Breaking the web: life beyond the at-risk mental state for psychosis

Psychiatry's most recent foray into the area of risk and prevention has been spear-headed by work on at-risk mental states for psychotic disorders. Twenty-five years' research and clinical application have led us to reformulate the clinical evolution of these syndromes, blurred unhelpful conceptual boundaries between childhood and adult life by adopting a developmental view and has changed the shape of many mental health services as part of a global movement to increase quality. But there are problems: fragmentary psychotic experiences are common in young people but transition from risk-state to full syndrome is uncommon away from specialist clinics with rarefied referrals and can, anyway, be subtle; diagnostic over-shadowing by the prospect of schizophrenia and other psychotic disorders may divert clinical attention from the kaleidoscopic and disabling range of probably treatable psychopathology with which people with risk syndromes present. We use a 19th Century lyric poem, The Lady of Shallot, as an allegory for Psychiatry warning us against regarding these mental states only as pointers towards diagnoses that probably will not occur. Viewed from the fresh perspective of common mental disorders they tell us a great deal about the psychopathological crucible of the second and third decades, the nature of diagnosis, and point towards new treatment paradigms.