The psychosis risk syndrome and its proposed inclusion in the DSM-V: A risk-benefit analysis

The inclusion of a psychosis risk syndrome has been proposed for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. The appropriateness of inclusion of this new risk syndrome in the DSM depends on a careful analysis of both anticipated benefits and risks. Purported benefits include early recognition and case identification, and the hypothetical benefit of preventive intervention of psychotic disorders, for which there is as yet no clear evidence base. However, there is a potential for high rates of false positives particularly at the community level given the difficulty in discriminating mild symptoms from normal variants and low base rates of the syndrome in the general population. High false-positive rates in and of themselves are not necessarily problematic if the risk-benefit ratio is significantly favorable, as with screening for cardiovascular risk factors. For the psychosis risk syndrome, by contrast, there are substantial risks, for both stigma and discrimination, and for unnecessary exposure to antipsychotic medications, which make the high false-positive rate associated with the psychosis risk designation particularly problematic. More research is needed to improve the positive predictive value of the psychosis risk syndrome so that it can be considered for inclusion in future editions of the DSM.