Psych · General adult psychiatry — clinical high risk / attenuated psychosis
Clinical high risk and attenuated psychosis syndrome
Also known as Clinical high risk · CHR · CHR-P · Ultra-high risk · UHR · Attenuated psychosis syndrome · APS · At-risk mental state · ARMS · Prodromal psychosis · CAARMS · SIPS · BLIPS
Exam-exhaustive fellowship reference on clinical high risk (CHR) and ultra-high risk (UHR) for psychosis — APS/BLIPS/genetic-risk criteria, CAARMS and SIPS instruments, conversion rates and predictors, DSM-5-TR attenuated psychosis syndrome as Section III construct, indicated prevention evidence (CBT, omega-3 equipoise, antipsychotics not first-line), monitoring and escalation to FEP. Distinct from the first-episode psychosis pathway monograph. FRANZCP-primary, globally tagged.
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Target exams
FRANZCPMRCPsychABPNMD-DNBNEET-SS
Red flags
- Attenuated symptoms escalating to fixed delusions, full hallucinations with loss of insight, or sustained frank psychosis — reclassify as first-episode psychosis and start the FEP pathway
- New psychosis-spectrum presentation with fever, seizure, fluctuating attention, dysautonomia or rapid cognitive decline — exclude delirium, encephalitis and other organic causes before a pure CHR label
- Active suicidal intent or plan in a help-seeking CHR youth — same-day senior review; do not discharge on conversion-risk numbers alone
- Recurrent BLIPS that no longer fully resolve, or continuous full-threshold symptoms — treat as emerging FEP, not watchful waiting
- Heavy high-THC cannabis or stimulant use with escalating perceptual anomalies — dual-diagnosis plan and risk monitoring; do not wait for perfect abstinence
- Late first presentation after age 40 sold as 'prodrome' — intensify organic work-up; CHR language is for youth-enriched indicated risk, not a substitute for late-onset psychosis assessment
Meet the patient
A 17-year-old is brought by his mother because his grades have collapsed. He says, carefully: "Sometimes I think the teachers are talking about me. I know that's probably stupid. But I check." He sleeps badly. His mother's sister has schizophrenia. He has heard his name called twice this month — and each time decided it probably wasn't real.[1][2][3]
The examiner's question is not "is this psychosis?" It is: "What do you offer this family — and what do you refuse to offer?" Every word of that answer is examinable.[7][21]
References23ShowHide
- [1]Yung AR, Yuen HP, McGorry PD, et al. Mapping the onset of psychosis: the Comprehensive Assessment of At-Risk Mental States Aust N Z J Psychiatry, 2005.PMID 16343296
- [2]Miller TJ, McGlashan TH, Rosen JL, et al. Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability Schizophr Bull, 2003.PMID 14989408
- [3]Yung AR, Stanford C, Cosgrave E, et al. Testing the Ultra High Risk (prodromal) criteria for the prediction of psychosis in a clinical sample of young people Schizophr Res, 2006.PMID 16630707
- [4]Fusar-Poli P, Bonoldi I, Yung AR, et al. Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk Arch Gen Psychiatry, 2012.PMID 22393215
- [5]Fusar-Poli P, Cappucciati M, Borgwardt S, et al. Heterogeneity of Psychosis Risk Within Individuals at Clinical High Risk: A Meta-analytical Stratification JAMA Psychiatry, 2016.PMID 26719911
- [6]Salazar de Pablo G, Radua J, Pereira J, et al. Probability of Transition to Psychosis in Individuals at Clinical High Risk: An Updated Meta-analysis JAMA Psychiatry, 2021.PMID 34259821
- [7]Fusar-Poli P, Salazar de Pablo G, Correll CU, et al. Prevention of Psychosis: Advances in Detection, Prognosis, and Intervention JAMA Psychiatry, 2020.PMID 32159746
- [8]Cannon TD, Cadenhead K, Cornblatt B, et al. Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America Arch Gen Psychiatry, 2008.PMID 18180426
- [9]Ruhrmann S, Schultze-Lutter F, Salokangas RK, et al. Prediction of psychosis in adolescents and young adults at high risk: results from the prospective European prediction of psychosis study Arch Gen Psychiatry, 2010.PMID 20194824
- [10]Nelson B, Yuen HP, Wood SJ, et al. Long-term follow-up of a group at ultra high risk ("prodromal") for psychosis: the PACE 400 study JAMA Psychiatry, 2013.PMID 23739772
- [11]McGorry PD, Yung AR, Phillips LJ, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms Arch Gen Psychiatry, 2002.PMID 12365879
- [12]McGlashan TH, Zipursky RB, Perkins D, et al. Randomized, double-blind trial of olanzapine versus placebo in patients prodromally symptomatic for psychosis Am J Psychiatry, 2006.PMID 16648318
- [13]Morrison AP, French P, Stewart SL, et al. Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial BMJ, 2012.PMID 22491790
- [14]van der Gaag M, Smit F, Bechdolf A, et al. Preventing a first episode of psychosis: meta-analysis of randomized controlled prevention trials of 12 month and longer-term follow-ups Schizophr Res, 2013.PMID 23870806
- [15]Amminger GP, Schäfer MR, Papageorgiou K, et al. Long-chain omega-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo-controlled trial Arch Gen Psychiatry, 2010.PMID 20124114
- [16]McGorry PD, Nelson B, Markulev C, et al. Effect of ω-3 Polyunsaturated Fatty Acids in Young People at Ultrahigh Risk for Psychotic Disorders: The NEURAPRO Randomized Clinical Trial JAMA Psychiatry, 2017.PMID 27893018
- [17]Davies C, Cipriani A, Ioannidis JPA, et al. Lack of evidence to favor specific preventive interventions in psychosis: a network meta-analysis World Psychiatry, 2018.PMID 29856551
- [18]Tsuang MT, Van Os J, Tandon R, et al. Attenuated psychosis syndrome in DSM-5 Schizophr Res, 2013.PMID 23773295
- [19]Fusar-Poli P, Nelson B, Valmaggia L, et al. Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis Schizophr Bull, 2014.PMID 23180756
- [20]Schultze-Lutter F, Ruhrmann S, Fusar-Poli P, et al. Basic symptoms and the prediction of first-episode psychosis Curr Pharm Des, 2012.PMID 22239566
- [21]Galletly C, Castle D, Dark F, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders Aust N Z J Psychiatry, 2016.PMID 27106681
- [22]McGorry PD, Mei C, Amminger GP, et al. A Sequential Adaptive Intervention Strategy Targeting Remission and Functional Recovery in Young People at Ultrahigh Risk of Psychosis: The Staged Treatment in Early Psychosis (STEP) Sequential Multiple Assignment Randomized Trial JAMA Psychiatry, 2023.PMID 37378974
- [23]Di Forti M, Quattrone D, Freeman TP, et al. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study Lancet Psychiatry, 2019.PMID 30902669