Beyond the At-Risk Mental State: Metastability and Hybrid States of Reality in Emerging Psychosis.
Philippe Nuss, Maharajah Ponnaiah, Vince D Calhoun
Schizophrenia Bulletin August 20, 2026 DOI: 10.1093/schbul/sbag126 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Theoretical or philosophical paper Peer reviewed |
|---|---|
| Topics | Philosophy of mind |
| Keywords | At-risk mental state Ecological momentary assessment Metastability Non-stationary dynamics Schizophrenia |
| Key points | Argues that ARMS/UHR is better understood as a relatively enduring clinical configuration, rather than a brief transitional stage, in which unusual perceptions or beliefs coexist with ordinary reality while coherence is preserved. Proposes that this configuration corresponds to a self-sustaining, non-stationary metastable brain network state that does not necessarily progress to psychosis, and that clinical care should aim to strengthen flexibility and reduce neural and cognitive effort. |
Abstract
The ultra-high-risk (UHR) and at-risk mental state (ARMS) constructs were originally developed to identify individuals at imminent risk of transition to psychosis. However, declining transition rates, limited predictive value, and the persistence of significant non-psychotic morbidity increasingly challenge the view of ARMS as a brief, transitional stage along a linear continuum from health to illness.Here, we propose here an alternative conceptualization of ARMS/UHR as a relatively enduring clinical configuration. Clinically, this state is characterized by persistent experiences in which unusual perceptions or beliefs are layered onto ordinary reality, maintaining a sense of coherence. From this perspective, symptoms are not only markers of pathology, but can be understood as coherence-seeking responses when the self is destabilized. At the neurobiological level, we argue that this clinical configuration is paralleled by brain dynamics operating in a metastable regime. The brain is viewed as a dynamic system that flexibly reorganizes large-scale networks, balancing integration and segregation while minimizing energetic costs. Within this framework, ARMS may be understood as a self-sustaining, non-stationary network configuration that accommodates psychotic-like experiences without necessarily progressing to psychosis. Integrating phenomenological accounts of lived experience with systems-level models of brain dynamics, this perspective moves beyond risk prediction alone. It supports clinical approaches aimed at strengthening flexibility and reducing neural and cognitive effort while preserving adaptive functioning, and motivates research paradigms capable of capturing individual-level, time-varying brain dynamics in real-world contexts.
Comparable studies
Other theoretical and historical papers on philosophy of mind, most cited first.
| Study | Year | Design | Participants |
|---|---|---|---|
| Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. | 2003 | Theoretical or philosophical paper | |
| From dopamine to salience to psychosis--linking biology, pharmacology and phenomenology of psychosis. | 2005 | Theoretical or philosophical paper | |
| How do the brain's time and space mediate consciousness and its different dimensions? Temporo-spatial theory of consciousness (TTC). | 2017 | Theoretical or philosophical paper | |
| The phenomenology of deep brain stimulation-induced changes in OCD: an enactive affordance-based model. | 2013 | Theoretical or philosophical paper | |
| Looking for the Self: Phenomenology, Neurophysiology and Philosophical Significance of Drug-induced Ego Dissolution | 2017 | Theoretical or philosophical paper |
Citations in the library
Cites 9
- Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry 2003
- The Predictive Coding Account of Psychosis. Biological Psychiatry May 25, 2018
- The lived experience of psychosis: a bottom-up review co-written by experts by experience and academics. World Psychiatry June 1, 2022
- Temporal structure of consciousness and minimal self in schizophrenia. Frontiers in Psychology 2014
- Is Schizophrenia a Disorder of Consciousness? Experimental and Phenomenological Support for Anomalous Unconscious Processing. Frontiers in Psychology 2017
and 4 more in the library