High-risk-states for psychoses and schizophrenia

Abstract

Revision 5 of the diagnostic and statistical manual for mental disorders (DSM-V) has stimulated a debate about the inclusion of a risk for psychosis syndrome in order to facilitate the prevention of psychosis.

The presentation critically outlines the course of this debate, focusing particularly on the question of how the inclusion of such a syndrome could be justified in DSM-V and ICD-11.

Most participants in the debate have initially opposed the inclusion of a risk for a psychosis syndrome. They justified this dismissive attitude with scientific, clinical and ethical arguments. The predictive power of eligible criteria for first psychotic episodes appeared to be too low. Their use as diagnostic criteria would involve the danger of hastily treating many falsely diagnosed individuals at risk for psychosis with antipsychotics and unjustifiably putting them at risk for side effects. In general, diagnoses should be based on grounds of manifest illnesses and not include at risk states for later diseases.

Meanwhile, the understanding, that the risk of disease symptoms already has a pathological significance and therefore requires treatment has by now begun to be accepted. This applies both to the risk symptoms in the early initial prodrome, as well as to the high risk symptoms in the late initial prodrome. It would therefore be reasonable to use these two sets of criteria for the definitional operationalisation of the new diagnostic category in the classification systems. This would allow the continuation of preventive efforts but also the development of evidence-based treatment within standard care.