Psychosis-Risk Syndromes

Abstract

Identifying individuals at risk for psychotic disorders is now a major focus of research. The key objectives of this work are to identify mechanisms underlying the emergence of psychosis and predict impending illness, with the goal of developing preventive interventions. Despite notable progress, there is a dearth of ethically informed policies to guide disclosure, documentation, and treatment practices. The limited predictive validity of psychosis-risk criteria and stigma surrounding psychotic disorders hinder such policy development. Thus, several challenging questions remain: Does the psychosis-risk designation achieve an adequate predictive power to indicate risk for a more serious disorder? When and how should individuals learn that they are at risk for a psychotic illness, and should such information be included in medical records? What, if any, treatment recommendations should be made? This article addresses these challenges and frames the central issues confronting ethically informed policies and practices for identifying and treating psychosis-risk syndromes.

Keywords

psychosis risk early detection psychosis prevention ethical decision making risk disclosure policy

Clinical and ethical considerations in the development of policies for early detection and intervention in risk for psychosis.

Key Points

Developments in early detection of youth at risk for psychosis offer an important opportunity to prevent or delay illness onset.

However, there are currently no policies in place to help clinicians navigate disclosure, documentation, or treatment practices.

A number of clinical and ethical factors complicate decision making and policy development due, in large part, to the nature of the psychosis-risk designation and the stigma surrounding psychotic disorders.

A flexible and individualized approach to decision making that weights clinical, intra-individual, and socio-contextual factors is proposed to help guide policy development in the coming years.

Introduction

Psychotic disorders are among the most personally devastating and economically costly conditions in all of medicine (World Health Organization, 2004). In the past two decades, interest has shifted to the period preceding onset of psychotic illness, which, for most patients, involves a gradual onset of sub-threshold psychotic symptoms and decline in functioning (Yung & McGorry, 1996). This pre-onset (“prodromal”) period provides a unique opportunity to investigate disease onset while also allowing timely initiation of preventive interventions. Research consortiums in the United States (North American Prodrome Longitudinal Study [NAPLS]), Europe (European Prediction of Psychosis Study [EPOS]), and Australia (Personal Assessment and Crisis Evaluation [PACE]) have developed criteria for prospectively identifying individuals at risk for developing psychosis, in hopes of characterizing the prodromal period and refining early detection efforts. These psychosis-risk criteria are based largely on the presence of sub-threshold psychotic symptoms including unusual ideas, suspiciousness, perceptual abnormalities, and subtle disturbances in cognition and language (Woods et al., 2009; Yung & McGorry, 1996). Although these symptoms are often experienced as confusing and distressing, they do not reach the level of conviction and impairment characteristic of full-threshold psychotic disorders.

Among individuals identified as at risk for psychosis, 20% to 35% convert to a psychotic disorder within 2 years (Cannon et al., 2008; Cannon et al., 2016; Fusar-Poli et al., 2012; Nelson et al., 2013). These early detection efforts offer an exciting opportunity to initiate interventions that could prevent or delay the onset of psychosis, reduce the duration of untreated illness, and generally improve outcomes (Fusar-Poli et al., 2013). However, no consensus or policies specify how or when to disclose risk status, whether to document and communicate with other health care professionals, or what treatment referrals to make. Such policies must appreciate the complexities of psychosis-risk syndromes and attend to ethical principles of autonomy, beneficence, and non-maleficence. Accordingly, this article aims to (a) review the unique challenges of the psychosis-risk syndrome; (b) highlight clinical and ethical considerations for disclosure, documentation, and treatment provision; and (c) introduce a framework for the relevant decision making.

Complexities and Context

Unique characteristics of the psychosis-risk designation set it apart from other medical and psychiatric conditions and are relevant to disclosure, documentation, and treatment practices. Chief among these is the relatively low positive predictive value (PPV) of current psychosis-risk designations. PPV denotes the probability that an individual with a positive screening test (meeting psychosis-risk criteria) truly has the disease (will develop psychosis). As mentioned above, roughly a third of those meeting psychosis-risk criteria will develop psychosis in the ensuing years. Although the predictive power of this risk-designation clearly improves over general population predictions, it still yields a high false positive rate (Perälä et al., 2007). Nearly 60% to 80% of youth designated as at risk will not develop psychosis. Two years from baseline, about 25% of these non-converters remain stably symptomatic (no worsening of symptoms), and over 30% show a remittance in symptoms (symptoms decline to normal range and functioning improves; Addington et al., 2015). Unfortunately, identifying these different subgroups prospectively is not yet possible, and researchers may never decrease false positives using clinical measures alone. For a potentially devastating and stigmatizing disorder like psychosis, this is problematic.

A second complexity involves the distressing and symptomatic nature of the psychosis-risk designation. Unlike other latent risk factors in medicine, in which individuals are asymptomatic and unaware of any impairment, individuals who meet criteria for psychosis-risk are largely symptomatic, distressed, help seeking, and functionally impaired (Addington et al., 2015; Cadenhead et al., 2010). Thus, regardless of portending future psychosis, the psychosis-risk syndrome itself fulfills the broad criteria for a “mental disorder” (American Psychiatric Association [APA], 2013). In addition, psychosis-risk samples report high rates (82%-86%) of help seeking prior to assessment in specialized clinical research settings (Cadenhead et al., 2010; Katsura et al., 2014). Thus, independent of true risk status and eventual conversion to a psychotic disorder, contemporary treatment standards in mental health assume this syndrome warrants attention.

Finally, psychosis-risk syndromes are not formally recognized by the medical community or listed as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013). Currently, the Attenuated Psychosis Syndrome is listed under “Conditions for Further Study” (Section III), which denotes syndromes that have a research base but are not understood fully enough to be considered a formal clinical diagnosis. This is problematic for those trying to utilize services, as well as for diagnosis and communication among health care providers. The confusion extends even beyond direct clinical issues as the DSM sets the standard of care for researchers, drug regulation, health insurance, pharmaceutical companies, and the legal system.

These complexities of the psychosis-risk designation have implications for the ethics of disclosure, documentation, and treatment. The following sections highlight salient benefits and risks in light of ethical principles (e.g., non-maleficence, beneficence, and autonomy) to illustrate the challenges at hand.

Disclosure

Whether and how individuals should be informed of risk requires careful analysis of ethical and clinical considerations. Moreover, these issues must be considered in light of the fact that the modal developmental stage for the onset of the prodrome is adolescence/early adulthood, a period when concerns about future health risks are especially salient to both the individual and his or her family.

Disclosure Benefits

Disclosing risk status to an individual promotes patient autonomy and, often, beneficence. Most at-risk individuals are help seeking and experience significant distress from confusing symptoms and experiences that are poorly understood by general health care providers. A clear label of a psychosis-risk syndrome may help explain symptoms and clarify previous incorrect diagnoses (Mittal, Dean, Mittal, & Saks, 2015). Disclosure of risk also affords the opportunity to make lifestyle changes and treatment decisions that could reduce risk for psychosis conversion. For example, both stress and cannabis increase likelihood of conversion to psychosis in at-risk individuals (Holtzman et al., 2013; Kristensen & Cadenhead, 2007), and cognitive behavioral therapy (CBT) aimed at enhancing reality testing may reduce likelihood of conversion (Hutton & Taylor, 2014). If provided with this information, individuals may choose to prioritize stress reduction, reduce cannabis use, and develop strategies for reality testing, all of which could conceivably alter the course of illness. Early disclosure of risk also allows individuals and families valuable time to plan, setting up advanced directives and crisis plans for preferred treatment if incapacitated by severe mental illness. Such planning, while the individual is still mentally competent and able to participate in decision making, could spare families, courts, and patients substantial costs (McGlashan, 2005).

Disclosure Risks

Simultaneously, risk-status disclosure could violate the non-maleficence principle and introduce both stigma and iatrogenic distress. Although psychosis-risk only denotes vulnerability to psychosis, not psychotic disease, these subtleties are often overlooked. A professional’s risk disclosure can be easily interpreted as a quasi-diagnosis. Across mental disorders, a psychotic label evokes the most negative stereotypes, emotional reactions, social distance, and general pessimism (Angermeyer & Matschinger, 2003). In addition, psychotic disorders are frequently misrepresented in the media, further perpetuating false stereotypes and misunderstanding.

Stigma associated with psychiatric illness can lower self-esteem, treatment adherence, and sociality (Corrigan, Watson, & Barr, 2006; Yang et al., 2013; Yang, Wonpat-Borja, Opler, & Corcoran, 2010). Although at-risk individuals typically do not exhibit florid psychotic symptoms that garner public stigma, risk for self-stigma remains high. Self-stigma can have long-term consequences on adolescents, whether they eventually develop psychosis or not, by unduly influencing choices about education, employment, relationships, and other life goals (Corcoran, 2016). Disclosure can also engender additional—and potentially unnecessary—stress, anxiety, and helplessness. Increased stress plays a precipitating role in the onset of psychosis in current etiologic models (Walker, Mittal, & Tessner, 2008). Thus, stress generated by disclosure may be iatrogenic, exacerbating sub-threshold psychotic symptoms or precipitating other psychiatric conditions (depression, anxiety).

Weighing Disclosure Risks/Benefits

The risk–benefit ratios of disclosure likely vary among individuals as a function of symptom severity, distress, impairment, and stigma risk. The more severe the symptoms, the more likely that being identified at risk will be “just a footnote” (Corcoran, Malaspina, & Hercher, 2005). Rather than increasing apprehension in highly symptomatic patients, disclosure may offer clarity that outweighs any added distress. On the contrary, disclosure in less-symptomatic and younger patients may introduce distress and constrain opportunities due to what may be transient, time-limited symptoms.

In this light, some propose a conservative disclosure approach which limits information given to individuals and families and uses value-neutral language that avoids mention of psychosis or schizophrenia risk (see Mittal et al., 2015, for disclosure strategies). This approach aims to protect the individual from misunderstanding information and to reduce both stress and stigma risk. Despite certain benefits, censoring information may pose ethical violations. Limiting information, even in the effort to protect, is incompatible with patient autonomy and informed consent. In addition, individuals who lack complete understanding of risk and potential outcome may be less able or motivated to engage in potentially beneficial treatments or lifestyle changes.

Documentation

Documenting risk status in both internal records (e.g., medical records, therapy notes) and external communications (e.g., correspondence with third parties) poses similar ethical challenges. Given that psychosis-risk syndrome is not formally recognized, few legal regulations and clinical practice guidelines exist. However, documenting risk has significant implications for insurance, disability, conservatorship, confidentiality, and discrimination.

Documentation Benefits

Consistent with the beneficence principle, documenting psychosis risk can facilitate communication, collaboration, and cooperation among healthcare providers. Given the diagnostic ambiguity that surrounds psychosis-risk syndrome, such communications could aid coordination of treatment among providers (psychologists, psychiatrists, primary care providers) and increase patient benefits. The absence of such relevant information in an individual’s record may result in sub-standard care and possibly harm. In some cases, this communication is critical for balancing the potential impact of both concurrent and future treatments for other disorders. For example, many individuals at risk for psychosis report significant attentional difficulties and meet criteria for attention-deficit/hyperactivity disorder (ADHD). However, stimulant medication used to treat ADHD can exacerbate psychotic symptoms and is generally contraindicated in youth at risk for psychosis (Cressman et al., 2015). The individual may face avoidable harm if medication decisions do not consider the context of psychosis risk. This enters territory where efforts to conceal potentially stigmatizing information may indirectly result in sub-optimal medical care, or even harm at the hands of health care providers.

Communication among treatment providers can also coordinate symptom monitoring, with multiple eyes on a patient to detect symptom worsening or progression to psychosis. Documentation of risk status to third parties, such as schools, can help ensure that adolescents receive necessary accommodations. Under the Individuals With Disabilities Education Act (IDEA), youth with disabilities, including “emotional disturbances,” are afforded legal protections to ensure that they receive an adequate education. Thus, documentation may benefit individuals seeking support for treatment, services, and disability. Currently, the Affordable Care Act (ACA) obviates the potential for denial of coverage based on risk status and can facilitate treatment access (Mechanic & Olfson, 2016). Specific documentation of psychosis risk could also help individuals advocate for insurance coverage for specialty services (e.g., CBT for psychosis) that may not be offered by in-network providers.

Documentation Risks

However, both internal and external documentation pose risks to non-maleficence and autonomy. Records may be subpoenaed or even released at the individual’s request, and shared with insurance companies, employers, schools, community groups, and religious organizations. Although responsible clinicians may be prudent in documentation language, individuals or institutions may not appreciate the differences between risk and diagnosis (McGlashan, 2005). When risk status is accessible to third parties, there is potential for employers and/or schools to use information inappropriately and in a discriminatory fashion. Documentation of risk status could also be used against individuals in legal proceeding if subpoenaed. Indeed, attitudes toward children with neuropsychiatric disorders influence evaluations regarding allegations of childhood sexual abuse (Lainpelto, Isaksson, & Lindblad, 2016). A neuropsychiatric disorder can confer unjustified skepticism about trustworthiness and cognitive capacity. This is likely to be amplified with psychotic disorders, given mass misperceptions and stereotyping.

Weighing Documentation Risks/Benefits

Again, risk–benefit ratios of documentation likely vary across individuals as a function of symptom severity, functional impairment, comorbid psychiatric conditions, third-party involvement, and health care access. For individuals who rely on insurance for mental health care and cannot pay for treatment, documented risk status may help secure services. It may also be crucial to future treatment planning when other psychiatric conditions are present. However, official documentation could be shared with third parties, at a significant cost.

Treatment

Early intervention is a primary goal of prodromal research (Insel, 2007). However, determining whether, and what kind of, treatment recommendations poses a dilemma. In contrast to other psychiatric conditions with empirically supported treatments, psychosis risk has no gold standard treatment and specialized services are difficult to find outside of psychosis clinical research centers. Yet, a “wait-and-watch” approach has considerable risks. The United Kingdom National Institute for Health and Care Excellence (NICE; 2014) outlines treatment guidelines for individuals who manifest psychosis-risk syndromes that include CBT, psychotropics to treat mood symptoms, and no antipsychotics. They do not, however, address the challenging ethical questions about interventions that may be unwarranted, harmful, or ineffective.

Treatment Benefits

The major benefit of treating individuals at risk for psychosis is the potential to delay, or even prevent, progression to a full psychotic disorder. Three meta-analyses (Preti & Cella 2010; Stafford, Jackson, Mayo-Wilson, Morrison, & Kendall, 2013; van der Gaag et al., 2013) comparing available treatments (e.g., antipsychotics, Omega-3s, CBT), using the outcome measure of transition to a full psychotic disorder, suggest that early interventions are associated with overall risk reductions. Even if early intervention cannot prevent onset of a psychotic illness, early contact with treatment providers and appropriate psychoeducation can aid quicker, more efficient entry into appropriate care early in the first psychotic episode. This potentially reduces duration of untreated psychosis (DUP), which is associated with worse prognosis (Marshall et al., 2005).

Most individuals who meet contemporary psychosis-risk criteria report symptom-related distress and impairments that are targets for treatment, regardless of future disorder. Moreover, these individuals often have other comorbid disorders (depression, anxiety) that warrant clinical attention (Fusar-Poli, Nelson, Valmaggia, Yung, & McGuire, 2014). Interventions that target the specific symptoms causing distress and disability, while also continuously monitoring possible illness progression, may benefit patients regardless of eventual psychotic conversion.

Treatment Risks

Treating an at-risk group, of whom only a minority will go on to develop psychosis, risks unnecessarily treating transient symptoms that will remit spontaneously. Unnecessary use of antipsychotics raises serious concern, given adverse side effects (e.g., extra-pyramidal symptoms, weight gain, metabolic syndrome; Arana, 2000; Nasrallah, 2008). Moreover, the long-term effects of these medications on brain development are unknown, which is especially concerning as most people meeting psychosis-risk criteria are youth, whose brains are still developing. Finally, given the adverse side effects and health problems related to antipsychotics, using these medications as first-line treatments for psychosis-risk patients may diminish the likelihood that they will seek or comply with future treatment. Nevertheless, increasing antipsychotic prescriptions, and limited access to CBT for psychosis, indicates that the prescription of antipsychotic medication is likely to continue as a first-line treatment approach by many providers despite alternate recommendations.

Despite presenting less overt risk, psychotherapy does risk societal and self-stigma, and “needing therapy” may imply disorder or incompetence to teens and young adults still forming a stable self-concept. Uncertainty of prognosis makes it difficult to determine when to stop an intervention, when to change intervention strategies, and when to deem it effective. For example, should a 15-year-old female identified as at risk be required to engage in active treatment until she passes the mean age of illness onset (27 years) or would periodic monitoring of symptom severity suffice?

Weighing Treatment Risks/Benefits

Treatment’s risk–benefit analysis should heavily weight symptom severity and impairment. Although antipsychotic medication’s risks are typically considered the greatest potential source of malfeasance in treating psychosis-risk syndromes, these medications may also benefit those suffering from more frequent and distressing positive psychotic-like symptoms.

On the other extreme, interventions aimed at healthy lifestyle changes are unlikely to pose much risk, regardless of illness course, and may be ethically applied more broadly. However, they are unlikely to provide significant benefit to the sickest individuals, and if other treatments are available, withholding them may be unethical. Several researchers suggest starting with less potentially risky interventions during the earlier stages (e.g., CBT for psychotic/prodromal symptoms, and antidepressants for comorbid mood disorders) and only resorting to antipsychotics if/when the individual continues to decompensate (Ruhrmann et al., 2007). This strategy flexibly balances the benefits/risks across illness progression. In applying the treatment, a focus on symptom reduction and improving functioning may also be a more appropriate therapeutic goal than a focus on preventing psychosis. This has the best potential to meet the heterogeneous needs of the psychosis-risk population, while sidestepping the issue of generally low conversion rates (Thompson, Marwaha, & Broome, 2016).

Minor Status

Another layer of complexity to disclosure, documentation, and treatment involves the autonomy of minors. Most individuals assessed for early psychosis risk are under 18 years old (Kelleher & Cannon, 2011; Laurens et al., 2007), on the cusp of competence with regard to both age and mental status. This raises issues about an adolescent’s competence to handle disclosures, to consent to treatment, and to consent to confidentiality provisions.

Given potential self-stigma while developing identity, disclosure-related risks may amplify for minors. Health care providers should carefully analyze the youth’s cognitive and socioemotional capacity, and any information provided should be appropriate to developmental stage and maturity. Although the best interest of the youth and family typically align, this is not always the case (McGlashan, 2005). For many families, efforts to eliminate risk drive decision making, leading parents to act on protective impulses that inadvertently constrain growth opportunities for their at-risk child. In addition, parents may advocate for aggressive medication regimes to avoid possible psychosis (Corcoran et al., 2005)—which may be at odds with the wishes, and best interest, of the adolescent. Moreover, parents and legal guardians typically can waive a child’s privacy rights, which may compromise the youth’s confidentiality (Hiriscau, Stingelin-Giles, Stadler, Schmeck, & Reiter-Theil, 2014).

Compared to adults, adolescents are less likely to consent to, and participate in, decision making regarding treatment. This raises questions about whether parents of minors retain the authority to refuse interventions. State laws vary in their assessments of minor capacity and handling of these issues, and often minors cannot legally consent to medical treatment. Clinicians and policy makers alike must confront this issue, given that antipsychotics’ side effects are often aversive to adolescents (e.g., weight gain). Unfortunately, no easy formula balances the autonomy of the adolescent with the obligation of providing informed consent and treatment.

Considerations for Policy Development

Complicated, and often competing, issues arise in developing ethically informed policies regarding the early detection and prevention of psychosis. A one-size-fits-all approach will not suffice. Policies and treatment guidelines need to remain flexible and responsive to individual differences. Figure 1 highlights factors related to the clinical presentation, the individual, and the broader social context that should guide decision making regarding disclosure, documentation, and treatment of psychosis risk. This framework requires decisions are made in accord with ethical principles and acknowledges that applying these principles will vary as a function of an individual’s experience and context. For example, a disclosure may promote non-maleficence in one individual’s context, but may violate and increase harm for another.

Figure 1.

A framework for conceptualizing ethical decision-making processes in the identification and treatment of psychosis-risk syndromes.

Clinical Factors

Although a risk-label is categorical, individuals at risk for psychosis vary in symptom profiles and severity, level of functioning, and distress, all of which are relevant to ethical decision making (see Figure 1). The psychosis-risk designation encompasses a spectrum of severity, ranging from individuals who just barely meet criteria to those who almost reach the psychotic threshold (Addington et al., 2015). In addition, symptom profiles differ greatly with respect to the type of positive symptoms reported, as well as the constellation of positive, negative, and disorganized symptoms. Different symptom profiles likely connote different degrees of risk for psychosis, and symptom presentation may thus influence decisions about disclosure, documentation, and treatment. Objective algorithms can help reduce subjectivity in this weighted decision making. A psychosis-risk calculator that weights multiple risk indicators (e.g., symptom type, age, family history, functioning) to predict psychosis conversion was recently published (Cannon et al., 2016; Carrión et al., 2016). Unusual thoughts, suspiciousness, poor social functioning, and younger age were the strongest predictors (Cannon et al., 2016), highlighting a potential role for weighted risk profiles in decision-making practices.

For example, a clinician may decide not to disclose or document psychosis risk in a high-functioning 25-year-old at the lower end of the psychosis-risk threshold, endorsing moderate grandiosity and fleeting perceptual abnormalities. Such disclosure may pose greater harm than benefit to the individual. The clinician may decide to wait and see if this is a transient phase, so as to not introduce potentially unnecessary risk of self-stigma, stress, and discrimination. If appropriate, treatment may aim at general symptoms such as depression, anxiety, and stress management but not include explicit language regarding psychosis. In contrast, the same clinician may choose to disclose and document risk for a help-seeking 14-year-old, endorsing high levels of suspiciousness, unusual ideas, and increasing difficulties in school. Such disclosure may promote non-maleficence, beneficence, and autonomy. Recommended interventions may be more aggressive and psychosis-specific (e.g., CBT for psychosis, considering medication options, future planning).

Intra-Individual Factors

Although it is tempting to focus on clinical factors alone, it is important to consider additional intra-individual and socio-contextual factors. Relevant intra-individual factors (Figure 1) include developmental stage, pre-morbid functioning, social cognitive and neurocognitive abilities, as well as individual goals and aspirations. Besides providing information about risk and resiliency, this constellation highlights individual differences in potential for self-stigma, legal ability to consent, and cognitive capacity to engage in treatment planning. These factors influence both ethical analysis and clinician decision making. For example, an adolescent’s ability to handle disclosures will vary widely with maturity and cognitive capacity, which influences what is disclosed (e.g., using the label “psychosis risk” vs. focusing only on symptoms) and to whom (e.g., parent/guardian, the youth). An individual’s personal goals—rarely considered by health care providers—may also be relevant for ethical disclosures and future planning. For example, if an individual’s goals include extended study in a high-stress environment (e.g., medical, law, other graduate studies), disclosure may help individuals prepare, which may include proactive planning for managing environmental stressors, or planning for alternate paths should illness derail their original plans. Alternatively, a clinician may decide that disclosure and documentation would cause undue risks by limiting the individual’s opportunities and unnecessarily undermining self-concept.

Socio-Contextual Factors

Broader socio-contextual factors also warrant attention (Figure 1). This includes consideration of family dynamics, availability of treatment, insurance benefits, cultural factors, and discrimination potential. For example, given that most individuals are identified during adolescence, clinicians should anticipate how families may react to information and how these reactions may harm the patient by compromising self-determination and autonomy. Families may react differently to disclosure of psychosis-risk status based on cultural understanding of mental illness and exposure to others with mental illness. For example, many youth at risk for psychosis and their parents have watched relatives deal with severe mental illness, and depending on the course of their relative’s illness, they may have especially strong reactions and negative connotations associated with the term “psychosis.” This may affect decisions about whether or how to disclose risk status. If full disclosure is warranted, then extensive psychoeducation about the causes, newer treatment options, and likely outcomes may reflect the ethical principle of non-maleficence.

Other contextual factors include access to services and insurance coverage. As mentioned, disclosure and documentation can help individuals access insurance coverage for treatment. However, the weighting of this particular benefit may vary considerably depending on an individual’s insurance status (e.g., it may not provide much benefit to the uninsured) and ability to access services otherwise (e.g., families with financial resources may prefer to pay out of pocket for treatment, believing that documentation may increase risk of discrimination). This particular issue will vary dramatically depending on the state and federal laws at the time. Whether or not clinicians should be expected to take such factors into account is an ethical question that exemplifies the complexity of the decision-making process.

Conclusion

Advances in early detection and preventive interventions for psychosis must be accompanied by ethically informed policies and guidelines. This requires coordination and communication among researchers, clinicians, and policy makers to ensure policies are designed to handle the complexity and heterogeneity of the psychosis-risk syndrome. Also, risk states are not easily measurable entities and depend on the precision of assessment tools and prognostic confidence. The development of more accurate prediction algorithms will likely incorporate more domains, including measures of the individual’s pre-morbid developmental course, measures of intra-individual and contextual factors, and biomarkers relevant to brain function. However, until more fine-grained diagnostic tools develop, careful analysis of relevant factors must guide clinical research, clinical practice, and policy regarding psychosis-risk syndromes.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Psychosis-Risk Syndromes

Abstract

Keywords

Tweet

Key Points

Introduction

Complexities and Context

Disclosure

Disclosure Benefits

Disclosure Risks

Weighing Disclosure Risks/Benefits

Documentation

Documentation Benefits

Documentation Risks

Weighing Documentation Risks/Benefits

Treatment

Treatment Benefits

Treatment Risks

Weighing Treatment Risks/Benefits

Minor Status

Considerations for Policy Development

Clinical Factors

Intra-Individual Factors

Socio-Contextual Factors

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References