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November 20, 2019

Clinical Validity of DSM-5 Attenuated Psychosis Syndrome: Advances in Diagnosis, Prognosis, and Treatment

Author Affiliations
  • 1Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
  • 2Institute of Psychiatry and Mental Health, Department of Psychiatry, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Centro de Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
  • 3Department of Psychiatry, Basurto University Hospital, Bilbao, Spain
  • 4Mental Health Group, BioCruces Health Research Institute, Bizkaia, Spain
  • 5Neuroscience Department, University of the Basque Country UPV/EHU, Leioa, Spain
  • 6OASIS Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
  • 7Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
  • 8Maudsley Biomedical Research Centre, National Institute for Health Research, South London and Maudsley NHS Foundation Trust, London, United Kingdom
JAMA Psychiatry. 2020;77(3):311-320. doi:10.1001/jamapsychiatry.2019.3561
Key Points

Question  What is the clinical validity of DSM-5 attenuated psychosis syndrome (DSM-5–APS)?

Findings  In this systematic review including 56 articles and meta-analysis including 23 cohort studies, the clinical validity of DSM-5–APS was tested against evidence-based antecedent, concurrent, and prognostic validators. DSM-5–APS has received substantial concurrent and prognostic validation, mostly from psychometric research in the field of the clinical high-risk state for psychosis, while precipitating and predisposing epidemiological factors, neurobiological research, and treatments have been underinvestigated to date.

Meaning  Although current evidence supports the potential clinical validity of DSM-5–APS, more research should address the epidemiological profile of this diagnostic category as well as predisposing and precipitating risk factors, neurobiological correlates, and effectiveness of treatments.


Importance  Since the release of the DSM-5 diagnosis of attenuated psychosis syndrome (DSM-5–APS) in 2013, several research studies have investigated its clinical validity. Although critical and narrative reviews have reviewed these progresses, no systematic review has comprehensively summarized the available evidence regarding the clinical validity of DSM-5–APS.

Objective  To provide current evidence on the clinical validity of DSM-5–APS, focusing on recent advances in diagnosis, prognosis, and treatment.

Evidence Review  A multistep literature search using the Web of Science database, Cochrane Central Register of Reviews, Ovid/PsychINFO, conference proceedings, and trial registries from database inception to June 16, 2019, was conducted following PRISMA and MOOSE guidelines and PROSPERO protocol. Studies with original data investigating individuals diagnosed using DSM-5–APS or meeting comparable criteria were included. The results of the systematic review were summarized in tables and narratively synthesized against established evidence-based antecedent, concurrent, and prognostic validators. A quantitative meta-analysis was conducted to explore the cumulative risk of psychosis onset at 6, 12, 24, and 36 months in individuals diagnosed using DSM-5–APS criteria.

Findings  The systematic review included 56 articles, which reported on 124 validators, including 15 antecedent, 55 concurrent, and 54 prognostic validators. The epidemiological prevalence of the general non–help-seeking young population meeting DSM-5–APS criteria was 0.3%; the prevalence of individuals meeting DSM-5–APS criteria was variable in clinical samples. The interrater reliability for DSM-5–APS criteria was comparable with that of other DSM-5 mental disorders and can be optimized by the use of specific psychometric instruments. DSM-5–APS criteria were associated with frequent depressive comorbid disorders, distress, suicidality, and functional impairment. The meta-analysis included 23 prospective cohort studies, including 2376 individuals. The meta-analytical risk of psychosis onset was 11% at 6 months, 15% at 12 months, 20% at 24 months, and 23% at 36 months. Research into predisposing and precipitating epidemiological factors, neurobiological correlates, and effective treatments for DSM-5–APS criteria has been limited.

Conclusions and Relevance  Over recent years, DSM-5–APS criteria have received substantial concurrent and prognostic validation, mostly driven by research into the clinical high-risk state for psychosis. Precipitating and predisposing factors, neurobiological correlates, and effective treatments are undetermined to date.

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