Clinical high risk for psychosis, also called the prodrome, is the period of attenuated psychotic symptoms and functional decline that often precedes the first frank psychotic episode by months to years. CHR is now a recognized clinical state with structured assessment criteria, ongoing research into early intervention, and growing clinical practice in specialized programs.
CHR criteria (using the Structured Interview for Prodromal Syndromes — SIPS — or similar):
(1) Attenuated Psychotic Symptoms Syndrome: presence of sub-threshold positive psychotic symptoms (mild delusional thinking, unusual perceptual experiences, mild disorganization) at meaningful frequency and severity but not reaching full delusional or hallucinatory threshold.
(2) Brief Intermittent Psychotic Symptoms: psychotic symptoms that resolve spontaneously within minutes to days, not meeting duration criteria for any psychotic disorder.
(3) Genetic Risk and Deterioration: first-degree family history of psychotic illness plus significant decline in function over the past year.
Typical clinical presentation: an adolescent or young adult (often 16-25) with months of declining academic or occupational performance, social withdrawal, brief odd beliefs the patient themselves questions, mild perceptual abnormalities (intermittent voices, visual misperceptions), sometimes mood and anxiety symptoms. Substance use may be present and complicate assessment.
Conversion to psychosis historically estimated at 15-35% of CHR-identified patients over 2-3 years, though more recent cohorts show somewhat lower rates (perhaps reflecting earlier identification or better intervention). Not everyone with CHR develops psychosis; many improve.
Intervention at CHR stage aims to reduce conversion risk and improve overall outcomes. Cognitive therapy for at-risk states (van der Gaag, Stafford protocols) has the most evidence. Family support reduces relapse and improves trajectory. Careful management of comorbid mood/anxiety/SUD matters. Antipsychotics generally reserved for actual psychotic transition or severe sub-threshold symptoms with high risk — early antipsychotic exposure may not prevent conversion and carries side effect costs.
Coordinated specialty care for first-episode psychosis often extends to CHR populations in well-resourced systems. Multidisciplinary teams provide structured assessment, monitoring, family work, and graduated intervention. Recognition is the first step — many CHR patients are missed or attributed to "adolescence" or substance use until frank psychosis emerges.
When you encounter an adolescent or young adult with declining function, social withdrawal, and unusual perceptual or thought experiences, structured CHR assessment is appropriate. Early identification offers opportunities for intervention that may alter trajectory.