Psychiatric Diagnostic Classification Research Articles

Psychiatric diagnostic classification system based on new forms of parenting practices: Narrative review and invite for a rethink

Psychiatric diagnostic classification system based on new forms of parenting practices: Narrative review and invite for a rethink

Adolescent perspectives on depression as a disease of loneliness: a qualitative study with youth and other stakeholders in urban Nepal

BackgroundThere is a lack of research on the adolescent experience of depression in low- and middle-income countries. Criteria derived from research conducted primarily among adult Western populations inform current diagnostic standards for depression. These clinical categories are often used without exploration of their relevance to adolescent experience. Also, reliance on these categories may overlook other symptoms of depression that manifest in non-western settings. Cross-cultural qualitative work with adults in non-Western settings has suggested some differences with experience of depression and symptoms that are most relevant to service users. Research into adolescent experiences of depression is warranted to inform the development of effective interventions.MethodsQualitative interviews were conducted in Nepal with adolescents with depressive symptoms (n = 9), healthy adolescents (n = 3), parents (n = 6), teachers (n = 10), social workers (n = 14), primary (n = 6) and mental (n = 6) healthcare providers, and policymakers (n = 6). Two focus groups were conducted with parents (n = 12) of depressed and non-depressed adolescents. Data were analyzed according to the framework approach methodology.ResultsLoneliness was the hallmark experience that stood out for all adolescents. This was connected with 5 other clusters of symptoms: low mood and anhedonia; disturbances in sleep and appetite, accompanied by fatigue; irritability and anger; negative self-appraisals including hopelessness and self-doubt; and suicidality. Adolescents distinguished depression from other forms of stress, locally referred to as tension, and described depression to involve having “deep tension.” Perceived causes of depression included (1) Family issues: neglectful or absent parents, relationship problems, and family discord; (2) Peer relationships: romantic problems, bullying, and friendship problems; and (3) Social media: social comparison, popularity metrics, cyberbullying, and leaking of personal information.ConclusionsConsistent with other cross-cultural studies, loneliness was a core element of the adolescent experience of depression, despite its absence as a primary symptom in current psychiatric diagnostic classifications. It is important to note that among youth, symptoms were clustered together and interrelated (e.g., sleep and appetite changes were connected with fatigue). This calls for the need for more cross-cultural qualitative research on experience of depression among adolescents, and potential for modification of diagnostic criteria and prevention and treatments to focus on the experience of loneliness.

A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria.

To identify the most relevant clinical and video-polysomnographic characteristics of patients with sleep-related dissociative disorders (SRDDs) and to propose a framework for new diagnostic criteria. We searched potential SRDD cases from the scientific literature and from a database of patients referred for clinical and video-polysomnographic assessment in a single sleep disorders center for disruptive nocturnal behaviors (n = 731). The most relevant clinical and neurophysiological characteristics of the cases were extracted and a descriptive analysis was performed. Twenty-six SRDD cases (8 new and 18 previously published cases) were reviewed. Almost all cases of SRDDs occurred in a context of past traumatic events or abuse and were associated with at least 1 comorbid psychiatric disorder. We highlighted 4 relevant clinical characteristics of SRDD useful for the differential diagnosis with parasomnias: episodes of long duration of more than 1 hour (90.9%), self-inflicted injuries (83.3%), occurrence while awake close to bedtime (35.7%), and the presence of daytime dissociative symptoms (72.7%). The video-polysomnography documented typical episodes of SRDD with prolonged wakefulness before, during, and after the event in 11/26 cases. New diagnostic criteria for SRDD were proposed, with 3 levels of certainty for the diagnosis based on clinical, video-polysomnographic, and homemade video findings. More than 30 years after its formal identification, SRDD is not currently recognized as an official diagnostic entity. We better delineate the clinical and neurophysiological features of SRDD and propose a framework for its reinstatement in the next revisions of the sleep and psychiatric disorders classifications. Lopez R, Lefevre L, Barateau L, Micoulaud-Franchi J-A, Dauvilliers Y, Schenck CH. A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria. J Clin Sleep Med. 2022;18(2):563-573.

Risk profiles for mental disorders

Abstract BodyPrognostication is at the bedrock of clinical practice. In essence, diagnosis aims to inform clinicians for decision-making processes by providing a picture of future events such as course, outcome, and treatment response. To make a better clinical prediction on a case-by-case basis, diagnosis is enriched by individual characteristics and (bio)markers, with the aims of stratifying patients first and ultimately reaching the mountaintop: personalized medicine. However, there are two major obstacles on the road to personalized psychiatry. First, the current psychiatric diagnostic classification system is inadequate for tailoring individualized management plan, let alone for guiding the clinician for diagnosis-specific treatment selection—such that response to the same treatment plan largely varies among patients with the same psychiatric diagnosis, whereas patients with different psychiatric diagnoses benefit similarly from the same treatment protocol. Second, except for a few tests for ruling out other medical conditions, there exists no diagnostic, prognostic, or predictive (bio)marker in psychiatry. Risk profiling is even a more challenging and ambitious goal as early psychopathology is multidimensional, fluid, and pluripotent with heterotypic outcomes that cut across traditional diagnostic boundaries. By acknowledging this complexity and the shortcomings of current taxonomy, the field has recently shifted from risk profiling frameworks that rely on discrete diagnostic categories in isolation for prognostication (i.e. clinical high-risk for psychosis) to transdiagnostic clinical staging models. In this session, I will attempt to discuss where we are at with risk profiling in psychiatry and what steps need to be taken to achieve this ambitious goal.DisclosureNo significant relationships.

Consortium neuroscience of attention deficit/hyperactivity disorder and autism spectrum disorder: The ENIGMA adventure.

Neuroimaging has been extensively used to study brain structure and function in individuals with attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) over the past decades. Two of the main shortcomings of the neuroimaging literature of these disorders are the small sample sizes employed and the heterogeneity of methods used. In 2013 and 2014, the ENIGMA‐ADHD and ENIGMA‐ASD working groups were respectively, founded with a common goal to address these limitations. Here, we provide a narrative review of the thus far completed and still ongoing projects of these working groups. Due to an implicitly hierarchical psychiatric diagnostic classification system, the fields of ADHD and ASD have developed largely in isolation, despite the considerable overlap in the occurrence of the disorders. The collaboration between the ENIGMA‐ADHD and ‐ASD working groups seeks to bring the neuroimaging efforts of the two disorders closer together. The outcomes of case–control studies of subcortical and cortical structures showed that subcortical volumes are similarly affected in ASD and ADHD, albeit with small effect sizes. Cortical analyses identified unique differences in each disorder, but also considerable overlap between the two, specifically in cortical thickness. Ongoing work is examining alternative research questions, such as brain laterality, prediction of case–control status, and anatomical heterogeneity. In brief, great strides have been made toward fulfilling the aims of the ENIGMA collaborations, while new ideas and follow‐up analyses continue that include more imaging modalities (diffusion MRI and resting‐state functional MRI), collaborations with other large databases, and samples with dual diagnoses.

Heterogeneity in psychiatric diagnostic classification

The theory and practice of psychiatric diagnosis are central yet contentious. This paper examines the heterogeneous nature of categories within the DSM-5, how this heterogeneity is expressed across diagnostic criteria, and its consequences for clinicians, clients, and the diagnostic model. Selected chapters of the DSM-5 were thematically analysed: schizophrenia spectrum and other psychotic disorders; bipolar and related disorders; depressive disorders; anxiety disorders; and trauma- and stressor-related disorders. Themes identified heterogeneity in specific diagnostic criteria, including symptom comparators, duration of difficulties, indicators of severity, and perspective used to assess difficulties. Wider variations across diagnostic categories examined symptom overlap across categories, and the role of trauma. Pragmatic criteria and difficulties that recur across multiple diagnostic categories offer flexibility for the clinician, but undermine the model of discrete categories of disorder. This nevertheless has implications for the way cause is conceptualised, such as implying that trauma affects only a limited number of diagnoses despite increasing evidence to the contrary. Individual experiences and specific causal pathways within diagnostic categories may also be obscured. A pragmatic approach to psychiatric assessment, allowing for recognition of individual experience, may therefore be a more effective way of understanding distress than maintaining commitment to a disingenuous categorical system.

Fatores associados à depressão em homens e mulheres presos

The prevalence of depression is high in the prison system, and the differences between sex regarding associated risk factors are still not clear. We analyzed the correlated factors of depression among incarcerated men and women in the state of São Paulo, Brazil. A cross-sectional study with stratified and multi-stage probabilistic sample was performed. Composite International Diagnostic Interview (CIDI) was applied for psychiatric diagnostic classification, as well as a questionnaire on criminal history with 1,192 men and 617 women. Lifetime prevalence of mental disorder was calculated, and association analysis performed by multinomial logistic regression stratified by sex. A dependent variable was categorized into depression, any other mental disorder and no mental disorder (reference). The prevalence of depression was of 33.3% -(30.3 - 36.5) in women and 12.9% (11.1 - 15.0) in men. Depression was associated with disciplinary penalty, being in a stable relationship, physical health problems and history of infringement in adolescence in men. Regarding other mental illnesses, the correlated factors were historical transgression during adolescence and re-offense. Among women, depression was associated with physical health problems, drug crimes, violent crimes and being imprisoned. Results confirmed the differences between associated factors with depression regarding sex. Differences in the profile between men and women require effective specialized programs, considering the need for coping strategies for incarcerated men and health-related rehabilitation for women with depression.

Processes of attention to children and adolescents under 20 years in La Castañeda: evolution of the concept of childhood in psychiatry

Today, there is evidence that shows that children and adolescents can experience developmental problems and psychiatric disorders. This was possible because of two main reasons, the evolution of the concept of infancy and the progress made in medical and psychiatric diagnostic classification. This manuscript offers a glance to early psychiatric attention in Mexico, particularly the care processes provided to 36 children and adolescents under twenty, admitted in the mental asylum La Castañeda, during the first half of the XX century. Admission causes, length of stay, diagnosis, treatment and discharge motives, are some of the aspects described in this study. Finally, it also reflects about the challenge it is for a child psychiatric hospital nowadays, with such a history, to become an innovative institution able to claim a place in the medical field in favor of those minors that can barely defend themselves.

Why Psychiatric Research Must Abandon Traditional Diagnostic Classification and Adopt a Fully Dimensional Scope: Two Solutions to a Persistent Problem.

Why Psychiatric Research Must Abandon Traditional Diagnostic Classification and Adopt a Fully Dimensional Scope: Two Solutions to a Persistent Problem.

Comorbidity, age of onset and suicidality in obsessive–compulsive disorder (OCD): An international collaboration

ObjectivesTo collate data from multiple obsessive–compulsive disorder (OCD) treatment centers across seven countries and five continents, and to report findings in relation to OCD comorbidity, age of onset of OCD and comorbid disorders, and suicidality, in a large clinical and ethnically diverse sample, with the aim of investigating cultural variation and the utility of the psychiatric diagnostic classification of obsessive–compulsive and related disorders. MethodsResearchers in the field of OCD were invited to contribute summary statistics on current and lifetime psychiatric comorbidity, age of onset of OCD and comorbid disorders and suicidality in their patients with OCD. ResultsData from 3711 adult patients with primary OCD came from Brazil (n=955), India (n=802), Italy (n=750), South Africa (n=565), Japan (n=322), Australia (n=219), and Spain (n=98). The most common current comorbid disorders were major depressive disorder (28.4%; n=1055), obsessive–compulsive personality disorder (24.5%, n=478), generalized anxiety disorder (19.3%, n=716), specific phobia (19.2%, n=714) and social phobia (18.5%, n=686). Major depression was also the most commonly co-occurring lifetime diagnosis, with a rate of 50.5% (n=1874). OCD generally had an age of onset in late adolescence (mean=17.9years, SD=1.9). Social phobia, specific phobia and body dysmorphic disorder also had an early age of onset. Co-occurring major depressive disorder, generalized anxiety disorder and psychotic disorders tended to have a later age of onset than OCD. Suicidal ideation within the last month was reported by 6.4% (n=200) of patients with OCD and 9.0% (n=314) reported a lifetime history of suicide attempt. ConclusionsIn this large cross-continental study, comorbidity in OCD was common. The high rates of comorbid major depression and anxiety disorders emphasize the need for clinicians to assess and monitor for these disorders. Earlier ages of onset of OCD, specific phobia and social phobia may indicate some relatedness between these disorders, but this requires further study. Although there do not appear to be significant cultural variations in rates or patterns of comorbidity and suicidality, further research using similar recruitment strategies and controlling for demographic and clinical variables may help to determine whether any sociocultural factors protect against suicidal ideation or psychiatric comorbidity in patients with OCD.

Robert Spitzer and psychiatric classification: technical challenges and ethical dilemmas.

Dr Robert Leopold Spitzer (May 22, 1932-December 25, 2015), the architect of modern psychiatric diagnostic criteria and classification, died recently at the age of 83 in Seattle. Under his leadership, the American Psychiatric Association's (APA) Diagnostic and Statistical Manuals (DSM) became the international standard.

Neurosteroid, GABAergic and hypothalamic pituitary adrenal (HPA) axis regulation: what is the current state of knowledge in humans?

A robust epidemiological literature suggests an association between chronic stress and the development of affective disorders. However, the precise biological underpinnings of this relationship remain elusive. Central to the human response and adaptation to stress, activation and inhibition of the hypothalamic pituitary adrenal (HPA) axis involves a multi-level, multi-system, neurobiological stress response which is as comprehensive in its complexity as it is precarious. Dysregulation in this complex system has implications for human stress related illness. The pioneering research of Robert Purdy and colleagues has laid the groundwork for advancing our understanding of HPA axis regulation by stress-derived steroid hormones and their neuroactive metabolites (termed neurosteroids), which are potent allosteric modulators of GABAA receptor function in the central nervous system. This review will describe what is known about neurosteroid modulation of the HPA axis in response to both acute and chronic stress, particularly with respect to the current state of our knowledge of this process in humans. Implications of this research to the development of human stress-related illness are discussed in the context of two human stress-related psychiatric disorders - major depressive disorder and premenstrual dysphoric disorder. Neurosteroid-mediated HPA axis dysregulation is a potential pathophysiologic mechanism which may cross traditional psychiatric diagnostic classifications. Future research directions are identified.

751 – Characterizing psychopathology, neuropsychology and functioning in delusional disorder as opposed to other psychosis

Introduction Delusional disorder is traditionally considered a less severe clinical entity than schizophrenia or schizoaffective disorder. From the dimensional approach to psychiatric diagnostic classification it might be necessary redefine the diagnostic classification of psychosis. Aim To assess differences found in psychopathology, neuropsychology and functioning among schizophrenia, schizoaffective disorder and delusional disorder. Methods 59 patients were included in this study. 30 out of them presented a diagnostic of schizophrenia, 15 patients delusional disorder and 14 schizoaffective disorder. All of them were assessed through different scales including PANSS, GAF, SIX, SCIP and DKEFS Stroop. To compare the different groups ANOVA, Post hoc Bonferroni analysis and X2 test were carried out. Results We found statistically significant differences regarding negative symptoms between patients with schizophrenia and delusional disorder, being those less intense and severe in the last ones. In that way, a inversely proportional trend regarding negative and positive PANNS subtypes between schizophrenia and delusional disorder was observed. Conclusions In spite of the fact that the delusional disorder is considered less severe disease than other psychosis we only found a less degree of severity for negative symptoms. Further studies with greater sample size must be conducted.

Exposure to War as a Risk Factor for Mental Disorders

While large-scale national psychiatric epidemiologic studies have been conducted in Western industrialized nations [1–3], studies in the Arab world have generally been limited to smaller populations [4–6]. In addition, while exposure to war as a risk factor for the development of mental disorders in military populations has previously been described [7,8], the effect of war upon first onset of a range of mental disorders in civilian populations at a national level has not been explored. Over the last quarter-century, advances in psychiatric diagnostic classification, the development of fully structured diagnostic interviews, and the refinement of household survey technology have led to greater understanding of the epidemiology of psychiatric illness in the Western hemisphere. With the publication of the Diagnostic and Statistical Manual, 3rd edition [9], the American Psychiatric Association truly operationalized the diagnostic criteria for psychiatric disorders. Based on these criteria, Robins and colleagues created the Diagnostic Interview Schedule (DIS)—the first fully structured diagnostic interview that could be administered by trained lay persons [10]. The DIS was administered to over 20,000 individuals in the Epidemiologic Catchment Area Study, a landmark community-based survey of mental health disorders conducted in selected neighborhoods in five United States communities [1]. Widespread dissemination of the Epidemiologic Catchment Area study results led to replication studies in other countries and the development of other structured diagnostic interviews. The most widely used of these is the World Health Organization Composite International Diagnostic Interview (WHO CIDI), developed to encourage cross-national research by integrating the validated methodological approach of the DIS with the WHO's International Classification of Diseases [11]. The sophisticated study of disasters—war is one type of human-made disaster—and their impact on mental health is also relatively recent [12]. More than 29 armed conflicts are occurring now around the globe involving 25 countries [13]. The public health response to large-scale public health emergencies and catastrophes requires consideration of the mental disorders (e.g., post-traumatic stress disorder, depression), distress (e.g., sleep disturbance, fear, changes in economic behaviors such as purchasing houses), and health risk behaviors (e.g., increased alcohol and smoking, evacuation behaviors) of those exposed [14,15]. Linked Research Article This Perspective discusses the following new study published in PLoS Medicine: Karam EG, Mneimneh ZN, Dimassi H, Fayyad JA, Karam AN, et al. (2008) Lifetime prevalence of mental disorders in Lebanon: First onset, treatment, and exposure to war. PLoS Med 5(4): e61. doi:10.1371/journal.pmed.0050061 In a survey of 2,857 adults in Lebanon, Elie Karam and colleagues found a lifetime prevalence of any DSM-IV psychiatric disorder of 25.8%.

Phenotypic and genetic complexity of psychosis

Psychosis, like other major psychiatric disorders, is both genetically and clinically complex. Increasingly powerful molecular genetic studies have the potential to identify DNA variation that influences susceptibility to genetically complex disorders. There is a need to use a range of genetic approaches appropriate to identifying a spectrum of risk variants from the common through to the rare. Some variants might have large effects at the level of the individual but most are likely to have modest or small effects at both population and individual level. Extensive clinical heterogeneity is likely to have a significant impact on the power of even the largest studies and, more importantly, will lead to extensive variability between studies and hamper attempts at replication. If we are to realise the potential of molecular genetics, we need to overcome the major limitations imposed by current psychiatric diagnostic classifications and identify clinical phenotypes that reflect the presence of underlying entities with biological validity.

A configural analysis of psychiatric diagnostic stereotypes

This article is the second report of a series of investigations concerned with psychiatric diagnostic classification, designed to increase the understanding of psychiatric diagnosis and eventually to contribute toward an increase in the effectiveness of diagnostic procedures through the application of objective quantitative methods. The first article (Overall & Gcrham, 1963) reported the use of a Bayesian probability model and computer techniques to classify rating profiles of typical or stereotype cases. It was demonstrated that the computer could identify with high degree of accuracy the particular diagnostic types being rated. The fact that some errors in classification did occur and that they were more likely among certain categories than among others suggested the need for a further investigation of relationships and differences among symptom profiles associated with different diagnostic concepts. The present article reports application of the method of multiple discriminant analysis to the study of configural relationships among symptom profiles associated with thirteen psychotic types.

Inattentive Behavior in Childhood

Poor concentration is a relatively common childhood problem. The current North American psychiatric diagnostic classification system (Diagnostic and Statistical Manual of Mental Disorders, fourth edition; DSM-IV), American Psychological Association, 1994) differentiates children whose problems are distinguished primarily by symptoms of inattention (ADHD-I) from those whose difficulties are characterized by overactive, impulsive behavior by providing various subtypes within a broad diagnostic category. Yet, comparatively little is known about children who exhibit purely inattentive behavior. This study aims to redress this issue by using a large, community-based, epidemiological sample of 7-year-old children to compare the developmental functioning, social, and environmental backgrounds of children with pure inattentive behavior to that of children with pure overactive behavior and combined problems of inattentive and overactive behavior. Five hypotheses, centered on the validity of distinguishing inattentive behavior from overactivity, are tested. Children with pure inattentive behavior were more likely to have general cognitive delays, particularly in the area of language development, and were more likely to come from a family in which the father was of low occupational status. The results are discussed in relation to the implications for research and the identification of needs and intervention with children who exhibit pure inattentive behavior.

A difference that matters: comparisons of structured and semi-structured psychiatric diagnostic interviews in the general population

Psychiatric case-identification in general populations allows us to study both individuals with functional psychiatric disorders and the populations from which they come. The individual level of analysis permits disorders to be related to factors of potential aetiological significance and the study of attributes of the disorders that need to be assessed in non-referred populations (an initially scientific endeavour). At the population level valid case identification can be used to evaluate needs for treatment and the utilization of service resources (a public health project). Thus, prevalence is of interest both to scientists and to those responsible for commissioning and planning services (Brugha et al. 1997; Regier et al. 1998). The quality of case identification techniques and of estimates of prevalence is thus of general concern (Bartlett & Coles, 1998).Structured diagnostic interviews were introduced into general population surveys in the 1970s as a method ‘to enable interviewers to obtain psychiatric diagnoses comparable to those a psychiatrist would obtain’ (Robins et al. 1981). The need to develop reliable standardized measures was partly driven by an earlier generation of prevalence surveys showing rates ranging widely from 10·9% (Pasamanick et al. 1956) to 55% (Leighton et al. 1963) in urban and rural North American communities respectively. If the success of large scale psychiatric epidemiological enquiries using structured diagnostic interviews and standardized classifications is measured in terms of citation rates it would seem difficult to question. But the development of standardized interviews of functional psychiatric disorders has not solved this problem of variability: the current generation of large scale surveys, using structured diagnostic interviews and serving strictly defined classification rules, have generated, for example, 12-month prevalence rates of major depression in the US of 4·2% (Robins & Regier, 1991) and 10·1% (Kessler et al. 1994). This calls into question the validity of the assessments, such that we must reopen the question of what they should be measuring and how they should do it.

Rationales, values, and DSM-IV: The case of “medication-induced movement disorders”

The DSM-IV has improved psychiatric diagnostic classification through initiating, among other things, the open disclosure of rationales for nosologic changes. It will be argued that a consideration of values is necessary in justifying nosologic changes, considerations missing from the DSM-IV rationales. In illustration of this, I examine the reasons for including the medication-induced movement disorders (MIMDs) on axis I by using a literature review, then compare the published rationales for including the MIMDs with the DSM-IV Task Force's own guidelines for including categories. Discrepancies are found between the Task Force's guidelines for including categories and the published rationales for including MIMDs. Strict adherence to the Task Force guidelines more strongly supports placing MIMDs in axis Ill. Discussion emphasizes the importance of value commitments in nosology development.

BOOK REVIEWS

Book Reviews in this Article: Ethics and Biotechnology, edited by Anthony Dyson and John Harris. Routledge Human In Vitro Fertilisation‐ A Case Study in the Regulation of Medical Innovation by Jennifer Gunning and Veronica English. Philosophical Perspectives on Psychiatric Diagnostic Classification, edited by John Z. Sadfer, Osborne P. Wiggins and Michael A. Schwartz Children of Choice: Freedom and the New Reproductive Technologies, by John A. Robertson. Religious Methods and Resources in Bioethics, edited by Paul F. Camenisch. Moral Matters: Ethical Issues in Medicine and the Life Sciences, by Arthur Caplan.Wo lfgang Wagner(ed.). Arzneimittel und Verantwortung. Grundlagen und Methoden der Pharmaethik prugs and Responsibility — The Foundations and Methods of pharmaethics]. GenEthics. Technological Intervetion in Human Reproduction as a Philosophical Problem by Kurt Bayertz. The Virtue in Medical Ethics, by Edmund D. Pellegrho and David C. Thomasma