Attenuated hallucinations (Criterion A2) include alterations in sensory perceptions, usually auditory and/ or visual. When the hallucinations are moderate, the sounds and images are often unformed (e.g., shadows, trails, halos, murmurs, rumbling), and they are experienced as unusual or puzzling. When the hallucinations are severe, these experiences become more vivid and frequent (i.e., recurring illusions or hallucinations that capture at- tention and affect thinking and concentration). These perceptual abnormalities may dis— rupt behavior, but skepticism about their reality can still be induced.
Disorganized communication (Criterion A3) may manifest as odd speech (vague, meta- phorical, overelaborate, stereotyped), unfocused speech (confused, muddled, too fast or too slow, wrong words, irrelevant context, off track), or meandering speech (circumstantial, tan- gential). When the disorganization is moderately severe, the individual frequently gets into irrelevant topics but responds easily to clarifying questions. Speech may be odd but under- standable. At the moderately severe level, speech becomes meandering and circumstantial, and when the disorganization is severe, the individual fails to get to the point without external guidance (tangential). At the severe level, some thought blocking and / or loose as- sociations may occur infrequently, especially when the individual is under pressure, but re- orienting questions quickly return structure and organization to the conversation.
The individual realizes that changes in mental state and / or in relationships are taking place. He or she maintains reasonable insight into the psychotic-like experiences and gen— erally appreciates that altered perceptions are not real and magical ideation is not compel- ling. The individual must experience distress and/ or impaired performance in social or role functioning (Criterion D), and the individual or responsible others must note the changes and express concern, such that clinical care is sought (Criterion A).
The individual may experience magical thinking, perceptual aberrations, difficulty in con- centration, some disorganization in thought or behavior, excessive suspiciousness, anxi- ety, social withdrawal, and disruption in sleep-wake cycle. Impaired cognitive function and negative symptoms are often observed. Neuroimaging variables distinguish cohorts with attenuated psychosis syndrome from normal control cohorts with patterns similar to, but less severe than, that observed in schizophrenia. However, neuroimaging data is not diagnostic at the individual level.
The prevalence of attenuated psychosis syndrome is unknown. Symptoms in Criterion A are not uncommon in the non-help-seeking population, ranging from 23%—13% for hallu- cinatory experiences and delusional thinking. There appears to be a slight male prepon- derance for attenuated psychosis syndrome.
Onset of attenuated psychosis syndrome is usually in mid-to-late adolescence or early adulthood. It may be preceded by normal development or evidence for impaired cogni- tion, negative symptoms, and/ or impaired social development. In help-seeking cohorts, criteria for a psychotic disorder. In some cases, the syndrome may transition to a depres- sive or bipolar disorder with psychotic features, but development to a schizophrenia spec- trum disorder is more frequent. It appears that the diagnosis is best applied to individuals ages 15—35 years. Long—term course is not yet described beyond 7—12 years.
Temperamental. Factors predicting prognosis of attenuated psychosis syndrome have not been definitively characterized, but the presence of negative symptoms, cognitive im- pairment, and poor functioning are associated with poor outcome and increase risk of transition to psychosis.
Genetic and physiological. A family history of psychosis places the individual with at- tenuated psychosis syndrome at increased risk for developing a full psychotic disorder.
Structural, functional, and neurochemical imaging data are associated with increased risk of transition to psychosis.