Attenuated Psychosis Syndrome & Shared Psychotic Disorder

The American Psychiatric Association (APA) has attempted to formulate the diagnostic criteria for the various mental health disorders according to a disease model specification using the same type of approach that physical diseases are diagnosed with. This approach has generated criticism from numerous sources, but APA continues to attempt to present the various forms of mental illnesses in its Diagnostic and Statistical Manual of Mental Disorders (DSM) in terms of discrete, disease-like conditions that can be diagnosed according to specific criteria. Although there are no formal medical tests that can be used to diagnose the vast majority of the disorders in the DSM, APA has attempted to maintain this approach using behaviorally based diagnostic criteria.

The stages of a physical disease have been listed in numerous sources, and depending on the source, there can be three, four or more stages. In a five-stage model, the stages of disease include:

Early researchers attempting to understand the psychotic disorder schizophrenia hypothesized that there was a prodromal period of the disorder where individuals begin to display some psychotic-like symptoms, but they were not distressing enough to warrant significant attention. The notion that individuals who develop schizophrenia undergo some prodromal period has continued to remain popular with psychiatrists and other researchers who continue to refine the diagnostic criteria for these disorders.

Attenuated Psychosis Syndrome

In the current edition of the DSM, the DSM-5, there is a proposal for a condition that researchers should study and consider for inclusion as a formal mental health disorder: attenuated psychosis syndrome. This is currently not a recognized psychological/psychiatric disorder, but it is included in the section Conditions for Further Study.

The main features of attenuated psychosis syndrome parallel the older notions of the prodromal phase of schizophrenia. The person has very low-grade symptoms of schizophrenia, such as delusions, hallucinations, or disorganized speech, and the symptoms have been present for short period of time and worsened, but the symptoms are below the level of severity that would warrant a diagnosis of a psychotic disorder, such as schizophrenia.

As this is a condition for further study and not an actual diagnosis, there is no information regarding its prevalence, any co-occurring conditions, or other information that would normally be included with the description of a formal diagnostic category in the DSM-5. The condition is considered to be potentially useful in determining a potential risk that someone may develop a full-blown psychotic disorder such as schizophrenia. Some individuals who meet the specifications for attenuated psychosis syndrome are eventually diagnosed with a psychotic disorder, and some are not.

The co-occurrence of attenuated psychosis syndrome and a substance use disorder is not well documented because this is not an actual clinical diagnosis. The research on schizophrenia indicates that there is a significant risk for individuals who are in the early stages of schizophrenia to also have substance abuse issues. Moreover, it has been noticed across numerous studies that individuals who use cannabis products in childhood or adolescence have an increased risk to later be diagnosed with schizophrenia compared to those who do not use cannabis, although cannabis products are not considered to be causes of schizophrenia.

Certainly, individuals who demonstrate subclinical or prodromal tendencies toward schizophrenia would be expected to also be at an increased risk for substance abuse issues. It should be stressed that substance abuse is not thought to cause schizophrenia and that there is a diagnosis of substance/medication-induced psychotic disorder, where individuals display schizophrenia-like symptoms as a result of medications or drugs.

Shared Psychotic Disorder

The principle feature of shared psychotic disorder, sometimes referred to as folie à deux (the madness of two), is a very committed belief by a secondary person in some other person’s primary delusion. Delusions are fixed, often bizarre, and false beliefs that some individuals adhere to, even in light of significant disconfirming evidence.

The most common forms of delusions in psychosis are paranoid delusions where the individual is convinced that some person, some group, or everyone is out to damage, persecute, or chastise them in some way, but there are numerous different types of delusions. The delusions that occur in shared psychotic disorder are often not as bizarre as the delusions that occur in schizophrenia, but they are typically fixed beliefs that are false and rigidly held by both individuals. The delusion held by the secondary individual may not be as severe as the one held by the primary or dominant person, but it still qualifies as a delusion.

Shared psychotic disorder remained a diagnostic category as late as the previous edition of the DSM (DSM-IV), but it is not included in the current edition. The DSM-5 does include a minor psychotic disorder labeled as delusional symptoms in partner of individual with delusional disorder that is very similar to the previous diagnosis of shared psychotic disorder. Other than a very brief description of this disorder, there are no diagnostic criteria and accompanying information regarding the prevalence of the disorder or any co-occurring issues.

According to the DSM-IV, the diagnostic criteria for shared psychotic disorder included:

The information on shared psychotic disorder is otherwise rather vague. There are case studies of this disorder occurring; however, the DSM-IV is now considered to be outdated. Disorders that did not transfer to the DSM-5 cannot be diagnosed according to DSM-IV criteria.

There is little information regarding the co-occurrence of substance use disorders in the former shared psychotic disorder; however, as mentioned above, there is sufficient research that indicates that individuals with psychotic disorders have an increased risk of developing numerous types of substance use disorders. Again, it should be stated that there are no valid explanations of substance abuse causing disorders like shared psychotic disorder or delusional symptoms in the partner of individual with a delusional disorder.

The upgraded disorder in the DSM-5 is intended to be used when a clinician is faced with a person who has what appears to be a psychotic disorder but does not meet any of the criteria for the other disorders in the DSM-5. These presentations are specified using the “other specified” designation to describe what the clinician believes might be going on with the person. Very often, these secondary diagnoses become refined when more information is available, and the person expressing the symptoms in question is given a different diagnosis.