Clinical High Risk (CHR) for psychosis represents a crucial area in mental health, focusing on early identification and intervention for individuals exhibiting subtle symptoms that might precede a psychotic disorder. While various definitions of CHR exist, they all underscore the importance of providing clinical care for individuals experiencing these symptoms and associated functional impairments. Although some individuals with CHR may eventually develop full psychosis, often within the schizophrenia spectrum, many others present a more complex diagnostic picture that necessitates careful consideration beyond just psychosis. These individuals display a range of mental health concerns, highlighting the need for appropriate clinical categorization and tailored mental health services. The central question then becomes: how do we effectively classify and understand the diverse psychopathology observed in individuals who are at risk of psychosis but may never fully develop the condition?
One potential avenue for classification is the Attenuated Psychosis Syndrome (APS), which is included in Section 3 of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for further research. APS, along with other CHR definitions, serves as a provisional diagnostic category, acknowledging that a definitive diagnosis may emerge over time. This approach recognizes the immediate need for evidence-based detection and intervention for individuals exhibiting CHR symptoms. While some may argue against formal diagnostic labels for “risk symptoms,” assigning a diagnostic code is often necessary for clinical care, facilitating evidence-based treatment and enabling clinical trials aimed at symptom reduction and preventing the onset of full psychosis. The establishment of a diagnostic class for CHR individuals has been debated, with both proponents and opponents presenting valid arguments.
Considering the current diagnostic landscape, what are the practical alternatives for classifying patients with CHR symptoms? There are at least four approaches within existing classifications, each with its own advantages and disadvantages.
Firstly, utilizing a V code for “other conditions that may be a focus of clinical attention” is a possibility. However, the broad nature of V codes, while capturing various clinical situations, fails to address the specific psychopathology at the core of the CHR concept. Given the extensive research and understanding surrounding CHR, such a non-specific classification seems inadequate.
Secondly, employing existing disorder classes like 300.02 Generalized Anxiety Disorder or 296.21 Major Depressive Disorder is another option. While some CHR individuals may eventually meet criteria for these disorders, this approach overlooks the crucial risk symptoms inherent to the CHR concept. It may be valid for some in the long run, but it misses critical current symptomatology and misaligns the CHR concept with scientific evidence. Established mood and anxiety disorders are intended for diagnosed conditions, not transient symptom descriptors present across various disorders.
Thirdly, a multi-diagnostic approach involving comorbid diagnoses could be considered. This involves assigning separate diagnoses for each presenting psychopathology, such as anxiety disorder for anxiety, sleep-wake disorder for sleep disturbances, and depressive disorder for depressed mood. While this approach acknowledges the various symptoms, it treats them as independent phenomena, lacking a cohesive overarching concept and failing to adequately address psychotic-like experiences. In contrast, within established psychotic disorders, co-occurring depression or anxiety are not viewed as independent comorbid disorders but rather as expected and integrated features of the broader psychotic condition. These initial three approaches fail to prioritize the psychosis-like symptoms central to the CHR construct.
A fourth, more pertinent option within DSM-5 is found under Other Specified Schizophrenia Spectrum and Other Psychotic Disorder 298.9, where Attenuated Psychosis Syndrome is explicitly listed as an example. This option offers certain advantages, yet remains part of a heterogeneous category potentially including individuals outside the CHR spectrum. Its informativeness is contingent on the explicit mention of APS.
Several key points emerge from this analysis:
- CHR is inherently a heterogeneous syndrome, implying that any diagnostic approach will likely lead to future reclassifications for many individuals.
- Clinical care must be individualized, addressing the specific psychopathology and functional impairments of each person, irrespective of diagnosis.
- Classification systems must facilitate the translation of CHR research into effective clinical care for those for whom the research is relevant.
Beyond the current classification system, the concept of a novel “placeholder” diagnostic category holds appeal. Despite its limitations, such a category could practically highlight the substantial variability among individuals in both their current needs and ultimate diagnostic classification. Conceptually, it could promote the integration of information across different psychopathology domains, rather than treating each symptom in isolation.
Acknowledging the inherent challenges in any approach to CHR conceptualization, four key considerations support the development of a new diagnostic class:
- 1. Extensive CHR research strongly validates this classification, revealing findings that are inconsistent with alternative diagnostic categories.
- 2. Initial treatment trials demonstrate that interventions can effectively reduce current symptoms, potentially improve functioning, and contribute to the secondary prevention of psychosis. Translating this evidence-based care to CHR individuals in general clinical practice necessitates a systematic identification approach.
- 3. Regardless of the diagnostic strategy, the CHR group encompasses individuals on diverse trajectories. Some may progress to psychosis, others may exhibit stable features aligning with other disorders (e.g., mood, anxiety, personality disorders), while some may recover without a definitive diagnostic clarification.
- 4. A placeholder diagnosis explicitly acknowledges the need for time for diagnostic clarification.
There is an urgent need to address this issue, particularly as clinical services for CHR populations are expanding rapidly, sometimes outpacing the systematic application of scientific findings. Immediate priorities include:
- 1. Achieving expert consensus on a diagnostic concept and clear criteria for CHR.
- 2. Demonstrating the reliable application of this diagnosis in routine clinical settings and developing guidelines to ensure the translation of research into practical clinical care.
- 3. Conducting clinical trials of interventions targeting the broad spectrum of psychopathology to determine optimal approaches for managing the range of symptoms, functional impairments, and quality of life issues, as well as for secondary prevention of psychosis.
Acknowledgment
The Authors have declared that there are no conflicts of interest in relation to the subject of this study.
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