Probably at-risk, but certainly ill - Advocating the introduction of a psychosis spectrum disorder in DSM-V

Current criteria for an increased risk of developing first-episode psychosis are associated with conversion rates many times higher than the general incidence of psychosis. Yet, non-conversions still outnumber conversions, and conversion rates across and within centres vary considerably, fueling the ongoing debate about clinical and ethical justification of indicated prevention. This debate, however, almost exclusively focuses on the predictive validity of at-risk criteria, thereby widely disregarding the main general finding: persons meeting at-risk criteria already suffer from multiple mental and functional disturbances for those they seek help. Moreover, they exhibit various psychological and cognitive deficits along with morphological and functional cerebral changes. Thereby, the majority of help-seeking at-risk persons fulfils DSM-IV's general criteria for mental disorders (defined as a clinically significant behavioural or psychological syndrome associated with disability and/or severe distress) and clearly have to be considered as 'ill', i.e., as 'patients' with a need and right for treatment. Hence, the clinical picture defined by current at-risk criteria should be more adequately perceived as not only a still insufficient attempt to define the psychotic prodrome but a psychosis spectrum disorder in its own right - akin to ICD-10's schizotypal disorder - with conversion to psychosis just being one of several outcomes. Such a disorder, whose criteria are proposed and discussed, should initially be part of DSM-V research criteria. Following from this shift in the perception of current at-risk criteria, access to standard medical care would have to be granted, and diagnosis- or symptom- rather than conversion-related interventions would have to be developed. (C) 2010 Elsevier B.V. All rights reserved.