis requires that symptoms have been recently progressive, while in schizotypal
personality they may be recently progressive or recently stable. Comorbidity between the
two syndromes is common.
Attention deficit disorder. Attention impairment is common in risk syndrome patients.
When attention impairment arises de novo during adolescence or young adulthood,
consideration should be given for a risk syndrome diagnosis. On the other hand, historical
onset of attentional impairment in early childhood does not rule out a current risk syndrome
diagnosis, especially if attentional impairment has been recently progressing. Early
childhood attentional impairment is potentially consistent with “premorbid” symptoms of
developing psychosis or with comorbid ADD.
Anxiety disorder. Symptoms of reality distortion to a nonpsychotic degree are common in
social anxiety disorder (such as an unrealistically appraisal of other’s opinions in social
anxiety disorder; or an unrealistic appraisal of dangers to one’s own health or the health of
others in panic disorder; or unrealistic appraisal of a threat to self in PTSD; or an unrealistic
appraisal of the consequences of nonperformance of rituals in OCD). Such common anxious
reality distortions do not qualify as characteristic symptoms for a psychosis risk syndrome.
However, anxiety symptoms that may sometimes qualify for a syndromal DSM-V diagnosis
are common in patients who do meet risk syndrome criteria based on characteristic
symptoms as described above. When risk syndrome criteria are met in the context of
prominent anxious symptoms, both diagnoses may be given, unless the otherwise
characteristic qualifying symptoms are clearly due to the anxiety disorder, in which case
criterion E is not met. When anxiety disorder and the psychosis risk syndrome co-occur,
either syndrome may be given as the principal diagnosis, based on severity and need for care.
Frank Psychosis. By definition, the risk syndrome for psychosis differs from Psychosis
NOS, Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, and
Schizophrenia in that the attenuated psychotic symptoms are not, and never have been, of
fully psychotic intensity.
Specific Culture, Age, and Gender Features
Specific cultural features associated with the risk syndrome have not been well studied but
may be similar to those described for schizophrenia. Onset for the risk syndrome typically
occurs from the early teens to the early thirties. The median age at presentation has been 1617 in most studies. More males than females are common in risk syndrome samples, as for
schizophrenia itself.
Prevalence
The prevalence of the risk syndrome for psychosis in the general population has not been
well-studied.
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Course
In the studies thus far the total duration of the prodromal phase in patients who progress to
frank psychosis averages 1-2 years. However, the time to psychosis onset after presentation
can be rapid, e.g. days or weeks.
Three general outcomes for the attenuated positive symptoms are to be expected among
untreated patients who meet risk syndrome criteria: progression to frank psychosis,
stabilization of symptoms, or remission. Generally 20-50% of patients are expected to
progress to frank psychosis within 1 month to 2 years of receiving a risk syndrome diagnosis.
This proportion may vary by the population from which the sample is drawn. For example, if
persons meeting prodrome criteria are identified by screening the general population, the risk
of psychosis may be lower. Conversely, if persons meeting prodrome criteria are identified
by referral of help-seeking patients, the risk of psychosis may be higher. Patients whose
symptoms stabilize may meet criteria for schizotypal personality disorder if symptoms are
sufficiently numerous. Lastly, attenuated positive symptoms are expected to remit fully
without specific treatment in a significant proportion of persons meeting prodrome criteria.
Nevertheless, it may be prudent to maintain contact with such patients in case attenuated
positive symptoms recur.
Progression to Psychosis: Definition of Onset
The risk syndrome for psychosis frequently progresses or “converts” to full psychosis. The
DSM heretofore has not defined a point at which psychosis is judged to begin. Research in
this field defines transition from prodrome to psychosis as follows. Both A and B are
required.
A. Positive symptoms are present at a fully psychotic level intensity, i.e.:
1. Unusual thought content, suspiciousness/persecution, or grandiosity with delusional
conviction (no doubt)
and/or
2. Perceptual abnormality perceived as fully distinct from self (full hallucinatory
perceptual intensity)
and/or
3. Speech that is blocked, incoherent, or unintelligible.
B. Any (A) criterion at frequency and duration or urgency, i.e.: sufficient to interfere
substantially with thinking, social relations, or other behavior, as evidenced by:
1. The symptom has occurred at fully psychotic intensity over a period of one month
for at least one hour per day at a minimum average frequency of 4 days per week
or
2. The symptom is seriously disorganizing or dangerous.
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Progression of Psychosis After Onset
Patients who do progress to full psychosis are expected initially to receive schizophrenia
spectrum diagnoses roughly half the time and affective psychosis diagnoses 10-25% of the
time. The remaining patients will receive other nonaffective psychosis diagnoses such as
psychosis NOS. Over time the proportion of schizophrenia spectrum diagnoses is expected
to increase, the proportion of affective psychosis diagnoses to remain relatively stable, and
the proportion of other nonaffective psychoses to decline.
Familial patterns
As many as 20% of risk syndrome patients are expected to have a family history of psychosis
in first degree relatives and as many as 33% in first or second degree relatives. Family
history of nonpsychotic psychiatric disorders is common but nonspecific.
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