Clinical high risk and attenuated psychosis — structured clinical viva

Definition. This is a clinical high-risk / ultra-high-risk presentation (attenuated positives with residual insight, functional impact, family loading) — not schizophrenia until sustained full-threshold criteria are met. Use CAARMS or SIPS to operationalise entry group (likely APS ± genetic risk elements).[1]

"Does she already have schizophrenia?" No. Explain APS/UHR as a risk state and service category; DSM attenuated psychosis syndrome is Section III research language, not day-one lifelong schizophrenia.[1]

Chances of conversion. Quote that a minority convert over 1–3 years in help-seeking samples and the majority do not; risk is higher with BLIPS than APS than pure genetic-risk-plus-decline. Avoid both false reassurance of zero risk and fatalism of certainty.[2][3]

Antipsychotic now? Not routine first-line for pure attenuated risk. Prefer engagement, treat comorbidity, cannabis reduction, CBT-informed care, family work, monitoring. Antipsychotics reserved for specialist rationale, near-threshold severe distress, or frank conversion — low dose with metabolic monitoring if used. Network meta-analysis: no single clearly superior preventive intervention.[4][7]

Fish oil? Amminger trial positive; NEURAPRO failed to replicate primary transition benefit — state equipoise; optional adjunct, not a guarantee.[5][6]

Monitoring. Scheduled reviews, crisis plan, conversion red flags (fixed conviction, sustained frank hallucinations, acting on beliefs). Escalate immediately to FEP multi-element care if threshold crossed.[3][4]