On the front page of the November 18th issue of Psychiatric News is an article titled "Attenuated Psychosis Diagnosis Still Up in the Air for DSM 5" It consists an interview with Rajiv Tandon, who is a member of the Psychotic Disorders Work Group, an esteemed researcher, an experienced clinician, and a reasonable man. He attempts to provide a balanced view on Psychosis Risk Syndrome (aka Attenuated Psychotic Symptoms) and provides some good news, but there is still much to worry about.
Good news first: 1) Dr Tandon assures us that no final decision for inclusion has yet been made and recognizes the considerable opposition even within the work group; 2) he concedes that 'psychosis risk' is in fact a very poor predictor of the later development of psychosis; and 3) he recognizes the risk that inclusion will increase the already troubling misuse of antipsychotic drugs.
But Dr Tandon's interview fails to meet any of the past concerns and raises a whole set of new ones:
1) Dr Tandon assertion that the work group is awaiting the results of the DSM 5 field trials before making its final decision makes absolutely no sense. As it is designed, the field trial could not be more irrelevant to the work group's decision making. For unclear reasons, it was limited to testing only reliability and was conducted only in academic settings. The results will therefore tell us nothing at all about what really counts- the rates of false positive diagnosis and the potential for misuse of antipsychotic drugs in typical clinical practice. The field tests cannot possibly provide any additional information that could warrant inclusion of psychosis risk in DSM 5. The work group is deluding itself in believing there are insufficient data right now to make the decision to exclude psychosis risk or that the field trial can somehow save it.
2) Dr Tandon provides a quote that perfectly sums up the problems that occur when researchers have too much influence in producing a DSM. He says the work group is trying to balance opposing values: "On the one hand are those who say there is going to be overdiagnosis of kids who might never go on to develop psychosis but who will unnecessarily be treated with antipsychotics. And on the other hand are those, especially in academic research, who say, 'How can you not include this category? This is a frontier of psychiatry. This is the future.' "
This is a no brainer- kids count more than researchers. DSM 5 has to be a workaday manual that is proven safe and scientifically sound as a guide to current clinical practice. It is not meant to be a risky cutting edge research instrument to be fully tested only after it is published. The potentially ruined lives of kids who develop obesity and diabetes from unnecessary antipsychotic treatment are orders of magnitude more important than satisfying the whims and dream lists of academic researchers.
3) Dr Tandon states that: "The field recognizes that we have to try to intervene earlier, if we can identify those at high risk and if we have safe and effective treatments that can decrease that risk. And we have a model from other branches of medicine for risk syndromes, such as hypercholesterolemia, that are aggressively treated." This states the problem in a nutshell. Yes, it would be nice to have preventive treatments. But No- we can't currently identify who is at high risk and we have no effective treatment, and the treatment that will most likely be used is remarkably risky.
4) The article goes on to state; "If included in the text, Tandon said there would need to be extensive education around the fact that people who meet criteria for APS may not necessarily convert to active psychosis, but may warrant close monitoring without routine treatment with antipsychotics". In an ideal world sure, but in the real world most 'education' is done by drug salesman who have pushed the sales of antipsychotics to an astounding $16 billion/year in the US alone. Their methods are so aggressive and misleading that three drug companies have been forced to pay huge fines a(Lilly's was for $1.4 billion and included admission of criminally promoting off-label usage, often targeted to children). The work group's suggestion that there would be counter balancing education is a naïve pipe dream.
Bottom Line: DSM 5 is filled with reckless proposals, but psychosis risk is by far the worst. It was the reason I felt compelled to begin criticizing DSM 5 and should have been dropped years ago. The best interest of APA and DSM 5 would be served not by keeping it 'up in the air', but instead by immediately dropping it like the lead balloon it is.
