Schizophrenia Research 131 (2011) 24–30

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Schizophrenia Research

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Practitioner perceptions of attenuated psychosis syndrome

Elizabeth Jacobs a, Emily Kline b, Jason Schiffman b,⁎a University of Hawaii, Manoa, United Statesb University of Maryland, Baltimore County, United States

⁎ Corresponding author at: Department of PsycholBaltimore County, Baltimore, MD 21250, United States. T410 455 1055.

E-mail address: schiffma@umbc.edu (J. Schiffman).

0920-9964/$ – see front matter © 2011 Elsevier B.V. Adoi:10.1016/j.schres.2011.06.022

a b s t r a c t

a r t i c l e i n f o

Article history:Received 13 March 2011Received in revised form 11 June 2011Accepted 20 June 2011Available online 20 July 2011

Keywords:DiagnosisDSMProdromePsychosisSchizophreniaVignette

The “Attenuated Psychosis Syndrome” (APS, sometimes referred to as the “schizophrenia prodrome”) ischaracterized by subthreshold psychotic-like symptoms and functional decline, and is often associated withsignificant disability. These symptoms may cause impairment and are of further interest due to theirpredictive relation to schizophrenia and other psychotic disorders. These symptoms currently are notrepresented in the diagnostic system for mental health, and it is unclear how they are conceptualized byrelevant professionals. The current study surveyed a national sample (n=303) of clinical psychologists,psychiatrists, and general practitioners regarding their clinical appraisal of APS. Practitioners were asked torespond to vignettes representing three conditions: psychosis, subthreshold psychosis (indicating‘attenuated’ psychosis symptoms), and no psychotic symptoms. Practitioners' responses suggested that APSis viewed consistently with a DSM-IV-TR defined mental disorder and that most clinicians may diagnose thiscondition as a full threshold psychotic disorder. Findings tentatively suggest that the inclusion of anattenuated psychosis symptoms category in the forthcoming DSM-5 may be helpful in improving diagnosticreliability and facilitating best practice among community practitioners.

ogy, University Of Maryland,el.: +1 410 455 1535; fax: +1

ll rights reserved.

© 2011 Elsevier B.V. All rights reserved.

1. Introduction

Among those who develop schizophrenia, approximately 70–90%experience attenuated psychotic symptoms prior to meetingdiagnostic criteria for the disorder (Yung and McGorry, 1996; Häfnerand an der Heiden, 1999; Compton et al., 2009). Recently, the DSM-5Psychotic Disorders Workgroup coined the term “Attenuated Psycho-sis Syndrome” (APS) to characterize subthreshold positive symptoms(e.g., unusual thought content, suspiciousness, perceptual distur-bances) that co-occur with distress and/or disability (AmericanPsychiatric Association, 2011). Though APS does not inevitably signalan impending psychotic break, attenuated symptoms may predictpsychosis onset and cause functional decline (Yung et al., 2010).

A growing body of literature documents the disability oftenassociated with attenuated psychotic symptoms. Researchers havereported average Global Assessment of Functioning (GAF) scores of60.5, 40, and 37 in samples of those with attenuated psychoticsymptoms, indicating notable impairment (Miller et al., 2003; Yunget al., 2003). In a study comparing quality of life among individualswith psychosis, attenuated psychosis, and no symptoms, Bechdolf

(Bechdolf et al., 2005) found that the attenuated psychosis groupreported the poorest quality of life. Preda (Preda et al., 2002) foundthat 90% of individuals meeting criteria for APS had prior treatmenthistory, suggesting high frequency of help-seeking behavior in thispopulation.

Recent research efforts (Cannon et al., 2008; Klosterkötter, 2008)have focused on conceptualizing the period of attenuated symptomsthat often precedes psychosis onset. Researchers have developedreliable instruments to identify those at heightened risk fordeveloping psychotic disorders, with rates of psychosis onset rangingfrom 14% to 54% over a one to two year period among individualsdetermined to be ‘high risk’ according to various paradigms(Klosterkötter et al., 2001; Miller et al., 2003; Yung et al., 2005;Cannon et al., 2008; Nelson and Yung, 2010; Ruhrmann et al., 2010).In addition, researchers tested promising treatments for APS that mayreduce associated distress and delay or prevent the onset of psychosis(McGlashan et al., 2006; Compton et al., 2007; Morrison et al., 2007;McGorry et al., 2009; Amminger et al., 2010). Advances in identifi-cation and treatment of APS are also important as shorter duration ofuntreated psychosis (DUP) has been associated with better long-termprognosis in schizophrenia (Marshall et al., 2005).

Despite this potential for improved treatments and outcomes,advances in research are not yet incorporated into the diagnosticsystem for mental disorders. The Diagnostic and Statistical Manual ofMental Disorders, fourth edition text revision (DSM-IV-TR) (AmericanPsychiatric Association, 2000) defines the term ‘psychotic’ loosely,referring simply to “the presence of certain symptoms” (i.e., delusions,

25E. Jacobs et al. / Schizophrenia Research 131 (2011) 24–30

hallucinations, and disorganization symptoms). The DSM-IV-TRacknowledges the existence of “prodromal” and “residual” periodsin which individuals “may express a variety of unusual or odd beliefs;they may have unusual perceptual experiences; their speech may begenerally understandable but digressive, vague, or overly abstract orconcrete; and their behavior may be peculiar but not grosslydisorganized” (2000; p. 302). Though it contains this description ofattenuated psychotic symptoms within the section on schizophrenia,the DSM-IV-TR gives clinicians no diagnosis which uniquely capturesthe construct. Attenuated symptoms are restricted to a subset ofpersonality disorders (e.g., schizotypal personality disorder), whichare, by definition, “stable over time.” APS, in contrast, can result invarious outcomes, and often precedes further deterioration intopsychotic symptoms (Yung et al., 2010).

Despite the evidence that individuals experiencing APS exist andseek treatment in community settings, there is no diagnostic categoryappropriate for this group. It is unclear how community providersdiagnose or conceptualize individuals with APS. Assessment tools forthe identification of APS have been employed in tightly controlledresearch contexts (Miller et al., 2003; Yung et al., 2005), but little isknown about providers' perspectives on such cases in real-worldpractice.

Technically, meeting criteria for APS alone would not warrant aformal diagnosis under the current classification system, yet thissyndrome indicates current impairment and implies future risk. Assuch, in many mental health systems, an individual with APS wouldnot be afforded care or future monitoring. Alternatively, cliniciansmight lower diagnostic thresholds in order to diagnose someoneexperiencing APS with a full psychotic disorder. In these cases,treatments would likely be made available, but the recommendedtreatments might be inappropriate for APS clients. APS creates apredicament for clinicians, who lack a diagnostic label for theseclients. Understanding how practitioners approach the currentdiagnostic dilemma related to APS may contribute to the ongoingdebate regarding the potential inclusion of an attenuated psychosisrisk category in DSM-5 (Carpenter, 2009; Corcoran et al., 2010; Yanget al., 2010).

The current study examines how providers perceive and diagnoseAPS. Clinicians were asked to read vignettes depicting individualswith different levels of psychotic-like symptoms and providediagnostic impressions. Given the impairment associated with APS,it was hypothesized that clinicians would lower the DSM-IV-TRthreshold for psychosis to incorporate cases illustrating APS into theschizophrenia spectrum class of disorders.

2. Methods

2.1. Participants

A national sample of clinical psychologists (n=500), psychia-trists (n=500), and general practitioners (n=500) was targetedfor participation in this study. The sample of clinical psychologistswas drawn from the membership directory of the AmericanPsychological Association (APA) through their Center for Work-force Studies. The samples of psychiatrists and general practi-tioners were obtained from the physician directory of the AmericanMedical Association (AMA) through one of their database licensees,Direct Medical Data.

This study was reviewed and found to be exempt by the Universityof Hawaii at Manoa institutional review board, as no significant riskwas anticipated from participation in a survey of practitionerbehavior. In addition, the study was reviewed by the APA Committeeon Workforce Studies to evaluate the study's appropriateness for itsmembers. It was also reviewed for appropriateness by the AMA'sdatabase licensee, Direct Medical Data.

2.2. Materials

The current study utilized a mail/web mixed mode survey design.Consistent with the recommendation of Dillman(2007), all surveymaterials (cover letter, postage paid envelope, survey including threevignettes with an identical set of questions following each vignette,and a set of basic demographic questions) were mailed to potentialparticipants with an option to participate by email via a link printedon the front of the survey booklet. To avoid differences in responsepatterns as a result of administrationmode, efforts weremade to keepthe presentation of the information in both formats as similar aspossible.

Prior to receiving their survey, participants were mailed a pre-notice letter. One week later, they were mailed the first survey alongwith a cover letter and postage paid return envelope. Approximatelytwo weeks after the first survey was mailed, a reminder postcard wassent to those individuals who had not responded. Two weeks later, areplacement surveywasmailed to thosewho did not respond initially,along with the second version of the cover letter.

2.3. Vignettes

Vignette methodology has numerous strengths when compared tosimilar methods to assess practitioner performance in clinical settings(e.g., chart review, standardized patients; Fihn, 2000). Strengthsinclude the ability to craft standardized cases, to alter casessystematically, and to present cases to a large sample of practitionersgiven relative time and cost effectiveness.

Vignettes in this study were developed by the first author of thisstudy (E.J.) using methods similar to those of Epstein et al.(2001) andKirk et al.(1999). The author created four ‘cases’ of fictional in-dividuals (Diego, Paul, Mike, and Claire) and drafted three ‘conditions’for each case, resulting in twelve individual vignettes. Conditionsrepresented variations in the level of psychotic symptoms. Eachvignette described the presenting case with no psychotic symptoms;attenuated psychotic symptoms; and ‘fully’ psychotic symptomsconsistent with definitions of psychotic disorder presented in theDSM-IV-TR. Demographic descriptions of each character remainedconsistent for each symptom condition. ‘Psychosis’-level vignettes alldepicted individuals in the first episode of psychotic illness. Fourcharacters were created in order to avoid systematic covariations ofsymptom level, gender, and ethnicity.

The vignettes were initially rated by five graduate students in aclinical psychology doctorate program trained in the administration ofthe most widely used diagnostic instrument for APS (SIPS; Miller etal., 2003). Raters were asked to (a) compare the vignettes to a set ofcriteria used to develop the vignettes, (b) write which level ofsymptomswere being described, and (c) estimate the GAF score of theindividual depicted in each vignette. Graduate student raters were incomplete agreement on 12 of 12 vignettes as to which levels ofsymptoms were being described. Average GAF scores were in theintended range for each vignette with the exception of one attenuatedsymptoms' vignette that was subsequently revised.

Each vignette was then reviewed by five experts in the field ofpsychotic disorders and was further revised based on expertsuggestions. All vignettes were rated by one of the authors (J.S.), aswell as a Masters level clinical psychology graduate student of theauthor (five relevant publications) who was otherwise uninvolvedwith this study. Other experts included six clinical psychologists(average of 31 relevant publications), one Masters level psychologyresearcher (nine publications), and two psychiatrists (average of 13relevant publications).

Experts were asked to read vignettes developed by the authorand respond to the question “How well do you feel the vignettedepicts the construct of someone experiencing [psychotic level, APSlevel, and no psychotic] symptoms?” At least 80% of the expert raters

26 E. Jacobs et al. / Schizophrenia Research 131 (2011) 24–30

described each vignette as representing the intended conditions“well” or “very well.” See Table 1 for sample vignettes for eachsymptom level.

Table 1Vignette excerpts illustrating symptom levels.

Symptomlevel

Excerpt

Nopsychosis

Mike is an 18-year-old African American male, currently enrolled inhis senior year of high school. His parents brought him to see youafter noticing “odd” behavior that caused them concern. Mike'sfather reported that Mike had gotten into several fights in the lastyear and this worried them. Mike reported that he understood hisparents' concerns, but that the fights had been in self-defense, whichthe school and his teachers confirmed. Mike has been, according toall reporters, a consistently good student (A–B range) and is well-liked by his peers. He had recently won a high level chess tournamentfor which he was given recognition, and his mother said that thiscaused some of the students at his school to tease him. He reported toyou that he was taking the situation “in stride”, knowing that hewould soon be graduating, and did not feel he needed any help. Hesaid that, in general, he maintains a positive outlook even whendifficult situations arise. Throughout the interview, Mike wascooperative and communicated in a clear, effective manner about hissituation. Mike and his mother reported that Mike has no history ofalcohol or drug use. Medical tests have also not produced anysignificant findings.

Attenuatedpsychosis

Claire is a 17-year-old Caucasian female, currently enrolled in herjunior year of high school. Her mother brought Claire to see you afternoticing “odd” behavior that caused her concern. Claire has an unclewith schizophrenia. Her mother reported that Claire's “strange”behavior has been occurring for approximately 5 months. Clairereported that once or twice per week she has heard a whisperingvoice when she's in her room alone, but she was not sure where itwas coming from orwhat it was saying. Claire felt it was possible thatit might be a problem with her hearing, though it sounded real.During the interview, Claire at times needed to be redirected back tothe topic and would bring up unrelated issues. Her mother reportedthat she was concerned because Claire hardly went out with herfriends at all lately, and they were not calling the house anymore.Claire reported that she thinks her friends gossip about her behindher back, but she was not sure what theywere saying. Claire's motherhad also been contacted by a school counselor who informed her thatClaire's academic performance was deteriorating dramatically froman A average to a C–D average. Claire and her mother both reportedthat Claire has no history of alcohol or drug use. Medical tests havealso not produced any significant findings.

Psychosis Diego is a 17-year-old Hispanic male, currently attending his junioryear of high school. His mother brought him to see you after noticing“odd” behavior that caused her concern. Diego's mother reportedthat his father has resided in a psychiatric hospital in Mexico foryears for “strange” behavior including hearing voices. Diego's motherreported that she would have brought him in sooner, but previouslyhe had refused saying he did not want to talk to anyone about hisexperiences. She said that recently, he has not spoken much toanyone. She reported that approximately a year ago, he started beingparticularly picky about his food, and more recently blamed theneighbor of trying to poison him to take him “out of the picture”. Hismother reported that there was no evidence for this and that theneighbor was a close family friend, but that Diego has become veryangry in the past when she has attempted to challenge his beliefs.She also said that Diego is frequently agitated at school because hefeels other teenagers are plotting against him. Diego initially refusedto talk to you, but later opened up, saying in a slow, flat voice that hefelt depressed, that the world was “so cruel”, and that he would“probably die soon” from other people's actions. However, he couldnot provide specific details on why he thought this. He said that hefound it very difficult to do anything and to express himself to others.Diego's mother stated that he has been in all special education classesfor several years, and that she was considering withdrawing himfrom classes as he was not progressing in his work. Diego reportedthat he very occasionally has one or two alcoholic beverages whenwith friends. Medical tests have not produced any significantfindings.

2.4. Mailing

Participants received stapled surveys containing vignettes depict-ing three of the four different cases (Claire, Diego, Mike and Paul) andquestions following each vignette. Twelve versions of the survey werecreated. Each survey included one vignette describing psychosis, onevignette describing attenuated symptoms, and one vignette describ-ing no psychosis. The order of the three vignettes in the differentversions was counterbalanced by level of psychotic symptoms tocontrol for order effects. Each vignette (case and level) wasrepresented equally across versions.

Instructions were provided for participants to read each vignetteand answer questions that followed. Respondents were asked to mark‘yes’ or ‘no’ in response to the question, “Do you think that theindividual described above has a MENTAL DISORDER as described bythe DSM-IV-TR?” Respondents were asked to provide diagnosticimpressions both by choosing a DSM-IV-TR disorder category (e.g.,adjustment disorders, mood disorders, personality disorders) from aprovided list as well as by generating the diagnostic code or fulldisorder name for the diagnosis they felt would be most appropriate.

3. Results

The overall adjusted response rate was 20.8% (n=303) aftereliminating those without forwarding addresses (n=27) and thosewho were retired (n=14). Response rates by practitioner types were26.3% (n=130) for psychologists, 20.4% (n=98) for psychiatrists,and 14.8% (n=72) for general practitioners. Missing data acrossvariables ranged from 1.0% to 8.3% and were analyzed as a separatecategory as has been done in other studies using similar analyses(Baldwin et al., 2009; Lindstrom and Mohseni, 2009; Nikula et al.,2009).

3.1. Practitioner characteristics

The average age of clinicians who participated was 52.7 years(median=53.0 years); 52.4% were male; 86.3% were White. Allparticipants reported that they were licensed to practice in theirfield. They reported an average length of time of 21.2 years as activepractitioners. Missing data included 2.4% of participants who did notrespond to demographic information.

3.2. Primary analyses

The primary research aim was to examine the frequency withwhich vignette cases of attenuated psychosis symptoms wereconsidered by practitioners to have a mental disorder. The firstsurvey item following each vignette queried practitioners with regardto whether they thought the individual described in the vignette had amental disorder, as defined by the DSM-IV-TR. As no significantdifferences were found between provider types in their considerationof APS to be a mental disorder (χ2=5.0, P=.16), data were collapsedacross provider type. Results for all three symptom levels arepresented in Table 2.

Table 2Practitioners' ratings of whether vignettes depicted a disorder as defined by DSM-IV-TR.

Symptom level Mental disorder?

Yes No

No psychosis (missing=5) 40 (13.4%) 258 (86.6%)Attenuated psychosis (missing=16) 265 (92.3%) 22 (7.7%)Full-threshold psychosis (missing=8) 280 (94.9%) 15 (5.1%)

APS vignettes vs. no symptoms vignette as representative of a mental disorder(χ2=364.80, Pb .001).APS vignettes vs. full-threshold psychosis vignette as representative of a mentaldisorder (χ2=1.62, P=NS).

27E. Jacobs et al. / Schizophrenia Research 131 (2011) 24–30

Chi-square statistics were calculated to evaluate the degree towhich practitioners view APS as a mental disorder relative to theother symptom levels. In other words, we were interested in whetherpractitioners were more likely to conceptualize APS more similarly tono psychosis or more similarly to full psychosis. Practitioners weresignificantly more likely to consider vignettes depicting APS asrepresentative of a mental disorder compared with vignettes depict-ing “no symptoms” (χ2=364.80, Pb .001). No significant differencesemerged between the number of practitioners who consideredsymptoms of full-threshold psychosis to indicate the presence of amental disorder relative to symptoms of APS (χ2=1.62, P=.40).

The secondary research aimwas to discover the DSM-IV-TR classesof disorders which practitioners utilized to diagnose APS. A graphdepicting practitioners' choices of diagnostic classes for eachsymptom level appears below (Fig. 1). Schizophrenia and otherpsychotic disorders was the class most frequently chosen bypractitioners responding to both the psychosis vignettes (280 of 295responders, or 94.9%) and the APS vignettes (228 of 291 responders,or 78.4%). For the ‘no psychosis’ condition, only 5 of 298 responders(1.7%) considered the symptoms in the vignette to representschizophrenia or other psychotic disorders.

Statistically, the APS vignette was far more likely to be ratedwithinthe schizophrenia spectrum relative to the no psychosis vignette(χ2=362.00, Pb .001, effect size d=2.53). The APS vignette wassignificantly less likely to be rated within the schizophrenia spectrumrelative to the psychosis vignette (χ2=34.84, Pb .001, effect sized=0.50). Although the vast majority of practitioners diagnosed theAPS vignettes as in the schizophrenia spectrum, relative to thepsychosis vignettes, visual analysis of graphed response frequencyshows that the APS vignettes were categorized more often by thissample as personality disorders, anxiety disorders, adjustmentdisorders, and “deferred” compared with the psychosis vignettes.

0 10 20

No Diagnosis

Adjustment Disorders

Anxiety Disorders

Cognitive Disorders

Childhood Disorders

Dissociative Disorders

Eating Disorders

Factitious Disorders

Impulse Control Disorders

Mental Disorders due to GMC

Mood Disorders

Other Conditions that may be Focus

Personality Disorders

Schizophrenia and Other Psychotic Disorders

Sexual Identity Disorders

Sleep Disorders

Somatic Disorders

Substance Use Disorders

Unspecified Mental Disorder (nonpsychotic)

Deferred

Missing

% Pract

Fig. 1. Disorder classes chosen by prac

Within the schizophrenia spectrum, more practitioners assigned a“schizophreniform” or “psychosis NOS” label to APS vignettes relativeto full psychosis vignettes (Fig. 2).

Also of interest are differences with regard to which diagnosticcategories were chosen in response to the APS vignette by the threetypes of practitioners surveyed. Fig. 3 illustrates the percentage ofeach type of practitioner choosing the various diagnostic classes.

4. Discussion

4.1. Implications of current findings

Real-world practitioner participants in this study were asked toapply DSM-IV-TR criteria for a mental disorder to symptoms of APS, acategory not formally recognized by the manual. They were asked toconsider whether individuals exhibiting APS have a mental disorder,and if so, which class of disorder best captures these symptoms. TheDSM-IV-TR defines a ‘mental disorder’ somewhat loosely as:

A clinically significant behavioral or psychological syndrome orpattern that occurs in an individual and that is associated withpresent distress (e.g., a painful symptom) or disability (i.e.,impairment in one or more important areas of functioning) orwith a significantly increased risk of suffering death, pain,disability, or an important loss of freedom (American PsychiatricAssociation, 2000).

The results presented above indicate that the vast majority (92.3%)of practitioners sampled considered APS to constitute a mentaldisorder. These clinicians categorized APS as a mental disorder aboutas often as they did psychosis itself. Research suggesting that

30 40 50 60 70 80 90 100itioners Endorsing Diagnostic Category

No Psychosis VignetteAPS VignettePsychosis Vignette

titioners responding to vignettes.

% Practitioners Endorsing Diagnostic Category

Fig. 2. Schizophrenia spectrum disorders chosen by practitioners responding to vignettes .

28 E. Jacobs et al. / Schizophrenia Research 131 (2011) 24–30

attenuated psychotic symptoms are often associated with distress andimpairment (Rosen et al., 2002; Bechdolf et al., 2005; Yung et al.,2010) supports the appropriateness of this conceptualization of APSas a mental disorder.

The great majority of clinicians judged APS to be within theschizophrenia spectrum of disorders. Thus, clinicians in our samplerecognized APS as being more related to psychosis than to other classesof disorders. Clinically this may be problematic, as these symptoms donot reflect ‘true’ psychosis. Practitioners who diagnose clients with APSas having a schizophrenia spectrum disorder may, for instance,

0 10 2

No Diagnosis

Adjustment Disorders

Anxiety Disorders

Cognitive Disorders

Childhood Disorders

Dissociative Disorders

Eating Disorders

Factitious Disorders

Impulse Control Disorders

Mental Disorders due to GMC

Mood Disorders

Other Conditions that may be Focus

Personality Disorders

Schizophrenia and Other Psychotic Disorders

Sexual Identity Disorders

Sleep Disorders

Somatic Disorders

Substance Use Disorders

Unspecified Mental Disorder (nonpsychotic)

Deferred

% P

Fig. 3. Disorder classes chosen in response

implement the American Psychiatric Association (APA) recommenda-tion of antipsychotic medication as a first-line treatment for schizo-phrenia (Lehman et al., 2004), despite the lack of evidence supportingpharmacotherapy's effectiveness for treating APS (International EarlyPsychosis Writing Group, 2005). Nelson and Yung (2010) found thatmany community practitioners appear to over-prescribe antipsychoticmedications to individuals with APS symptoms.

Within the schizophrenia spectrum, APS vignettes were morelikely to elicit diagnoses of schizophreniform disorder or psychosisNOS than were full psychosis vignettes, which were more frequently

0 30 40 50 60 70 80 90 100

ractitioners Endorsing Diagnostic Category

Clinical PsychologistsPsychiatristsGeneral Practitioners

to APS vignette, by practitioner type.

29E. Jacobs et al. / Schizophrenia Research 131 (2011) 24–30

categorized as schizophrenia. This divergence may indicate thatrespondents were mindful of the emerging or subthreshold nature ofsymptoms in the APS vignettes, and sought out a diagnostic categoryto reflect this difference.

Not all clinicians, however, categorized the APS group within theschizophrenia spectrum. As such, clinicians in our sample exhibitedgreater divergence with regard to which diagnostic class bestcaptured the symptoms of APS compared to the symptoms of fullpsychosis. This result suggests that clinicians were not as reliable inselecting an existing category for APS. The absence of a diagnosticcategory which specifically captures subthreshold psychosis symp-toms in DSM-IV-TR may undermine diagnostic reliability for clientswho present with APS.

Clinical guidance for the treatment of APS has been issued by boththe APA (Lehman et al., 2004) and the International Early PsychosisWriting Group (2005). In the most recent Practice Guideline, the APArecommends that persons who are “prodromally symptomatic and atrisk for psychosis” receive assessment and monitoring until symp-toms remit or evolve into “schizophrenia or another diagnosable andtreatable mental disorder” (Lehman et al., 2004). Similarly, theInternational group advises regular monitoring of symptoms, treat-ment for any comorbid syndromes such as depression or substanceabuse, and psychoeducation for individuals with APS (InternationalEarly Psychosis Writing Group, 2005). This group states that due tohigh rates of adverse effects and limited evidence supporting theusefulness of pharmacotherapy for attenuated psychosis, antipsy-chotic medications are not recommended for APS except in the case ofrapid deterioration or severe suicidal risk (International EarlyPsychosis Writing Group, 2005).

These treatment guidelines place clinicians who encounter in-dividuals with APS in a bind. Providers have practice guidelines for adisorder that cannot be diagnosed using the current manual. Thus thepractice guidelines of the APA and Early Psychosis Writing Groupapply, at least theoretically, to a clinical population that does not exist.Clients whomeet criteria for APS are in a position of being either over-or under-treated. This confusion is relevant to current discussionsregarding the inclusion of APS in DSM-5, as it highlights the primacyproblem at the core of the debate. Which comes first, the diagnosticcategory or the treatment guidelines?

4.2. Limitations

Limitations of the current study include the low response rate andlimitations inherent to vignette methodology. The overall cruderesponse rate for practitioners targeted in our sample was 20.2%.Responding was likely non-random and may have been related tovariables such as practitioner experience, type, and setting. Non-responding clinicians may also represent those who did notparticipate due to lack of familiarity and confidence with APSsymptoms. Nonetheless, efforts to capture a wide sample ofpractitioners yielded a fairly large N, providing confidence in thepattern of findings.

Vignettes also convey limitations relative to real-world practicedata. Although vignettes provide a time- and cost-efficient standard-ized assessment of clinician practices, vignettes lack the complexityand ambiguity of real-life practice situations (Fihn, 2000). Vignettesmay elicit optimized responses from practitioners that do notaccurately reflect everyday practice (Leonard and Masatu, 2005).

4.3. DSM-5 discussion

The findings presented above may be useful in the current debateover the possible inclusion of an attenuated symptoms category in theforthcoming DSM-5. Data from the current study indicate that the vastmajority of clinicians surveyed perceive APS to constitute a mentaldisorder, and that the lack of an appropriate diagnostic category in

DSM-IV-TRmay undermine diagnostic reliability. Taken together withthe existence of reliable instruments to identify APS (e.g., the SIPS),these findings tentatively suggest that the inclusion of an APScategory may help to improve diagnostic reliability and facilitateevidence-based practice.

Role of funding sourceThe project described was supported in part by the Katz Family Foundation within

the National Alliance for Research on Schizophrenia and Depression, and the NationalInstitute of Mental Health (NIMH Grant Number R03MH076846).

ContributorsDrs. Jacobs and Schiffman contributed to study design, implementation, data

analysis, interpretation, and write-up. Ms. Kline contributed to data analysis,interpretation, and write-up.

Conflict of interestThere are no conflicts of interest to report.

AcknowledgementNone.

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