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An at-risk mental state (ARMS) is a clinical condition in which a person has early warning signs that substantially increase the likelihood of developing a psychotic disorder, but full psychosis has not yet emerged. This is often discussed under terms such as “clinical high risk” or “ultra-high risk” for psychosis.

An ARMS describes people who have subtle or intermittent psychotic-like experiences (for example, brief or attenuated hallucinations or delusional ideas), plus other risk factors such as functional decline or family history, and who therefore have a much higher than average risk of later transition to a first-episode psychosis.

Not everyone with ARMS goes on to develop psychosis, but the risk is high enough that early assessment and intervention are recommended. Typical Common features include: Attenuated psychotic symptoms: unusual perceptual experiences, suspiciousness, or odd beliefs that are milder, less frequent, or more reality-tested than in full psychosis.

Brief limited psychotic episodes that resolve spontaneously within days, with full return to baseline and preserved insight between episodes. Marked recent decline in functioning (social, academic, or occupational), often accompanied by anxiety, depression, or negative symptoms such as withdrawal and reduced motivation.

Most specialized early psychosis services conceptualize ARMS using three broad inclusion pathways: Attenuated psychotic symptoms over weeks to months that are distressing or impairing. Brief, self-remitting psychotic-like episodes (sometimes called BLIPS: brief limited intermittent psychotic symptoms).

A combination of genetic risk (first-degree relative with psychosis or schizotypal personality disorder) plus a clear decline in functioning. Risk and prediction People meeting ARMS/clinical high-risk criteria have a substantially elevated risk of transition to psychosis compared with the general population, with some cohorts showing transition rates of roughly a quarter to a third over the first few years of follow-up.

Predictors of higher risk within this group include longer duration of prodromal symptoms, poorer social functioning, cognitive problems (such as poor attention), and having both attenuated symptoms and genetic risk. Why early identification matters ARMS is important because intervening at this stage can reduce distress, improve functioning, and may delay or prevent transition to a first episode of psychosis in some individuals.

Intervention typically focuses on psychoeducation, family work, cognitive–behavioural or other psychotherapy, management of comorbid anxiety/depression, and careful monitoring, with judicious use of medication when indicated. Several specific symptom patterns and related features in people at clinical high risk (at-risk mental state) are associated with a higher chance of later transition to full psychosis: Positive symptoms and distress More severe attenuated positive psychotic symptoms (for example, more intense or frequent subthreshold hallucinations, delusional ideas, or suspiciousness) are among the most robust predictors of transition.

High distress linked to these attenuated symptoms, along with distress from anxiety and substance use, also increases risk, suggesting that how threatening or uncontrollable the experiences feel is clinically important. Brief psychotic episodes (BLIPS) Brief Limited Intermittent Psychotic Symptoms (BLIPS) – short-lived psychotic episodes that remit without sustained treatment – carry a particularly high transition risk, with roughly half of such individuals developing a psychotic disorder over several years.

BLIPS that recur, or that involve seriously disorganizing or dangerous behavior, are associated with an especially high probability of later full psychosis. Negative, disorganized, and cognitive symptoms Prominent negative symptoms such as social withdrawal, anhedonia, and reduced motivation modestly increase transition risk, especially when combined with positive symptoms and functional decline.

Disorganized communication and thought disorder, lower IQ, poorer verbal memory, and slowed information processing have each been linked to higher likelihood of transition within clinical high-risk samples. Functioning and broader clinical picture Lower global functioning at baseline (worse social, academic, or occupational performance) predicts higher transition risk, whereas better functioning appears somewhat protective.

Early social dysfunction in adolescence, schizotypal personality traits, and movement abnormalities (e.g., subtle motor signs) has also been associated with elevated transition risk in high-risk cohorts. Overall risk pattern Meta-analytic data show that, taken together, these symptom and functioning markers identify a group whose probability of developing psychosis is much higher than in the general population, with cumulative transition risks around one-quarter within 3 years and continuing to rise over longer follow-up.

However, even in high-risk clinics, most individuals do not make a full transition, which is why careful monitoring, psychosocial support, and targeted treatment of current symptoms are emphasized rather than assuming psychosis is inevitable. References Brasso, C., Giordano, B.,Badino, C., Bellino, S., Bozzatello, P., Montemagni, C. & Rocca, P. (2021, November 19).

Primary Psychosis: Risk and Protective Factors and Early Detection of the Onset. Diagnostics. Carrion, R.E., Demmin, D., Auther, A.M., Mclaughlin, D., Olsen, R., Lencz, T., Correll, C. & Cornblatt, B.A. (2017, October 1). Duration of Attenuated Positive and Negative Symptoms in Individuals at Clinical High Risk: Associations with Risk of Conversion to Psychosis and Functional Outcome.

Journal in Psychiatric Research. De Pablo, G.S., Radua, J., Pereira, J., Bonoldi, I., Arienti, V., et al. (2021, July 14). 78(9):1-9. Probability of Transition to Psychosis in Individuals at Clinical High Risk.JAMA Psychiatry. Keshavan, M.S., DeLisi, L.E. & Seidman, L.J. (2012, July 3).

Early and Braodly Defined Psychosis Risk Mental States. Schizophrenia Research. MOntermagni, C., Belliono, S., Bracale, N., Bozzatello, P. & Rocca, P. (2020, March 24). Models Predicting Psychosis in Patients with High Clinical Risk: A Systematic Review.

Frontiers in Psychiatry. Thompson, A., Marwaha, S. & Broome, M.R. (2018, January 2). At-Risk Mental State for Psychosis: Identification and Current Treatment Approaches. Advances. Cambridge University Press.

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