Potential stigma associated with inclusion of the psychosis risk syndrome in the DSM-V: An empirical question

While the "clinical high-risk state" for psychosis has demonstrated good reliability and fair predictive validity for psychotic disorders, over 50% of identified subjects do not progress to psychosis. Despite the benefits that early detection and treatment might offer, debate concerning the official inclusion of a "psychosis risk syndrome" in the upcoming DSM-V frequently involves concerns about the impact of stigma on patients, families and institutions. We add to this debate by providing an analysis of the theoretical and empirical stigma literature to evaluate the potential effects of stigma associated with the psychosis risk syndrome. Theorists' conceptualizations of how stigma exerts its negative effects emphasize internalization of pejorative societal stereotypes ('self-stigma'), negative emotional reactions, harmful behavioral coping strategies, and structural discrimination as key mechanisms. Studies assessing the comparative effects of symptomatic behavior when compared with a psychiatric diagnosis label in predicting rejecting social attitudes indicate that treating symptomatic behaviors is likely to diminish overall stigma. However, any publically held 'preexisting conceptions' about what a psychosis risk syndrome means are still likely to exert negative effects. Additionally, particular features of this syndrome-that it occurs during adolescence when identity formation may be in flux- may also shape manifestations of stigma. Utilizing other well-established 'at-risk' conditions (e.g., genetic susceptibility) to model potential discrimination for this syndrome, we suggest that future discrimination is likely to occur in insurance and family domains. We conclude by proposing stigma measurement strategies, including recommending that field trials prior to DSM-V adopt systematic measures to assess any stigma that this psychosis risk syndrome might confer via future community use.