MIKE (not his real name) had always been an unusual child. Even as a toddler, he had difficulties relating to others and making friends, and he seemed strikingly suspicious of other people. After he entered high school, Mike became increasingly angry, paranoid and detached. He worried that people were searching his room and his locker when he was not around. His grades plummeted as he turned inward during class, sketching outlandish scenes in his notebooks and muttering to himself rather than listening to the instructor.
Paranoia and difficulties connecting with others are signs of psychosis, a mental illness in which people lose touch with reality. Psychotic individuals usually have problems forming rational, coherent thoughts. They also may hear voices or hallucinate while believing that what they perceive is real. Often such delusions result in bizarre behavior and, in severe cases, an inability to manage everyday life. But a psychiatrist deemed Mike’s symptoms too mild to qualify him as psychotic. Mike obviously needed some kind of professional intervention, so he bounced among psychiatrists who could not figure out how to help him.
Cases such as Mike’s have prompted some practitioners to propose the inclusion of a new psychosis risk diagnosis to the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the “bible” of mental health diagnoses. To receive this diagnosis, a patient would first need to report, for example, having delusions or hallucinations about once a week (as opposed to most of the time for at least one month for clinical psychosis). In addition, either the patient or a loved one must be significantly distressed by those symptoms. The idea of including such a diagnosis in the DSM is highly controversial, but supporters argue that patients such as Mike not only need immediate help, they are at increased risk for developing full-blown psychosis, an outcome doctors might be able to prevent with early intervention.
An Ounce of Prevention
Currently patients diagnosed with full-blown psychosis find relief from so-called atypical antipsychotic medications such as risperidone and olanzapine, which help to reduce hallucinations and delusions. Patients may also benefit from some forms of psychotherapy. And data suggest that the earlier such patients receive help by either method, the better they fare. In a study published in 2005 psychiatrist David L. Penn of the University of North Carolina at Chapel Hill and his colleagues analyzed 30 studies evaluating treatments for first-episode psychosis. The researchers found that early, aggressive treatment with medication and psychotherapy, as compared with no treatment, showed promise in reducing both psychotic symptoms and their impact on patients’ lives. Thus, intervening with patients earlier, at the “risk” stage, could conceivably be even more beneficial, some argue.
In addition, several recent studies have found that two forms of psychotherapy alone—without medication—can help control psychotic symptoms even before a person can be officially diagnosed as psychotic. Using cognitive-behavior therapy, practitioners encourage patients to look for evidence supporting their hallucinations and delusions. And so-called acceptance and commitment therapy alleviates psychotic symptoms by teaching patients mindfulness—the ability to focus on the moment in a nonjudgmental way. What is more, in a study published in 2010 psychiatrist G. Paul Amminger of the Medical University of Vienna in Austria and his colleagues found that over-the-counter omega-3 fatty acid supplements reduced the onset of full-blown psychosis by 23 percent in young people with subclinical psychosis.
As a result of such data, psychiatrists such as William T. Carpenter, Jr., of the University of Maryland, who chairs the Psychotic Disorders Work Group for DSM-5, believe that intervening at a prepsychotic stage could ameliorate and even thwart this serious mental illness in a large number of people. Preliminary studies, he says, show that individuals who fit the putative criteria for the psychosis risk syndrome—now officially dubbed attenuated psychosis syndrome—are tens to hundreds of times more likely to develop schizophrenia and psychosis than the average person. Preventing some of these cases would be a huge boon to the individuals affected and would lift the burden on their families, communities and the mental health system as a whole.
Nevertheless, critics contend that accurately identifying a person at risk for psychosis is very difficult and far from foolproof. Although severe cases of psychosis are generally easy to recognize, early warning signs can be subtle. Is Mike’s increasing paranoia a harbinger of an imminent psychotic episode, or does it reflect a slightly more extreme version of teenage difficulties? Symptoms of drug addiction, depression or other medical conditions can also be mistaken for those of psychosis.
Perhaps because of such ambiguities, most people who receive the psychosis-risk label will never actually become psychotic, according to Allen Francis, a psychiatrist emeritus at Duke University and chair of the group that created the DSM-IV. In a 2003 study, for example, a team led by psychiatrist Patrick McGorry of the University of Melbourne in Australia found that six out of every 10 people deemed at high risk of psychosis did not end up developing it.
False diagnoses are problematic, Francis says, because of the perils of unnecessary treatment. People recognized as having mental health disorders are often prescribed antipsychotic drugs, which can be dangerous, he notes. Side effects can include significant weight gain, increases in blood glucose and cholesterol levels, and movement problems. If a patient is falsely labeled, he or she can end up enduring those side effects unnecessarily.
To improve the accuracy of such verdicts, researchers are trying to identify better warning signs of psychosis, such as finding genetic signatures that may foretell the illness and anatomical patterns that doctors might see in brain scans. (Some scientists are working on parallel projects geared toward finding biological markers that can help them predict other mental disorders, such as bipolar disorder and major depression.)
At the moment, treating people such as Mike with nondrug remedies can minimize the hazards of misdiagnoses. For Mike, a course of cognitive-behavior therapy and, eventually, a low dose of antidepressants controlled the worst of his symptoms. No one knows for sure whether Mike was in danger of becoming psychotic, but he is slowly improving. Such cases will warrant consideration as the DSM-5 Psychotic Disorders Work Group decides whether to adopt attenuated psychosis syndrome as a valid diagnosis, reject it entirely, or include it as a provisional diagnosis and request more research. The final decision will be made public by May 2013.