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Clinical High Risk Controversies and Challenge for the Experts.

At risk mental states, ultra high risk and attenuated psychosis syndrome are terms associated with the rapidly expanding field of clinical high risk (CHR) research and initiatives in clinical care. Much is debated as indicated in the theme introduction by Fusar-Poli1 (this issue). Lee et al2 (this issue) address risk prediction for psychopathology beyond the focus on psychosis. Woods et al3 (this issue) test the hypothesis that CHR categories involve pathological processes that are pleuripotential resulting in risk for various disorders. Findings do not support this hypothesis and support a more narrow prediction for associated psychotic disorders. Fusar-Poli et al4 (this issue) provide evidence for the clinical usefulness of the DSM5, Section 3 attenuated psychosis syndrome. In this, editorial controversies in the field and challenges to the experts will be summarized. Early detection and intervention is time honored throughout medicine. However, the rapidly growing interest regarding mental disorders has been met with substantial concern and opposition. The primary focus emerged from re-conceptualizing schizophrenia prodromal psychopathology as early disorder manifestations. Viewing attenuated psychosis as a clinical disorder, the question of secondary prevention of psychosis came into play. Follow-up studies revealed a robust prediction of transition to full psychosis, usually schizophrenia.5 Within 3 years or so over a quarter of the CHR cases developed a psychotic disorder. This compares with rates for a 3-year period in individuals undergoing CHR assessment, but not meeting intake criteria, of 2%, and a 3-year general population rate of far less than 1%. CHR is a risk category for psychosis as well as a clinical syndrome where all persons merit clinical care. The few clinical trials have suggested that intervention (usually testing CBT vs treatment as usual) is effective in reducing transition to full psychosis, hence providing face validity for risk detection and effective intervention6 So, what could be controversial? A few issues are: