Parental bonding, childhood maltreatment and eating disorder psychopathology: an investigation of their interactions

PURPOSE

Childhood trauma and parental bonding have been widely recognized as risk factors for eating disorders (EDs). However, their interplay in determining ED psychopathology has been poorly investigated. Consequently, we have assessed their interaction with core ED psychopathological symptoms.

METHODS

Fifty-seven patients with anorexia nervosa, 43 with bulimia nervosa and 77 healthy women completed the Childhood Trauma Questionnaire, the Parental Bonding Instrument and the Eating Disorder Inventory-2. Chi square test and regression analyses with a moderation model were performed to investigate the interplay between childhood trauma, parental bonding and ED symptoms such as ineffectiveness, social insecurity, drive to thinness, interoceptive awareness, impulsivity and perfectionism.

RESULTS

Compared to controls, patients with EDs showed higher levels of trauma and parental control perception and lower levels of parental care. Childhood maltreatment was more prevalent in patients with the affectionless control parental style. Moderation analyses revealed that higher maternal control significantly predicted the ED symptom of social insecurity only when participants experienced lower levels of emotional abuse.

CONCLUSIONS

These findings demonstrate an interplay between deranged problematic parental bonding and childhood trauma in promoting a possible vulnerability to social insecurity, one of the most central dimensions of ED psychopathology. This interaction might have psychotherapeutic implications.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The association between insight and depressive symptoms in schizophrenia: Undirected and Bayesian network analyses

Background.

Greater levels of insight may be linked with depressive symptoms among patients with schizophrenia, however, it would be useful to characterize this association at symptom-level, in order to inform research on interventions.

Methods.

Data on depressive symptoms (Calgary Depression Scale for Schizophrenia) and insight (G12 item from the Positive and Negative Syndrome Scale) were obtained from 921 community-dwelling, clinically-stable individuals with a DSM-IV diagnosis of schizophrenia, recruited in a nationwide multicenter study. Network analysis was used to explore the most relevant connections between insight and depressive symptoms, including potential confounders in the model (neurocognitive and social-cognitive functioning, positive, negative and disorganization symptoms, extrapyramidal symptoms, hostility, internalized stigma, and perceived discrimination). Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association between insight and depression.

Results.

After adjusting for confounders, better levels of insight were associated with greater self-depreciation, pathological guilt, morning depression and suicidal ideation. No difference in global network structure was detected for socioeconomic status, service engagement or illness severity. The DAG confirmed the presence of an association between greater insight and self-depreciation, suggesting the more probable causal direction was from insight to depressive symptoms.

Conclusions.

In schizophrenia, better levels of insight may cause self-depreciation and, possibly, other depressive symptoms. Person-centered and narrative psychotherapeutic approaches may be particularly fit to improve patient insight without dampening self-esteem.

Better insight seems associated with depressive symptoms in schizophrenia.

Network analyses were used to explore this association in a large sample.

Insight was associated with self-depreciation, guilt, and suicidal ideation.

Although cross-sectional, data suggest causal direction from insight to depression.

Coercive measures in italian inpatient units: results from eunomia study

Introduction

The use of coercive measures in clinical practice represents a common, but understudied problem in Europe. In 2002–2005, the European Commission funded the study “European Evaluation of coercion in psychiatry and harmonization of best clinical practice” (EUNOMIA), coordinated by the Department of Psychiatry of the University of Dresden and carried out in 12 European countries.

Objectives

This study, carried out on the Italian EUNOMIA sample, aims to:

1)

Methods

The Italian sample included 294 admitted patients. Data were collected on coercive measures (physical restraint, seclusion and forced medication)

Results

Almost 30% of the patients received coercive measures during their hospitalization; in particular, 22% received forced medication, 9% were restrained or fixed by mechanic devices, 7% were seclused. The most frequent reason for prescribing coercive measures was aggression against others. Patients who received coercive measures were more frequently male, with higher BPRS scores and a worse social functioning. At three months after discharge, they showed higher levels of positive symptoms, and reported more negative opinions on the need of hospital admission and on the appropriateness of psychiatric treatments.

Conclusions

In Italy coercive measures are in most of the cases applied to the patients affected by more severe psychopathology and disability.

How to improve clinical practice on involuntary hospital admissions of psychiatric patients: Suggestions from the EUNOMIA study

Number and procedures of involuntary hospital admissions vary in Europe according to the different socio-cultural contexts. The European Commission has funded the EUNOMIA study in 12 European countries in order to develop European recommendations for good clinical practice in involuntary hospital admissions. The recommendations have been developed with the direct and active involvement of national leaders and key professionals, who worked out national recommendations, subsequently summarized into a European document, through the use of specific categories. The need for standardizing the involuntary hospital admission has been highlighted by all centers. In the final recommendations, it has been stressed the need to: providing information to patients about the reasons for hospitalization and its presumable duration; protecting patients’ rights during hospitalization; encouraging the involvement of family members; improving the communication between community and hospital teams; organizing meetings, seminars and focus-groups with users; developing training courses for involved professionals on the management of aggressive behaviors, clinical aspects of major mental disorders, the legal and administrative aspects of involuntary hospital admissions, on communication skills. The results showed the huge variation of involuntary hospital admissions in Europe and the importance of developing guidelines on this procedure.

Clinical Presentation

This chapter reviews the clinical presentation of bipolar I and bipolar II disorders, and in particular of manic, hypomanic, depressive, and mixed episodes. The DSM-5 operational criteria and the ICD-11 clinical descriptions and diagnostic guidelines are summarized, but several aspects that emerge from the literature and are not considered by those diagnostic systems are also covered. The divergences between those systems and the issues that remain controversial are pointed out, and the limitations of “specifiers” (or “qualifiers”) in accounting for the heterogeneity of depressive episodes are emphasized. Different clinical presentations of manic and depressive episodes in children and adolescents are also briefly described. It is concluded that the familiarity with the DSM-5 and/or the ICD-11 is not sufficient to ensure an appropriate approach to the diagnosis of mood episodes and disorders, in the absence of adequate training and clinical expertise.

The interplay among psychopathology, personal resources, context-related factors and real-life functioning in schizophrenia: stability in relationships after 4 years and differences in network structure between recovered and non-recovered patients

Improving real-life functioning is the main goal of the most advanced integrated treatment programs in people with schizophrenia. The Italian Network for Research on Psychoses previously explored, by using network analysis, the interplay among illness-related variables, personal resources, context-related factors and real-life functioning in a large sample of patients with schizophrenia. The same research network has now completed a 4-year follow-up of the original sample. In the present study, we used network analysis to test whether the pattern of relationships among all variables investigated at baseline was similar at follow-up. In addition, we compared the network structure of patients who were classified as recovered at follow-up versus those who did not recover. Six hundred eighteen subjects recruited at baseline could be assessed in the follow-up study. The network structure did not change significantly from baseline to follow-up, and the overall strength of the connections among variables increased slightly, but not significantly. Functional capacity and everyday life skills had a high betweenness and closeness in the network at follow-up, as they had at baseline, while psychopathological variables remained more peripheral. The network structure and connectivity of non-recovered patients were similar to those observed in the whole sample, but very different from those in recovered subjects, in which we found few connections only. These data strongly suggest that tightly coupled symptoms/dysfunctions tend to maintain each other's activation, contributing to poor outcome in schizophrenia. Early and integrated treatment plans, targeting variables with high centrality, might prevent the emergence of self-reinforcing networks of symptoms and dysfunctions in people with schizophrenia.

Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies

An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO's focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.

Beyond diagnosis in psychiatric practice

In psychiatry, the information conveyed by diagnosis (i.e., the "type" to which the individual patient is reconducted) is in itself insufficient for therapeutic and prognostic purposes. Hence the need for a more detailed characterization of the individual case, with a special focus on the assessment of low-order and high-order psychopathological dimensions, the evaluation of the severity of the clinical picture, the assessment of the stage of development of the disorder, and the exploration of a series of antecedent and concomitant variables. We should start to promote the construction and validation of tools guiding the clinician systematically in this characterization, trying to incorporate in this effort elements of the approaches that are currently presented as "alternative" to the ICD and DSM.

Validation of the brief TEMPS-M temperament questionnaire in a clinical Italian sample of bipolar and cyclothymic patients

BACKGROUND

To assess psychometric proprieties of the short version of TEMPS-M in an Italian clinical sample of patients with bipolar disorder type I (BDI), type II (BDI) or cyclothymic disorder (CYC).

METHODS

All participants were recruited in two Italian university sites. They were asked to complete the Italian version of the short TEMPS-M, consisting of 35 items on a five-point Likert scale ranging from 1 to 5. The factorial structure of the instrument was assessed by principal components analysis with varimax rotation. The reliability of the subscales was assessed with Cronbach's alpha.

RESULTS

The 815 recruited patients had a diagnosis of BDI (430), CYC (227) or BDII (158); 60% of them were female and with a mean age of 44.4 (±14.6) years. Cronbach's alpha coefficients of subscales ranged from 0.808 to 0.898. The factor analysis confirmed five dimensions (depressive, cyclothymic, hyperthymic, irritable, anxious), as in the English version of the scale. All temperaments were more represented in CYC than in BDI patients. Depressive and anxious temperaments were more represented in BDII than in BDI; the hyperthymic temperament was represented more in BDI than in BDII patients.

LIMITATIONS

No other assessment instrument was used as a reference to assess the external or predictive validity of TEMPS-M; several socio-demographic and clinical characteristics have not been assessed.

CONCLUSION

The Italian version of the short TEMPS-M shows good reliability and validity. It might be used in clinical and research settings, for the dimensional exploration of the investigated domains.

Network Analysis Reveals the Latent Structure of Negative Symptoms in Schizophrenia

Prior studies using exploratory factor analysis provide evidence that negative symptoms are best conceptualized as 2 dimensions reflecting diminished motivation and expression. However, the 2-dimensional model has yet to be evaluated using more complex mathematical techniques capable of testing structure. In the current study, network analysis was applied to evaluate the latent structure of negative symptoms using a community-detection algorithm. Two studies were conducted that included outpatients with schizophrenia (SZ; Study 1: n = 201; Study 2: n = 912) who were rated on the Brief Negative Symptom Scale (BNSS). In both studies, network analysis indicated that the 13 BNSS items divided into 6 negative symptom domains consisting of anhedonia, avolition, asociality, blunted affect, alogia, and lack of normal distress. Separation of these domains was statistically significant with reference to a null model of randomized networks. There has been a recent trend toward conceptualizing the latent structure of negative symptoms in relation to 2 distinct dimensions reflecting diminished expression and motivation. However, the current results obtained using network analysis suggest that the 2-dimensional conceptualization is not complex enough to capture the nature of the negative symptom construct. Similar to recent confirmatory factor analysis studies, network analysis revealed that the latent structure of negative symptom is best conceptualized in relation to the 5 domains identified in the 2005 National Institute of Mental Health consensus development conference (anhedonia, avolition, asociality, blunted affect, and alogia) and potentially a sixth domain consisting of lack of normal distress. Findings have implications for identifying pathophysiological mechanisms and targeted treatments.

Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa

Characterized primarily by a low body-mass index, anorexia nervosa is a complex and serious illness1, affecting 0.9-4% of women and 0.3% of men2-4, with twin-based heritability estimates of 50-60%5. Mortality rates are higher than those in other psychiatric disorders6, and outcomes are unacceptably poor7. Here we combine data from the Anorexia Nervosa Genetics Initiative (ANGI)8,9 and the Eating Disorders Working Group of the Psychiatric Genomics Consortium (PGC-ED) and conduct a genome-wide association study of 16,992 cases of anorexia nervosa and 55,525 controls, identifying eight significant loci. The genetic architecture of anorexia nervosa mirrors its clinical presentation, showing significant genetic correlations with psychiatric disorders, physical activity, and metabolic (including glycemic), lipid and anthropometric traits, independent of the effects of common variants associated with body-mass index. These results further encourage a reconceptualization of anorexia nervosa as a metabo-psychiatric disorder. Elucidating the metabolic component is a critical direction for future research, and paying attention to both psychiatric and metabolic components may be key to improving outcomes.

A network analysis of psychological, personality and eating characteristics of people seeking bariatric surgery: Identification of key variables and their prognostic value

OBJECTIVE

The interplay among personality traits, anxiety and eating symptoms in candidates for bariatric surgery has never been investigated through the network analysis approach. Thus, we aimed to use this method to identify the key psychological traits that characterize these individuals and to assess their role as predictors of surgical outcomes.

METHODS

One-hundred-eighty-five candidates for bariatric surgery filled in the State Trait Anxiety Inventory (STAI), the Revised Restraint Scale, the Power of Food Scale and the Temperament and Character Inventory-Revised (TCI-R) questionnaires. All these variables were included in a network analysis. Then, the most central network nodes were entered as independent variables in a regression model that included 9-month follow-up weight outcomes as the dependent variable.

RESULTS

The network has showed a good stability. TCI-self directedness and harm avoidance scores and STAI state and trait anxiety scores were the nodes with the highest centrality in the network. Weight outcomes were assessed in 64 patients at follow-up. Among central nodes, low TCI-self directedness was found to be the only significant independent predictor of worse weight outcome.

CONCLUSIONS

Our findings show for the first time the interplay between personality traits and symptoms in candidates for bariatric surgery combining the network approach with a follow-up evaluation. Low self-directedness has been proved to be the node with highest centrality and the only predictor of short-term weight outcome. These data suggest the importance to take into consideration personality and psychological variables either in the pre-surgery assessment or as possible targets for pre or post-surgery psychotherapeutic interventions.

ORCID

0000-0002-6786-4458.

The effects of childhood maltreatment on brain structure in adults with eating disorders

Objectives: Childhood maltreatment is a non-specific risk factor for eating disorders (EDs). However, so far, no study has assessed the impact of childhood maltreatment on brain structure of adults with EDs. Therefore, we investigated brain area volumes and fibre tract integrity of childhood maltreated (Mal) and non-maltreated (noMal) patients with EDs. Methods: Thirty-six ED women and 16 healthy women underwent an MRI scan, including acquisition of a diffusion tensor imaging (DTI) sequence and a high-resolution T1-weighted scan. ED participants were classified as Mal (18 patients) or noMal (18 patients) according to their childhood exposure to traumatic events assessed by the Childhood Trauma Questionnaire (CTQ). Results: Significantly reduced grey matter volume was detected in the right paracentral lobule and in the left inferior temporal gyrus of Mal patients. DTI analyses revealed reduced white matter integrity in the corpus callosum, internal capsule, posterior thalamic radiation, longitudinal fasciculus and corona radiata of Mal patients. Negative correlations emerged between white/grey matter changes and CTQ emotional and physical neglect scores. Conclusions: These results show that childhood trauma affects the integrity of brain structures modulating brain processes, such as reward, taste and body image perception, which play a fundamental role in the psychopathology of EDs.

Questionnaire on Attitude towards Research and Care (QuARC): a survey of patients with psychosis

Background: The patients' appraisal, satisfaction and attitude toward research is crucial to obtain reliable information, in psychiatry frequently not objective.Aim: We operationalised the information derived from studies on satisfaction and attitude towards research and developed a standardized measure, whose internal consistency and factor structure was investigated.Method: The Questionnaire on Attitude towards Research and health Care (QuARC) is a 10-item self-report scale, administered to 116 patients with psychotic disorders participating in research protocols. Exploratory factor analysis was conducted and internal consistency evaluated.Results: Two factors have been identified: one labelled External Factor, including items related to information on the received treatment, relationship with third parties, and one labelled Internal Factor with items related to the disorder, perceived well-being and contribution to scientific knowledge. Cronbach's alpha internal consistencies were good.Conclusions: The QuARC is easy to use, well accepted, with good psychometric properties. The constructs identified are different from the original issues addressed (i.e. attitude and satisfaction), prevailing different constructs closer to the patient opinion on the research and personal condition. These constructs identify dimensions useful to delineate and understand the patients' experience of participating in a scientific project as well as their satisfaction.

Pathways to specialist care for eating disorders: An Italian multicentre study

Two hundred forty six patients with eating disorders (EDs) recruited from eight Italian specialized treatment centres were administered with the World Health Organization "Encounter Form," a standardized schedule that makes it possible to characterize the clinical pathways that patients follow to reach specialized care. The median time from symptoms onset to specialized care was 114 weeks. Primary "points of access to care" were general practitioners (25%), psychiatrists (18%), and clinical nutritionists (17%), followed by various other carers. All patients received specific psychotherapy, whereas only 11% of them were given psychotropic drugs. EDs are characterized by complex care pathways, with low rates of direct access to specialized care. Although the role of general practitioners remains crucial, they tend to follow different clinical routes to refer ED patients. Educational programmes on EDs should be addressed to general practitioners and clinical nutritionists, in order to ease the transition of ED patients to a mental health care setting.

Cross-cultural Validation of the 5-Factor Structure of Negative Symptoms in Schizophrenia

OBJECTIVE

Negative symptoms are currently viewed as having a 2-dimensional structure, with factors reflecting diminished expression (EXP) and motivation and pleasure (MAP). However, several factor-analytic studies suggest that the consensus around a 2-dimensional model is premature. The current study investigated and cross-culturally validated the factorial structure of BNSS-rated negative symptoms across a range of cultures and languages.

METHOD

Participants included individuals diagnosed with a psychotic disorder who had been rated on the Brief Negative Symptom Scale (BNSS) from 5 cross-cultural samples, with a total N = 1691. First, exploratory factor analysis was used to extract up to 6 factors from the data. Next, confirmatory factor analysis evaluated the fit of 5 models: (1) a 1-factor model, 2) a 2-factor model with factors of MAP and EXP, 3) a 3-factor model with inner world, external, and alogia factors; 4) a 5-factor model with separate factors for blunted affect, alogia, anhedonia, avolition, and asociality, and 5) a hierarchical model with 2 second-order factors reflecting EXP and MAP, as well as 5 first-order factors reflecting the 5 aforementioned domains.

RESULTS

Models with 4 factors or less were mediocre fits to the data. The 5-factor, 6-factor, and the hierarchical second-order 5-factor models provided excellent fit with an edge to the 5-factor model. The 5-factor structure demonstrated invariance across study samples.

CONCLUSIONS

Findings support the validity of the 5-factor structure of BNSS-rated negative symptoms across diverse cultures and languages. These findings have important implications for the diagnosis, assessment, and treatment of negative symptoms.

Impaired glucose metabolism in bipolar patients and response to mood stabilizer treatments

BACKGROUND

Metabolic dysfunctions in patients with bipolar disorder (BD) are critical factors that interfere with outcome, but only one study evaluated the influence of glucose dysmetabolism on the response to treatment with lithium. We aimed to investigate the potential impact of glucose metabolic status on clinical characteristics of BD patients and their response to treatment with different mood stabilizers in monotherapy or in combination.

METHODS

45 BD patients with insulin resistance (IR) or type 2 diabetes mellitus (DM2) and 46 patients with normal glucose metabolism, treated with mood stabilizers for at least one year were assessed by diagnostic and rating instruments. Their clinical characteristics were compared and an ordinal logistic regression model was adopted to identify possible predictors of response to mood stabilizer treatments.

RESULTS

Compared to patients with normal glucose metabolism, BD patients with impaired glucose metabolism showed a worse clinical presentation of their psychiatric illness and a worse response to mood stabilizers. Ordinal logistic regression analysis evidenced that impaired glucose metabolism was the only predictor of poor response to mood stabilizers (OR 4.3; 95% CI: 1.7-11.1; p < 0.002).

LIMITATIONS

Cross-sectional design and the relatively small sample size, are the main limitations of our study.

CONCLUSIONS

Our findings expand literature data suggesting that BD patients with impaired glucose metabolism are at a greater risk of not responding to lithium as well as to different mood stabilizer treatments.

Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.

Investigating polygenic burden in age at disease onset in bipolar disorder: Findings from an international multicentric study

OBJECTIVES

Bipolar disorder (BD) with early disease onset is associated with an unfavorable clinical outcome and constitutes a clinically and biologically homogenous subgroup within the heterogeneous BD spectrum. Previous studies have found an accumulation of early age at onset (AAO) in BD families and have therefore hypothesized that there is a larger genetic contribution to the early-onset cases than to late onset BD. To investigate the genetic background of this subphenotype, we evaluated whether an increased polygenic burden of BD- and schizophrenia (SCZ)-associated risk variants is associated with an earlier AAO in BD patients.

METHODS

A total of 1995 BD type 1 patients from the Consortium of Lithium Genetics (ConLiGen), PsyCourse and Bonn-Mannheim samples were genotyped and their BD and SCZ polygenic risk scores (PRSs) were calculated using the summary statistics of the Psychiatric Genomics Consortium as a training data set. AAO was either separated into onset groups of clinical interest (childhood and adolescence [≤18 years] vs adulthood [>18 years]) or considered as a continuous measure. The associations between BD- and SCZ-PRSs and AAO were evaluated with regression models.

RESULTS

BD- and SCZ-PRSs were not significantly associated with age at disease onset. Results remained the same when analyses were stratified by site of recruitment.

CONCLUSIONS

The current study is the largest conducted so far to investigate the association between the cumulative BD and SCZ polygenic risk and AAO in BD patients. The reported negative results suggest that such a polygenic influence, if there is any, is not large, and highlight the importance of conducting further, larger scale studies to obtain more information on the genetic architecture of this clinically relevant phenotype.

Assessment of de novo copy-number variations in Italian patients with schizophrenia: Detection of putative mutations involving regulatory enhancer elements

OBJECTIVES

Variants appearing de novo in genes regulating key neurodevelopmental processes and/or in non-coding cis-regulatory elements (CREs), as enhancers, may increase the risk for schizophrenia. However, CREs involvement in schizophrenia needs to be explored more deeply.

METHODS

We investigated de novo copy-number variations (CNVs) in the whole-genomic DNA obtained from 46 family trios of schizophrenia probands by using the Enhancer Chip, a customised array CGH able to investigate the whole genome with a 300-kb resolution, specific disease loci at a ten-fold higher resolution, and which was highly enriched in probes in more than 1,250 enhancer elements selected from Vista Enhancer Browser.

RESULTS

In seven patients, we found de novo CNVs, two of which overlapped VISTA enhancer elements. De novo CNVs encompass genes (CNTNAP2, MAGI1, TSPAN7 and MET) involved in brain development, while that involving the enhancer element hs1043, also includes ZIC1, which plays a role in neural development and is responsible of behavioural abnormalities in Zic mutant mice.

CONCLUSIONS

These findings provide further evidence for the involvement of de novo CNVs in the pathogenesis of schizophrenia and suggest that CNVs affecting regulatory enhancer elements could contribute to the genetic vulnerability to the disorder.

Clinical utility of ICD-11 diagnostic guidelines for high-burden mental disorders: results from mental health settings in 13 countries

In this paper we report the clinical utility of the diagnostic guidelines for ICD-11 mental, behavioural and neurodevelopmental disorders as assessed by 339 clinicians in 1,806 patients in 28 mental health settings in 13 countries. Clinician raters applied the guidelines for schizophrenia and other primary psychotic disorders, mood disorders (depressive and bipolar disorders), anxiety and fear-related disorders, and disorders specifically associated with stress. Clinician ratings of the clinical utility of the proposed ICD-11 diagnostic guidelines were very positive overall. The guidelines were perceived as easy to use, corresponding accurately to patients' presentations (i.e., goodness of fit), clear and understandable, providing an appropriate level of detail, taking about the same or less time than clinicians' usual practice, and providing useful guidance about distinguishing disorder from normality and from other disorders. Clinicians evaluated the guidelines as less useful for treatment selection and assessing prognosis than for communicating with other health professionals, though the former ratings were still positive overall. Field studies that assess perceived clinical utility of the proposed ICD-11 diagnostic guidelines among their intended users have very important implications. Classification is the interface between health encounters and health information; if clinicians do not find that a new diagnostic system provides clinically useful information, they are unlikely to apply it consistently and faithfully. This would have a major impact on the validity of aggregated health encounter data used for health policy and decision making. Overall, the results of this study provide considerable reason to be optimistic about the perceived clinical utility of the ICD-11 among global clinicians.

Mood Disorders in ICD-11 and DSM-5

This paper briefly reviews how the ICD-11 and DSM-5 are going to handle the various continua existing in the area of mood disorders. The two systems will address the continua between “normal” elation and hypomania, between unipolar depression and bipolar disorder, and between anxiety disorders and depression in a more consistent way than in the past, while there will be differences in the characterization of mixed states and schizoaffective disorders. A major weakness of both systems will be the fact that the boundary between “normal” sadness and depression will not be based on a solid empirical evidence.