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Disorder, not just state of risk: Meta-analysis of functioning and quality of life in people at high risk of psychosis

  • Paolo Fusar-Poli (a1), Matteo Rocchetti (a2), Alberto Sardella (a3), Alessia Avila (a3), Martina Brandizzi (a4), Edgardo Caverzasi (a5), Pierluigi Politi (a5), Stephan Ruhrmann (a6) and Philip McGuire (a7)...



The nosology of the psychosis high-risk state is controversial. Traditionally conceived as an ‘at risk’ state for the development of psychotic disorders, it is also conceptualised as a clinical syndrome associated with functional impairment.


To investigate meta-analytically the functional status of patients at high clinical risk for psychosis and its association with longitudinal outcomes.


Three meta-analyses compared level of functioning (n = 3012) and quality of life (QoL) (n = 945) between a high-risk group, a healthy control group and group with psychosis, and baseline functioning in people in the high-risk group who did or did not have a transition to psychosis at follow-up (n = 654).


People at high risk had a large impairment in functioning (P<0.001) and worse QoL (P = 0.001) than the healthy control group, but only small to moderately better functioning (P = 0.012) and similar QoL (P = 0.958) compared with the psychosis group. Among the high-risk group, those who did not develop psychosis reported better functioning (P = 0.001) than those who did.


Our results indicate that the high-risk state is characterised by consistent and large impairments of functioning and reduction in QoL similar to those in other coded psychiatric disorders.

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Corresponding author

Dr Paolo Fusar-Poli, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, PO Box 63, De Crespigny Park, London SE5 8AF, UK. Email:


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1 Fusar-Poli, P, Borgwardt, S, Bechdolf, A, Addington, J, Riecher-Rossler, A, Schultze-Lutter, F, et al. The psychosis high-risk state: a comprehensive state-of-the-art review. JAMA Psychiatry 2013; 70: 107–20.
2 Mrazek, PB, Haggerty, RJ, eds. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. National Academies Press, 1994.
3 Fusar-Poli, P, Bechdolf, A, Taylor, MJ, Bonoldi, I, Carpenter, WT, Yung, AR, et al. At risk for schizophrenic or affective psychoses? A meta-analysis of DSM/ICD diagnostic outcomes in individuals at high clinical risk. Schizophr Bull 2013; 39: 923–32.
4 Stafford, MR, Jackson, H, Mayo-Wilson, E, Morrison, AP, Kendall, T. Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ 2013; 346: f185.
5 Van der Gaag, M, Smit, F, Bechdolf, A, French, P, Linszen, DH, Yung, AR, 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; 149: 5662.
6 Fusar-Poli, P, Carpenter, WT, Woods, SW, McGlashan, TH. Attenuated psychosis syndrome: ready for DSM-5.1? Annu Rev Clin Psychol 2014; 10: 155–92.
7 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). APA, 2013.
8 Woods, SW, Walsh, BC, Saksa, JR, McGlashan, TH. The case for including attenuated psychotic symptoms syndrome in DSM-5 as a psychosis risk syndrome. Schizophr Res 2010; 123: 199207.
9 Schultze-Lutter, F, Schimmelmann, BG, Ruhrmann, S, Michel, C. ‘A rose is a rose is a rose’, but at-risk criteria differ. Psychopathology 2013; 46: 7587.
10 Blumenthal-Barby, JS. Psychiatry's new manual (DSM-5): ethical and conceptual dimensions. J Med Ethics 2014; 40: 531–6.
11 Addington, J, Penn, D, Woods, SW, Addington, D, Perkins, DO. Social functioning in individuals at clinical high risk for psychosis. Schizophr Res 2008; 99: 119–24.
12 Simon, AE, Graedel, M, Cattapan-Ludewig, K, Gruber, K, Ballinari, P, Roth, B, et al. Cognitive functioning in at-risk mental states for psychosis and 2-year clinical outcome. Schizophr Res 2012; 142: 108–15.
13 Ruhrmann, S, Paruch, J, Bechdolf, A, Pukrop, R, Wagner, M, Berning, J, et al. Reduced subjective quality of life in persons at risk for psychosis. Acta Psychiatr Scand 2008; 117: 357–68.
14 Ruhrmann, S, Paruch, J, Bechdolf, A, Pukrop, R, Wagner, M, Berning, J, et al. Reduced subjective quality of life in persons at risk for psychosis. Acta Psychiatr Scand 2008; 117: 357–68.
15 Stroup, DF, Berlin, JA, Morton, SC, Olkin, I, Williamson, GD, Rennie, D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–12.
16 Rosenthal, R. Meta-analysis: a review. Psychosom Med 1991; 53: 247271.
17 Juni, P, Witschi, A, Bloch, R, Egger, M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA 1999; 282: 1054–60.
18 Mertz, D, Kim, TH, Johnstone, J, Lam, PP, Science, M, Kuster, SP, et al. Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis. BMJ 2013; 347: f5061.
19 Borenstein M Hedges, L, Higgins, J, Rothstein, H. Comprehensive Meta-Analysis Version 2. Biostat, 2005.
20 Paulson, JF, Bazemore, SD. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA 2010; 303: 1961–9.
21 Lipsey, M, Wilson, D. Practical Meta-analysis. Sage, 2000.
22 Cooper, H, Hedges, L, Valentine, J. Handbook of Research Synthesis and Meta-Analysis. Sage, 2009.
23 Duval, S, Tweedie, R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–63.
24 Castle, DJ. The truth, and nothing but the truth, about early intervention in psychosis. Aust N Z J Psychiatry 2012; 46: 10–3.
25 Castle, DJ. Is it appropriate to treat people at high-risk of psychosis before first onset? – no. Med J Australia 2012; 196: 557.
26 Fusar-Poli, P, Meneghelli, A, Valmaggia, L, Allen, P, Galvan, F, McGuire, P, et al. Duration of untreated prodromal symptoms and 12-month functional outcome of individuals at risk of psychosis. Br J Psychiatry 2009; 194: 181–2.
27 Ruhrmann, S, Klosterkotter, J, Bodatsch, M, Nikolaides, A, Julkowski, D, Hilboll, D, et al. Chances and risks of predicting psychosis. Eur Arch Psychiatry Clin Neurosci 2012; 262 (suppl 2): S8590.
28 Ruhrmann, S, Schultze-Lutter, F, Klosterkotter, J. Probably at-risk, but certainly ill – advocating the introduction of a psychosis spectrum disorder in DSM-V. Schizophr Res 2010; 120: 2337.
29 Salokangas, RK, Ruhrmann, S, von Reventlow, HG, Heinimaa, M, Svirskis, T, From, T, et al. Axis I diagnoses and transition to psychosis in clinical high-risk patients EPOS project: prospective follow-up of 245 clinical high-risk outpatients in four countries. Schizophr Res 2012; 138: 192–7.
30 Fusar-Poli, P, Nelson, B, Valmaggia, L, Yung, AR, McGuire, PK. Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis. Schizophr Bull 2014; 40: 120–31.
31 Modinos, G, Allen, P, Frascarelli, M, Tognin, S, Valmaggia, L, Xenaki, L, et al. Are we really mapping psychosis risk? Neuroanatomical signature of affective disorders in subjects at ultra high risk. Psychol Med 2014; 44: 3491–501.
32 Ruhrmann, S, Schultze-Lutter, F, Salokangas, RKR, Heinimaa, M, Linszen, D, Dingemans, P, 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; 67: 241–51.
33 Hafner, H, Maurer, K, Trendler, G, an der Heiden, W, Schmidt, M, Konnecke, R. Schizophrenia and depression: challenging the paradigm of two separate diseases – a controlled study of schizophrenia, depression and healthy controls. Schizophr Res 2005; 77: 1124.
34 Mishara, AL, Fusar-Poli, P. The phenomenology and neurobiology of delusion formation during psychosis onset: Jaspers, Truman symptoms, and aberrant salience. Schizophr Bull 2013; 39: 278–86.
35 Fusar-Poli, P, Van Os, J. Lost in transition: setting the psychosis threshold in prodromal research. Acta Psychiatr Scand 2013; 127: 248–52
36 Kempton, MJ, Bonoldi, I, Valmaggia, L, McGuire, P, Fusar-Poli, P. Speed of psychosis progression in people at ultra-high clinical risk: a complementary meta-analysis. JAMA Psychiatry 2015; 72: 622–3.
37 Kaymaz, N, Drukker, M, Lieb, R, Wittchen, HU, Werbeloff, N, Weiser, M, et al. Do subthreshold psychotic experiences predict clinical outcomes in unselected non-help-seeking population-based samples? A systematic review and meta-analysis, enriched with new results. Psychol Med 2012; 42: 2239–53.
38 Kelleher, I, Murtagh, A, Molloy, C, Roddy, S, Clarke, MC, Harley, M, et al. Identification and characterization of prodromal risk syndromes in young adolescents in the community: a population-based clinical interview study. Schizophr Bull 2012; 38: 239–46.
39 Nelson, B, Yuen, HP, Wood, SJ, Lin, A, Spiliotacopoulos, D, Bruxner, A, et al. Long-term follow-up of a group at ultra high risk (‘prodromal’) for psychosis: the PACE 400 study. JAMA Psychiatry 2013; 70: 793802.
40 Gustavsson, A, Svensson, M, Jacobi, F, Allgulander, C, Alonso, J, Beghi, E, et al. Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011; 21: 718–79.
41 Grossman, LS, Harrow, M, Rosen, C, Faull, R. Sex differences in outcome and recovery for schizophrenia and other psychotic and nonpsychotic disorders. Psychiatr Serv 2006; 57: 844–50.
42 Velthorst, E, Nelson, B, Wiltink, S, de Haan, L, Wood, SJ, Lin, A, et al. Transition to first episode psychosis in ultra high risk populations: does baseline functioning hold the key? Schizophr Res 2013; 143: 132–7.
43 Cannon, TD, Cadenhead, K, Cornblatt, B, Woods, SW, Addington, J, Walker, E, et al. Prediction of psychosis in youth at high clinical risk. Arch Gen Psychiatry 2008; 65: 2837.
44 Velthorst, E, Nieman, DH, Linszen, D, Becker, H, de Haan, L, Dingemans, PM, et al. Disability in people clinically at high risk of psychosis. Br J Psychiatry 2010; 197: 278–84.
45 Thompson, A, Nelson, B, Yung, A. Predictive validity of clinical variables in the ‘at risk’ for psychosis population: international comparison with results from the North American Prodrome Longitudinal Study. Schizophr Res 2011; 126: 51–7.
46 Ustun, B, Kennedy, C. What is ‘functional impairment’? Disentangling disability from clinical significance. World Psychiatry 2009; 8: 82–5.
47 Samara, MT, Engel, RR, Millier, A, Kandenwein, J, Toumi, M, Leucht, S. Equipercentile linking of scales measuring functioning and symptoms: examining the GAF, SOFAS, CGI-S, and PANSS. Eur Neuropsychopharmacol 2014; 24: 1767–72.
48 Schultze-Lutter, F, Michel, C, Ruhrmann, S, Schimmelmann, BG. Prevalence and clinical significance of DSM-5 attenuated psychosis syndrome in adolescents and young adults in the general population: the Bern Epidemiological At-Risk (BEAR) Study. Schizophr Bull 2014; 40: 1499–508.
49 Wakefield, JC. Wittgenstein's nightmare: why the RDoC grid needs a conceptual dimension. World Psychiatry 2014; 13: 3840.
50 Epperson, CN, Steiner, M, Hartlage, SA, Eriksson, E, Schmidt, PJ, Jones, I, et al. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. Am J Psychiatry 2012; 169: 465–75.
51 Wakefield, JC. The DSM-5 debate over the bereavement exclusion: psychiatric diagnosis and the future of empirically supported treatment. Clin Psychol Rev 2013; 33: 825–45.
52 Hajek, T, Slaney, C, Garnham, J, Ruzickova, M, Passmore, M, Alda, M. Clinical correlates of current level of functioning in primary care-treated bipolar patients. Bipolar Disord 2005; 7: 286–91.
53 Schaub, A, Neubauer, N, Mueser, KT, Engel, R, Moller, HJ. Neuropsychological functioning in inpatients with major depression or schizophrenia. BMC Psychiatry 2013; 13: 203.
54 Phillips, KA, Quinn, G, Stout, RL. Functional impairment in body dysmorphic disorder: a prospective, follow-up study. J Psychiatr Res 2008; 42: 701–7.
55 Kelly, MM, Dalrymple, K, Zimmerman, M, Phillips, KA. A comparison study of body dysmorphic disorder versus social phobia. Psychiatr Res 2013; 205: 109–16.
56 Carrion, RE, Goldberg, TE, McLaughlin, D, Auther, AM, Correll, CU, Cornblatt, BA. Impact of neurocognition on social and role functioning in individuals at clinical high risk for psychosis. Am J Psychiatry 2011; 168: 806–13.
57 Chudleigh, C, Naismith, SL, Blaszczynski, A, Hermens, DF, Hodge, MA, Hickie, IB. How does social functioning in the early stages of psychosis relate to depression and social anxiety? Early Interv Psychiatry 2011; 5: 224–32.
58 Chung, YS, Kang, D-H, Shin, NY, Yoo, SY, Kwon, JS. Deficit of theory of mind in individuals at ultra-high-risk for schizophrenia. Schizophr Res 2008; 99:111–8.
59 Hui, C, Morcillo, C, Russo, DA, Stochl, J, Shelley, GF, Painter, M, et al. Psychiatric morbidity, functioning and quality of life in young people at clinical high risk for psychosis. Schizophr Res 2013; 148: 175–80.
60 Koren, D, Reznik, N, Adres, M, Scheyer, R, Apter, A, Steinberg, T, et al. Disturbances of basic self and prodromal symptoms among non-psychotic help-seeking adolescents. Psychol Med 2013; 43: 1365–76.
61 Lindgren, M, Manninen, M, Laajasalo, T, Mustonen, U, Kalska, H, Suvisaari, J, et al. The relationship between psychotic-like symptoms and neurocognitive performance in a general adolescent psychiatric sample. Schizophr Res 2010; 123: 7785.
62 Niendam, TA, Berzak, J, Cannon, TD, Bearden, CE. Obsessive compulsive symptoms in the psychosis prodrome: correlates of clinical and functional outcome. Schizophr Res 2009; 108: 170–5.
63 Schlosser, DA, Jacobson, S, Chen, Q, Sugar, CA, Niendam, TA, Li, G, et al. Recovery from an at-risk state: clinical and functional outcomes of putatively prodromal youth who do not develop psychosis. Schizophr Bull 2012; 38: 1225–33.
64 Serrani, D. Neurocognitive assessment of ultra high risk of psychosis states using the MATRICS battery (Measurement and Treatment Research to Improve Cognition in Schizophrenia). Rev Psiquiatr Clín 2011; 38: 130–4.
65 Shin, YS, Kim, SN, Shin, NY, Jung, WH, Hur, JW, Byun, MS, et al. Increased intra-individual variability of cognitive processing in subjects at risk mental state and schizophrenia patients. PLoS One 2013; 8: e78354.
66 Smieskova, R, Fusar-Poli, P, Aston, J, Simon, A, Bendfeldt, K, Lenz, C, et al. Insular volume abnormalities associated with different transition probabilities to psychosis. Psychol Med 2012; 42: 1613–25.
67 Stanford, AD, Messinger, J, Malaspina, D, Corcoran, CM. Theory of Mind in patients at clinical high risk for psychosis. Schizophr Res 2011; 131: 11–7.
68 Thompson, A, Papas, A, Bartholomeusz, C, Allott, K, Amminger, GP, Nelson, B, et al. Social cognition in clinical ‘at risk’ for psychosis and first episode psychosis populations. Schizophr Res 2012; 141: 204–9.
69 Van Rijn, S, Aleman, A, de Sonneville, L, Sprong, M, Ziermans, T, Schothorst, P, et al. Misattribution of facial expressions of emotion in adolescents at increased risk of psychosis: the role of inhibitory control. Psychol Med 2011; 41: 499508.
70 Van Tricht, MJ, Nieman, DH, Koelman, JHTM, van der Meer, JN, Bour, LJ, de Haan, L, et al. Reduced parietal P300 amplitude is associated with an increased risk for a first psychotic episode. Biol Psychiatry 2010; 68: 642–8.
71 Woods, SW, Addington, J, Cadenhead, KS, Cannon, TD, Cornblatt, BA, Heinssen, R, et al. Validity of the prodromal risk syndrome for first psychosis: findings from the North American Prodrome Longitudinal Study. Schizophr Bull 2009; 35: 894908.
72 Eastvold, AD, Heaton, RK, Cadenhead, KS. Neurocognitive deficits in the (putative) prodrome and first episode of psychosis. Schizophr Res 2007; 93: 266–77.
73 Fulford, D, Niendam, TA, Floyd, EG, Carter, CS, Mathalon, DH, Vinogradov, S, et al. Symptom dimensions and functional impairment in early psychosis: more to the story than just negative symptoms. Schizophr Res 2013; 147: 125–31.
74 Niendam, TA, Lesh, TA, Yoon, J, Westphal, AJ, Hutchison, N, Daniel Ragland, J, et al. Impaired context processing as a potential marker of psychosis risk state. Psychiatry Res 2014; 221: 1320.
75 Pruessner, M, Iyer, SN, Faridi, K, Joober, R, Malla, AK. Stress and protective factors in individuals at ultra-high risk for psychosis, first episode psychosis and healthy controls. Schizophr Res 2011; 129: 2935.
76 Quednow, BB, Frommann, I, Berning, J, Kuehn, KU, Maier, W, Wagner, M. Impaired sensorimotor gating of the acoustic startle response in the prodrome of schizophrenia. Biol Psychiatry 2008; 64: 766–73.
77 Rausch, F, Eifler, S, Esser, A, Esslinger, C, Schirmbeck, F, Meyer-Lindenberg, A, et al. The Early Recognition Inventory ERIraos detects at risk mental states of psychosis with high sensitivity. Compr Psychiatry 2013; 54: 1068–76.
78 Song, YY, Kang, JI, Kim, SJ, Lee, MK, Lee, E, An, SK. Temperament and character in individuals at ultra-high risk for psychosis and with first-episode schizophrenia: associations with psychopathology, psychosocial functioning, and aspects of psychological health. Compr Psychiatry 2013; 54: 1161–8.
79 Washida, K, Takeda, T, Habara, T, Sato, S, Oka, T, Tanaka, M, et al. Efficacy of second-generation antipsychotics in patients at ultra-high risk and those with first-episode or multi-episode schizophrenia. Neuropsychiatr Dis Treat 2013; 9: 861–8.
80 Kim, KR, Song, YY, Park, JY, Lee, EH, Lee, M, Lee, SY, et al. The relationship between psychosocial functioning and resilience and negative symptoms in individuals at ultra-high risk for psychosis. Aust N Z J Psychiatry 2013; 47: 762–71.
81 Bechdolf, A, Pukrop, R, Kohn, D, Tschinkel, S, Veith, V, Schultze-Lutter, F, et al. Subjective quality of life in subjects at risk for a first episode of psychosis: a comparison with first episode schizophrenia patients and healthy controls. Schizophr Res 2005; 79: 137–43.
82 Francey, SM, Jackson, HJ, Phillips, LJ, Wood, SJ, Yung, AR, McGorry, PD. Sustained attention in young people at high risk of psychosis does not predict transition to psychosis. Schizophr Res 2005; 79: 127–36.
83 Bearden, CE, Wu, KN, Caplan, R, Cannon, TD. Thought disorder and communication deviance as predictors of outcome in youth at clinical high risk for psychosis. J Am Acad Child Adolesc Psychiatry 2011; 50: 669–80.
84 Bechdolf, A, Thompson, A, Nelson, B, Cotton, S, Simmons, MB, Amminger, GP, et al. Experience of trauma and conversion to psychosis in an ultra-high-risk (prodromal) group. Acta Psychiatr Scand 2010; 121: 377–84.
85 Becker, HE, Nieman, DH, Wiltink, S, Dingemans, PM, de Fliert, JRV, Velthorst, E, et al. Neurocognitive functioning before and after the first psychotic episode: does psychosis result in cognitive deterioration? Psychol Med 2010; 40: 1599–606.
86 Brewer, WJ, Francey, SM, Wood, SJ, Jackson, HJ, Pantelis, C, Phillips, LJ, et al. Memory impairments identified in people at ultra-high risk for psychosis who later develop first-episode psychosis. Am J Psychiatry 2005; 162: 71–8.
87 Kim, HS, Shin, NY, Jang, JH, Kim, E, Shim, G, Park, HY, et al. Social cognition and neurocognition as predictors of conversion to psychosis in individuals at ultra-high risk. Schizophr Res 2011; 130: 170–5.
88 Koutsouleris, N, Davatzikos, C, Bottlender, R, Patschurek-Kliche, K, Scheuerecker, J, Decker, P, et al. Early recognition and disease prediction in the at-risk mental states for psychosis using neurocognitive pattern classification. Schizophr Bull 2012; 38: 1200–15.
89 Lam, MML, Hung, SF, Chen, EYH. Transition to psychosis: 6-month follow-up of a Chinese high-risk group in Hong Kong. Aust N Z J Psychiatry 2006; 40: 414–20.
90 Lemos-Giraldez, S, Vallina-Fernandez, O, Fernandez-Iglesias, P, Vallejo-Seco, G, Fonseca-Pedrero, E, Paino-Pineiro, M, et al. Symptomatic and functional outcome in youth at ultra-high risk for psychosis: a longitudinal study. Schizophr Res 2009; 115: 121–9.
91 Ziermans, TB, Schothorst, PF, Sprong, M, van Engeland, H. Transition and remission in adolescents at ultra-high risk for psychosis. Schizophr Res 2011; 126: 5864.
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Disorder, not just state of risk: Meta-analysis of functioning and quality of life in people at high risk of psychosis

  • Paolo Fusar-Poli (a1), Matteo Rocchetti (a2), Alberto Sardella (a3), Alessia Avila (a3), Martina Brandizzi (a4), Edgardo Caverzasi (a5), Pierluigi Politi (a5), Stephan Ruhrmann (a6) and Philip McGuire (a7)...
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The ever growing list of psychiatric disorders

Sathya Prakash, Senior Resident in Psychiatry, All India Institute of Medical Sciences, New Delhi
13 September 2015

The article in question deals with an extremely important and interesting area of psychiatric research. While the article itself may be written with good intentions, I would like to highlight some of the flaws and, caution against some wrong messages it is likely to convey. Psychiatry has always been criticized for having an ever increasing number of disorders without due regard for validity of the underlying constructs.1,2 A number of fundamental questions have plagued the field of psychiatry, including those concerning the boundaries of disorders with normalcy and boundaries separating individual disorders.1,2 This has been both a source of debate and embarrassment for the field of psychiatry. In this context, the title of the present article suggesting that the ‘at risk state’ is actually a disorder sends out a number of wrong signals. The authors’ assertion is based mainly on the comparable quality of life and functioning levels of those at risk for psychosis to that of several other better recognized psychiatric disorders. Labeling an entity as a disorder merely on the basis of quality of life and functioning may not be acceptable and also sets a dangerous precedent.2,3 By that logic, a number of conditions may be labeled as disorders without regard for the various issues surrounding defining a disorder itself.3,4 It may be noted that diagnostic guidelines for a number of disorders in the ICD 10 are silent on both dysfunction and quality of life – a stand that the manual has deliberately taken for various reasons.5 Moreover, the stated aim of the article was to ‘investigate meta-analytically the functional status of patients at high clinical risk for psychosis’ whereas the title is more keen on announcing that the ‘at risk state’ is actually a disorder. In any case announcing the results of a study in the title is not considered a good practice as the reader is given a message without him/ her verifying the underlying methodological basis. While the authors’ efforts to highlight the severity of dysfunction in the ‘at risk states’ are well taken, it must be remembered that needless references to newer entities as disorders may have unintended consequences on the reputation of psychiatry as a science itself, besides opening up newer avenues for dubious treatment strategies with commercial interests.


1.Maj M. “Psychiatric comorbidity”: an artefact of current diagnostic systems? Br J Psychiatry 2005; 186: 182-184.

2.Horwitz AV, Wakefield JC. All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders. Oxford University Press, 2012.

3.Kendell RE. The concept of disease and its implications for psychiatry. Br J Psychiatry 1975; 127: 305-315.

4.Berrios GE. Classifications in psychiatry: a conceptual history. Aust N Z J Psychiatry 1999; 33: 145-160.

5.World Health Organization. The International Statistical Classification of Diseases and Related Health Problems. 10th ed. Vol. 1. Geneva: World Health Organization, 1992.

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