Diagnosis and classification of psychopathology: challenges to the current system and future directions

The role of emotion regulation in predicting personality dimensions

Dimensional models of personality have been widely acknowledged in the field as alternatives to a trait-based system of nomenclature. While the importance of dimensional models has been established, less is known about the constructs underlying these personality dimensions. Emotion regulation is one such potential construct. The goal of the current study was to examine the relationship between personality dimensions and emotion regulation. More specifically, the predictive capacity of emotion regulation in accounting for personality dimensions and symptoms on the Schedule for Nonadaptive and Adaptive Personality-2 above and beyond a measure of general distress was evaluated. Emotion regulation was found to be predictive of most personality dimensions and symptoms of most personality disorders. Consistent with hypotheses, emotion regulation variables associated with undercontrol of emotions were most predictive of traits associated with Cluster B personality disorders whereas Cluster A and C traits were most associated with emotion regulation related to overcontrol of emotions. These findings provide preliminary evidence that some personality dimensions never assessed in relation to emotion regulation are strongly predicted by emotion regulation variables. Thus, the present study facilitates an initial step in understanding the relationship between personality dimensions and a multidimensional model of emotion regulation. Copyright © 2017 John Wiley & Sons, Ltd.

What do clinicians treat: Diagnoses or symptoms? The incremental validity of a symptom-based, dimensional characterization of emotional disorders in predicting medication prescription patterns

BACKGROUND

Although practice guidelines are based on disorders specified in diagnostic manuals, such as the DSM, practitioners appear to follow symptoms when making treatment decisions. Psychiatric medication is generally prescribed in a transdiagnostic manner, further highlighting how symptoms, not diagnoses, often guide clinical practice. A quantitative approach to nosology promises to provide better guidance as it describes psychopathology dimensionally and its organization reflects patterns of covariation among symptoms.

AIM

To investigate whether a quantitative classification of emotional disorders can account for naturalistic medication prescription patterns better than traditional diagnoses.

METHODS

Symptom dimensions and DSM diagnoses of emotional disorders, as well as prescribed medications, were assessed using interviews in a psychiatric outpatient sample (N=318, mean age 42.5years old, 59% female, 81% Caucasian).

RESULTS

Each diagnosis was associated with prescription of multiple medication classes, and most medications were associated with multiple disorders. This was largely due to heterogeneity of clinical diagnoses, with narrow, homogenous dimensions underpinning diagnoses showing different medication profiles. Symptom dimensions predicted medication prescription better than DSM diagnoses, irrespective of whether this was examined broadly across all conditions, or focused on a specific disorder and medication indicated for it.

CONCLUSIONS

Psychiatric medication was prescribed in line with symptoms rather than DSM diagnoses. A quantitative approach to nosology may better reflect treatment planning and be a more effective guide to pharmacotherapy than traditional diagnoses. This adds to a diverse body of evidence about superiority of the quantitative system in practical applications and highlights its potential to improve psychiatric care.

The Challenge of Transforming the Diagnostic System of Personality Disorders

While the DSM-5 alternative model of personality disorder (PD) diagnosis allows the field to systematically compare categorical and dimensional classifications, the ICD-11 proposal suggests a radical change by restricting the classification of PDs to one category, deleting all specific types, basing clinical service provision exclusively upon a severity dimension, and restricting trait domains to secondary qualifiers without defining cutoff points. This article reflects broad international agreement about the state of PD diagnosis. It is argued that diagnosis according to the ICD-11 proposal is based on broad, potentially stigmatizing descriptions of impaired functioning and ignores much of the impressive body of research and treatment guidelines that have advanced the care of adults and adolescents with borderline and other PDs. Before radically changing classification, which highly impacts the provision of health care, head-to-head field trials coupled with the views of patients as well as thorough debate among scientists are urgently needed.

Examining Subtypes of Behavioral/Emotional Risk Using Cluster Analysis

Behavioral and emotional problems among children and adolescents can lead to numerous negative outcomes without intervention. From a prevention standpoint, screening for behavioral and emotional risk is an important step toward identifying such problems before the point of diagnosis or referral. The present study conducted a k-means cluster analysis to determine the subtypes of risk captured by one such screening instrument, the Behavioral and Emotional Screening System (BESS). The final solution produced four clusters: Well-Adapted, Internalizing/Adjustment Problems, Mild Externalizing Problems, and General Problems-Severe; these results were similar to those found with the full Behavioral Assessment System for Children, Second Edition (BASC-2), suggesting that the BESS assesses similar constructs. Predictive validity evidence suggested that cluster membership was associated with standard achievement scores and in-school disciplinary incidents.

Self-report indicators of negative valence constructs within the research domain criteria (RDoC): A critical review

BACKGROUND

In 2010, the National Institute of Mental Health (NIMH) created the Research Domain Criteria (RDoC), a research framework for integrating multiple units of information to explicate basic dimensions of functioning underlying both adaptive and maladaptive behavior. Our goal in this review is to evaluate self-report indicators of negative valence systems constructs within RDoC.

METHODS

We review the content and correlates of several of the most popular self-report measures currently classified within the negative valence systems in the RDoC matrix, using both our own data and previously published results. We use these data to evaluate whether these measures are appropriately placed; in addition, wherever possible, we recommend better alternatives to assess key RDoC constructs.

RESULTS

Our findings indicate that many of the currently listed self-report measures are misplaced. Specifically, our data reveal that some of the purported fear scales are better conceptualized as measures of anxiety and/or anxious arousal. In addition, none of the currently listed measures of frustrative nonreward is a clear, unambiguous indicator of that construct.

LIMITATIONS

The RDoC matrix currently does not list any specific measures of either loss or sustained threat, which makes it difficult to identify appropriate measures of these constructs. In many cases, the specificity/discriminant validity of proposed measures remains uncertain.

CONCLUSIONS

Researchers wanting to include self-report measures of negative valence constructs currently receive little guidance from the RDoC matrix. Future assessment work should be oriented toward the development of measures that are explicitly designed to assess these RDoC constructs.

Cross-sectional Comparison of the Epidemiology of DSM-5 Generalized Anxiety Disorder Across the Globe

IMPORTANCE

Generalized anxiety disorder (GAD) is poorly understood compared with other anxiety disorders, and debates persist about the seriousness of this disorder. Few data exist on GAD outside a small number of affluent, industrialized nations. No population-based data exist on GAD as it is currently defined in DSM-5.

OBJECTIVE

To provide the first epidemiologic data on DSM-5 GAD and explore cross-national differences in its prevalence, course, correlates, and impact.

DESIGN, SETTING, AND PARTICIPANTS

Data come from the World Health Organization World Mental Health Survey Initiative. Cross-sectional general population surveys were carried out in 26 countries using a consistent research protocol and assessment instrument. A total of 147 261 adults from representative household samples were interviewed face-to-face in the community. The surveys were conducted between 2001 and 2012. Data analysis was performed from July 22, 2015, to December 12, 2016.

MAIN OUTCOMES AND MEASURES

The Composite International Diagnostic Interview was used to assess GAD along with comorbid disorders, role impairment, and help seeking.

RESULTS

Respondents were 147 261 adults aged 18 to 99 years. The surveys had a weighted mean response rate of 69.5%. Across surveys, DSM-5 GAD had a combined lifetime prevalence (SE) of 3.7% (0.1%), 12-month prevalence of 1.8% (0.1%), and 30-day prevalence of 0.8% (0). Prevalence estimates varied widely across countries, with lifetime prevalence highest in high-income countries (5.0% [0.1%]), lower in middle-income countries (2.8% [0.1%]), and lowest in low-income countries (1.6% [0.1%]). Generalized anxiety disorder typically begins in adulthood and persists over time, although onset is later and clinical course is more persistent in lower-income countries. Lifetime comorbidity is high (81.9% [0.7%]), particularly with mood (63.0% [0.9%]) and other anxiety (51.7% [0.9%]) disorders. Severe role impairment is common across life domains (50.6% [1.2%]), particularly in high-income countries. Treatment is sought by approximately half of affected individuals (49.2% [1.2%]), especially those with severe role impairment (59.4% [1.8%]) or comorbid disorders (55.8% [1.4%]) and those living in high-income countries (59.0% [1.3%]).

CONCLUSIONS AND RELEVANCE

The findings of this study show that DSM-5 GAD is more prevalent than DSM-IV GAD and is associated with substantial role impairment. The disorder is especially common and impairing in high-income countries despite a negative association between GAD and socioeconomic status within countries. These results underscore the public health significance of GAD across the globe while uncovering cross-national differences in prevalence, course, and impairment that require further investigation.

ADHS bei Erwachsenen

Zusammenfassung. Klassifizierungs- und Strukturierungsmöglichkeiten psychischer Störungen und Konstrukte sind in den letzten Jahren zu einem Schwerpunkt empirischer Forschung geworden. Im Mittelpunkt steht dabei die Debatte um die bisherige kategoriale versus einer neuen dimensionalen Sichtweise. ADHS gehört zu den Störungsbildern, für welche ein dimensionales Konzept plausibel erscheint. Empirische Belege hierfür liefern verschiedene taxonomische Studien an Kindern und Jugendlichen mit ADHS. Für Erwachsene gibt es bisher nur wenig empirische Untersuchungen zu dem Thema. Daher ist die vorliegende Studie eine erste Auseinandersetzung mit der Beschaffenheit von ADHS bei Erwachsenen, wobei den Befunden bei Kindern folgend von einer dimensionalen Struktur ausgegangen wird. Zwei Stichproben wurden zur Beantwortung der Fragestellung herangezogen: 605 Personen einer gesunden Normalstichprobe und 722 Personen aus einer klinischen Stichprobe, bestehend aus 336 Personen ohne ADHS-Diagnose und 386 Personen mit ADHS-Diagnose. Untersucht wurden alle Personen mittels der ADHS-Selbstbeurteilungsskala (ADHS-SB). Zur statistischen Überprüfung der Fragestellung wurden Diskriminanzanalysen und eine Faktorenanalyse durchgeführt, weiterhin wurden finite Mischverteilungsmodelle mit Hilfe des EM-Algorithmus gerechnet. Die Diskriminanzanalysen konnten zeigen, dass Grenzwerte nur bedingt dazu in der Lage sind, zwischen Personen mit und ohne ADHS zu diskriminieren. Die Faktorenanalyse ergab für alle Gruppen die gleiche Zwei-Faktoren-Lösung der ADHS, welche auch vom DSM-5 vorgeschlagen wird (Unaufmerksamkeit, Hyperaktivität/Impulsivität). Weiterhin wiesen die Mischmodelle der verschiedenen Gruppen keine Unterschiede auf, welche eine kategoriale Sichtweise rechtfertigen würden. Insgesamt ist eine dimensionale Struktur des Störungsbildes auch bei Erwachsenen als wahrscheinlich anzunehmen. Dies bedeutet, dass die Symptome der ADHS extreme Ausprägungen normaler psychischer Phänomene darstellen und es keine klaren Grenzen zwischen Personen mit und ohne einer adulten ADHS gibt. Trotz möglicher dimensionaler Struktur handelt es sich bei der ADHS um eine psychische Störung. Das Abklären funktioneller Beeinträchtigungen könnte vermehrt helfen, Behandlungswürdigkeit festzustellen.

Risk of Suicide and Dysfunctional Patterns of Personality among Bereaved Substance Users

Background: Research has shown that suicide is a phenomenon highly present among the drug dependent population. Different studies have demonstrated an upraised level of comorbidity between personality disorders (PD) and substance use disorders (SUD). This study aimed to describe which PDs are more frequent among those patients with a risk of suicide. Methods: The study was based on a consecutive non-probabilistic convenience sample of 196 bereaved patients attended to in a Public Addiction Center in Girona (Spain). Sociodemographic data, as well as suicide and drug related characteristics were recorded. The risk of suicide was assessed with the Spanish version of “Risk of suicide”. Personality disorders were measured with the Spanish version of Millon Multiaxial Clinical Inventory. Results: The PDs more associated with the presence of risk of suicide were depressive, avoidant, schizotypal and borderline disorders. However, the histrionic, narcissistic and compulsive PDs are inversely associated with risk of suicide even though the narcissistic scale had no statistical correlation. Conclusions: The risk of suicide is a significant factor to take into account related to patients with SUD and especially with the presence of specific PDs. These findings underline the importance of diagnosing and treating rigorously patients with SUD.

A hierarchical causal taxonomy of psychopathology across the life span

We propose a taxonomy of psychopathology based on patterns of shared causal influences identified in a review of multivariate behavior genetic studies that distinguish genetic and environmental influences that are either common to multiple dimensions of psychopathology or unique to each dimension. At the phenotypic level, first-order dimensions are defined by correlations among symptoms; correlations among first-order dimensions similarly define higher-order domains (e.g., internalizing or externalizing psychopathology). We hypothesize that the robust phenotypic correlations among first-order dimensions reflect a hierarchy of increasingly specific etiologic influences. Some nonspecific etiologic factors increase risk for all first-order dimensions of psychopathology to varying degrees through a general factor of psychopathology. Other nonspecific etiologic factors increase risk only for all first-order dimensions within a more specific higher-order domain. Furthermore, each first-order dimension has its own unique causal influences. Genetic and environmental influences common to family members tend to be nonspecific, whereas environmental influences unique to each individual are more dimension-specific. We posit that these causal influences on psychopathology are moderated by sex and developmental processes. This causal taxonomy also provides a novel framework for understanding the heterogeneity of each first-order dimension: Different persons exhibiting similar symptoms may be influenced by different combinations of etiologic influences from each of the 3 levels of the etiologic hierarchy. Furthermore, we relate the proposed causal taxonomy to transdimensional psychobiological processes, which also impact the heterogeneity of each psychopathology dimension. This causal taxonomy implies the need for changes in strategies for studying the etiology, psychobiology, prevention, and treatment of psychopathology. (PsycINFO Database Record

PTSD in Court I: Introducing PTSD for Court

The first part of the series of three articles on posttraumatic stress disorder (PTSD) in Court to appear in the journal reviews the history of the construct of PTSD and its presentation in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) and the ICD-11 (International Classification of Diseases, 11th Edition; World Health Organization, 2018). There are 20 symptoms of PTSD in the DSM-5. PTSD symptoms are arranged into a four-cluster model, which has received partial support in the literature. Other four-factor models have been found that fit the data even better than that of the DSM-5. There is a five-factor dysphoria model and two six-factor models that have been found to fit better the DSM-5 PTSD symptoms. Finally, research is providing support for a hybrid seven-factor model. An eighth factor on dissociation seems applicable to the minority of people who express the dissociative subtype. At the epidemiological level, individuals can expect trauma exposure to take place about 70% over one's lifetime. Also, traumatic exposure leads to traumatic reactions in about 10% of cases, with PTSD being a primary diagnosis for trauma. Once initiated, PTSD becomes prolonged in about 10% of cases. Polytrauma and comorbidities complicate these prevalence statistics. Moreover, the possibility of malingered PTSD presents confounds. However, the estimate for malingered PTSD varies extensively, from 1 to 50%, so that the estimate is too imprecise for use in court without further research. This first article in the series of three articles appearing in the journal on PTSD in Court concludes with discussion of complications related to comorbidities and heterogeneities, in particular. For example, PTSD and its comorbidities can be expressed in over one quintillion ways. This complexity in its current structure in the DSM-5 speaks to the individual differences involved in its expression.

Classification of Psychopathology

Many have criticized the Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV), and few regard it as a vehicle of truth, yet its most serious limitation is that its frank operationism in defining manifest categories has distracted attention from theories about what is going on at the latent level. We sketch a Generalized Interpersonal Theory of Personality and Psychopathology and apply it to interpersonal aspects of depression to illustrate how structural individual differences combine with functional dynamic processes to cause interpersonal behavior and affect. Such a causal account relies on a realist ontology in which manifest diagnoses are only a means to learning about the latent distribution, whether categorical or dimensional. Comorbidity of DSM diagnoses suggests that dimensionality will be the rule, not the exception, with internalization and externalization describing common diagnoses.

Gender and cultural issues in psychiatric nosological classification systems

Much has changed since the two dominant mental health nosological systems, the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), were first published in 1900 and 1952, respectively. Despite numerous modifications to stay up to date with scientific and cultural changes (eg, exclusion of homosexuality as a disorder) and to improve the cultural sensitivity of psychiatric diagnoses, the ICD and DSM have only recently renewed attempts at harmonization. Previous nosological iterations demonstrate the oscillation in the importance placed on the biological focus, highlighting the tension between a gender- and culture-free nosology (solely biological) and a contextually relevant understanding of mental illness. In light of the release of the DSM 5, future nosological systems, such as the ICD 11, scheduled for release in 2017, and the Research Development Criteria (RDoC), can learn from history and apply critiques. This article aims to critically consider gender and culture in previous editions of the ICD and DSM to inform forthcoming classifications.

Psychiatric Comorbidity and Complications

This article highlights the prevalence of co-occurring disorders among adolescents and underscores the complexity and opportunities of treating these patients in a systematic, comprehensive approach. As evidenced by this review, the need exists to develop and test models of care that integrate co-occurring disorders into both psychiatric and substance abuse treatment settings. The challenge for pediatric practitioners is to provide detailed assessments linked to evidence-based treatment plans to account for the variations in adolescent development and the unique risk factor profile of each patient. The issues related to co-morbidity are vast and continue to grow with rapidly increasing research literature.

The Co-evolution of Neuroimaging and Psychiatric Neurosurgery

The role of neuroimaging in psychiatric neurosurgery has evolved significantly throughout the field's history. Psychiatric neurosurgery initially developed without the benefit of information provided by modern imaging modalities, and thus lesion targets were selected based on contemporary theories of frontal lobe dysfunction in psychiatric disease. However, by the end of the 20th century, the availability of structural and functional magnetic resonance imaging (fMRI) allowed for the development of mechanistic theories attempting to explain the anatamofunctional basis of these disorders, as well as the efficacy of stereotactic neuromodulatory treatments. Neuroimaging now plays a central and ever-expanding role in the neurosurgical management of psychiatric disorders, by influencing the determination of surgical candidates, allowing individualized surgical targeting and planning, and identifying network-level changes in the brain following surgery. In this review, we aim to describe the coevolution of psychiatric neurosurgery and neuroimaging, including ways in which neuroimaging has proved useful in elucidating the therapeutic mechanisms of neuromodulatory procedures. We focus on ablative over stimulation-based procedures given their historical precedence and the greater opportunity they afford for post-operative re-imaging, but also discuss important contributions from the deep brain stimulation (DBS) literature. We conclude with a discussion of how neuroimaging will transition the field of psychiatric neurosurgery into the era of precision medicine.

HowNutsAreTheDutch (HoeGekIsNL): A crowdsourcing study of mental symptoms and strengths

HowNutsAreTheDutch (Dutch: HoeGekIsNL) is a national crowdsourcing study designed to investigate multiple continuous mental health dimensions in a sample from the general population (n = 12,503). Its main objective is to create an empirically based representation of mental strengths and vulnerabilities, accounting for (i) dimensionality and heterogeneity, (ii) interactivity between symptoms and strengths, and (iii) intra-individual variability. To do so, HowNutsAreTheDutch (HND) makes use of an internet platform that allows participants to (a) compare themselves to other participants via cross-sectional questionnaires and (b) to monitor themselves three times a day for 30 days with an intensive longitudinal diary study via their smartphone. These data enable for personalized feedback to participants, a study of profiles of mental strengths and weaknesses, and zooming into the fine-grained level of dynamic relationships between variables over time. Measuring both psychiatric symptomatology and mental strengths and resources enables for an investigation of their interactions, which may underlie the wide variety of observed mental states in the population. The present paper describes the applied methods and technology, and presents the sample characteristics. Copyright © 2015 John Wiley & Sons, Ltd.

Hierarchical structures of affect and psychopathology and their implications for the classification of emotional disorders

The Diagnostic and Statistical Manual of Mental Disorders-IV groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." The current mood and anxiety disorders reflect the logic of older models emphasizing the existence of discrete emotions and, consequently, are based on a fundamental distinction between depressed mood (central to the mood disorders) and anxious mood (a core feature of the anxiety disorders). This distinction, however, ignores subsequent work that has established the existence of a general negative affect dimension that (a) produces strong correlations between anxious and depressed mood and (b) is largely responsible for the substantial comorbidity between the mood and anxiety disorders. More generally, there are now sufficient data to eliminate the current rational system and replace it with an empirically based taxonomy that reflects the actual-not the assumed-similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching superclass of emotional disorders, which can be decomposed into three subclasses: the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia), and the bipolar disorders (bipolar I, bipolar II, cyclothymia). An empirically based system of this type will facilitate differential diagnosis and encourage the ultimate development of an etiologically based taxonomy.

Developmental psychopathology in an era of molecular genetics and neuroimaging: A developmental neurogenetics approach

The emerging field of neurogenetics seeks to model the complex pathways from gene to brain to behavior. This field has focused on imaging genetics techniques that examine how variability in common genetic polymorphisms predict differences in brain structure and function. These studies are informed by other complimentary techniques (e.g., animal models and multimodal imaging) and have recently begun to incorporate the environment through examination of Imaging Gene × Environment interactions. Though neurogenetics has the potential to inform our understanding of the development of psychopathology, there has been little integration between principles of neurogenetics and developmental psychopathology. The paper describes a neurogenetics and Imaging Gene × Environment approach and how these approaches have been usefully applied to the study of psychopathology. Six tenets of developmental psychopathology (the structure of phenotypes, the importance of exploring mechanisms, the conditional nature of risk, the complexity of multilevel pathways, the role of development, and the importance of who is studied) are identified, and how these principles can further neurogenetics applications to understanding the development of psychopathology is discussed. A major issue of this piece is how neurogenetics and current imaging and molecular genetics approaches can be incorporated into developmental psychopathology perspectives with a goal of providing models for better understanding pathways from among genes, environments, the brain, and behavior.

The Importance of Considering Clinical Utility in the Construction of a Diagnostic Manual

The development of major diagnostic manuals primarily has been guided by construct validity rather than clinical utility. The purpose of this article is to summarize recent research and theory examining the importance of clinical utility when constructing and evaluating a diagnostic manual. We suggest that construct validity is a necessary but not sufficient criterion for diagnostic constructs. This article discusses components of clinical utility and how these have applied to the current and forthcoming diagnostic manuals. Implications and suggestions for future research are provided.

Clinical neuroprediction: Amygdala reactivity predicts depressive symptoms 2 years later

Depression is linked to increased amygdala activation to neutral and negatively valenced facial expressions. Amygdala activation may be predictive of changes in depressive symptoms over time. However, most studies in this area have focused on small, predominantly female and homogenous clinical samples. Studies are needed to examine how amygdala reactivity relates to the course of depressive symptoms dimensionally, prospectively and in populations diverse in gender, race and socioeconomic status. A total of 156 men from predominately low-income backgrounds completed an fMRI task where they viewed emotional facial expressions. Left and right amygdala reactivity to neutral, but not angry or fearful, facial expressions relative to a non-face baseline at age 20 predicted greater depressive symptoms 2 years later, controlling for age 20 depressive symptoms. Heightened bilateral amygdala reactivity to neutral facial expressions predicted increases in depressive symptoms 2 years later in a large community sample. Neutral facial expressions are affectively ambiguous and a tendency to interpret these stimuli negatively may reflect to cognitive biases that lead to increases in depressive symptoms over time. Individual differences in amygdala reactivity to neutral facial expressions appear to identify those at most risk for a more problematic course of depressive symptoms across time.

Research Domain Criteria: toward future psychiatric nosologies

The Research Domain Criteria (RDoC) project was initiated by the National Institute of Mental Health (NIMH) in early 2009 as the implementation of Goal 1.4 of its just-issued strategic plan. In keeping with the NIMH mission, to “transform the understanding and treatment of mental illnesses through basic and clinical research,” RDoC was explicitly conceived as a research-related initiative. The statement of the relevant goal in the strategic plan reads: “Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.” Due to the novel approach that RDoC takes to conceptualizing and studying mental disorders, it has received widespread attention, well beyond the borders of the immediate research community. This review discusses the rationale for the experimental framework that RDoC has adopted, and its implications for the nosology of mental disorders in the future.

Incremental Validity of the DSM-5 Section III Personality Disorder Traits With Respect to Psychosocial Impairment

Traditional personality disorders (PDs) are associated with significant psychosocial impairment. DSM-5 Section III includes an alternative hybrid personality disorder (PD) classification approach, with both type and trait elements, but relatively little is known about the impairments associated with Section III traits. Our objective was to study the incremental validity of Section III traits--compared to normal-range traits, traditional PD criterion counts, and common psychiatric symptomatology--in predicting psychosocial impairment. To that end, 628 current/recent psychiatric patients completed measures of PD traits, normal-range traits, traditional PD criteria, psychiatric symptomatology, and psychosocial impairments. Hierarchical regressions revealed that Section III PD traits incrementally predicted psychosocial impairment over normal-range personality traits, PD criterion counts, and common psychiatric symptomatology. In contrast, the incremental effects for normal-range traits, PD symptom counts, and common psychiatric symptomatology were substantially smaller than for PD traits. These findings have implications for PD classification and the impairment literature more generally.

Neighborhood Disadvantage Alters the Origins of Children's Nonaggressive Conduct Problems

Neighborhood disadvantage plays a pivotal role in child mental health, including child antisocial behavior (e.g., lying, theft, vandalism; assault, cruelty). Prior studies have indicated that shared environmental influences on youth antisocial behavior increase with increasing disadvantage, but have been unable to confirm that these findings persist once various selection confounds are considered. The current study sought to fill this gap in the literature, examining whether and how neighborhood disadvantage alters the genetic and environmental origins of child antisocial behavior. Our sample consisted of 2,054 child twins participating in the Michigan State University Twin Registry, half of whom were oversampled to reside in modestly-to-severely impoverished neighborhoods. We made use of an innovative set of nuclear twin family models, thereby allowing us to disambiguate between, and simultaneously estimate, multiple elements of the shared environment as well as genetic influences. Although there was no evidence that the etiology of aggressive antisocial behavior was moderated by neighborhood disadvantage, the etiology of non-aggressive antisocial behavior shifted dramatically with increasing neighborhood disadvantage. Sibling-level shared environmental influences were estimated to be near zero in the wealthiest neighborhoods, and increased dramatically in the most impoverished neighborhoods. By contrast, both genetic risk and family-level shared environmental transmission were significantly more influential in middle- and upper-class neighborhoods than in impoverished neighborhoods. Such results collectively highlight the profound role that pervasive neighborhood poverty plays in shaping the etiology of child non-aggressive antisocial behavior. Implications are discussed.

Should Sexual Problems Be Included in the Internalizing Spectrum? A Comparison of Dimensional and Categorical Models

Preliminary research has suggested that sexual problems should be included in the internalizing spectrum alongside depressive and anxiety disorders. This study aimed to empirically examine and compare an extended internalizing spectrum model with a categorical framework model implied by the current nosological structure. Responses to an online survey from a community sample (n = 518) were analyzed to compare the fit of six alternative models of the relationship between sexual problems and depressive and anxiety disorders, separately for men and women. The best model for women (n = 336) was a dimensional spectrum model that included sexual arousal, orgasm, and pain difficulties in the internalizing spectrum. The results for men (n = 182) were less clear-cut: there were apparent categorical relationships for a small group (n = 8), and the spectrum model showed a good fit for 96% of the sample. These findings are consistent with a nosology that maintains discrete disorders and diagnostic chapters while recognizing the relationships between them, as in the new structure of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. As such, this study offers further evidence that there are dimensional relationships between sexual problems and depressive and anxiety disorders, which should be explicitly recognized in diagnostic systems.

Patterns of DSM-5 posttraumatic stress disorder and depression symptoms in an epidemiological sample of Chinese earthquake survivors: A latent profile analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) and depression are highly comorbid in association with serious clinical consequences. Nevertheless, to date, no study using latent class or latent profile analysis (LCA/LPA) has examined patterns of co-occurring PTSD and depression symptoms among natural disaster survivors, nor has the distinctiveness of DSM-5 PTSD and depression symptoms been clarified in the aftermath of trauma. This study was primarily aimed at filling these gaps.

METHODS

LPA was used to examine self-reported PTSD and depression symptoms in an epidemiological sample of 1196 Chinese earthquake survivors.

RESULTS

A 4-class solution characterized by low symptoms (53.9%), predominantly depression (18.2%), predominantly PTSD (18.9%) and combined PTSD-depression (9.0%) patterns fit the data best. Demographic characteristics and earthquake-related exposures were specifically or consistently associated with the non-parallel profiles varying in physical health impairment.

LIMITATIONS

A sample exposed to specific traumatic events was assessed by self-report measures.

CONCLUSIONS

The distinctiveness of DSM-5 PTSD and depression symptoms following an earthquake suggests that PTSD and depression may be independent sequelae of psychological trauma rather than a manifestation of a single form of psychopathology. The current findings support the distinction between PTSD and depression constructs, and highlight the need for identifications of natural disaster survivors at high risk for PTSD and/or depression, and interventions individually tailored to one's symptom presentations.

Measuring adolescents' exposure to victimization: The Environmental Risk (E-Risk) Longitudinal Twin Study

This paper presents multilevel findings on adolescents' victimization exposure from a large longitudinal cohort of twins. Data were obtained from the Environmental Risk (E-Risk) Longitudinal Twin Study, an epidemiological study of 2,232 children (1,116 twin pairs) followed to 18 years of age (with 93% retention). To assess adolescent victimization, we combined best practices in survey research on victimization with optimal approaches to measuring life stress and traumatic experiences, and introduce a reliable system for coding severity of victimization. One in three children experienced at least one type of severe victimization during adolescence (crime victimization, peer/sibling victimization, Internet/mobile phone victimization, sexual victimization, family violence, maltreatment, or neglect), and most types of victimization were more prevalent among children from low socioeconomic backgrounds. Exposure to multiple victimization types was common, as was revictimization; over half of those physically maltreated in childhood were also exposed to severe physical violence in adolescence. Biometric twin analyses revealed that environmental factors had the greatest influence on most types of victimization, while severe physical maltreatment from caregivers during adolescence was predominantly influenced by heritable factors. The findings from this study showcase how distinct levels of victimization measurement can be harmonized in large-scale studies of health and development.

Mental Health Service Use in Schools and Non-School-Based Outpatient Settings: Comparing Predictors of Service Use

Researchers have consistently documented a gap between the large number of US youth meeting criteria for a mental health disorder with significant associated impairment, and the comparatively few youth receiving services. School-based mental health care may address the need-services gap by offering services more equitably to youth in need, irrespective of family economic resources, availability of transportation, and other factors that can impede access to community clinics. However, diagnoses alone do not fully capture the severity of an individual's mental health status and need for services. Studying service use only in relation to diagnoses may restrict our understanding of the degree to which service use is reflective of service need, and inhibit our ability to compare school and non-school-based outpatient settings on their responsiveness to service need. The present study evaluated predictors of mental health service use in school- and community-based settings for youth who had had an active case in one of two public sectors of care, comparing empirically-derived dimensional measurements of youth mental health service need and impairment ratings against non-need variables (e.g., ethnicity, income). Three dimensions of youth mental health service need were identified. Mental health service need and non-need variables each played a significant predictive role. Parent-rated impairment was the strongest need-based predictor of service use across settings. The impact of non-need variables varied by service setting, with parental income having a particularly noticeable effect on school-based services. Across time, preceding service use and impairment each significantly predicted future service use.

Identifying Shared Latent Dimensions of Psychological Symptoms: Implications for the Psychological Correlates of Smoking

Shared latent dimensions may account for the co-occurrence of multiple forms of psychological dysfunction. However, this conceptualization has rarely been integrated into the smoking literature, despite high levels of psychological symptoms in smokers. In this study, we used confirmatory factor analysis to compare three models (1-factor, 2-factor [internalizing-externalizing], and 3-factor [low positive affect-negative affect-disinhibition]) of relations among nine measures of affective and behavioral symptoms implicated in smoking spanning depression, anxiety, happiness, anhedonia, ADHD, aggression, and alcohol use disorder symptoms. We then examined associations of scores from each of the manifest scales and the latent factors from the best-fitting model to several smoking characteristics (i.e., experimentation, lifetime established smoking [≥100 cigarettes lifetime], age of smoking onset, cigarettes/day, nicotine dependence, and past nicotine withdrawal). We used two samples: (1) College Students (N =288; mean age =20; 75 % female) and (2) Adult Daily Smokers (N=338; mean age=44; 32 % female). In both samples, the 3-factor model separating latent dimensions of deficient positive affect, negative affect, and disinhibition fit best. In the college students, the disinhibition factor and its respective indicators significantly associated with lifetime smoking. In the daily smokers, low positive and high negative affect factors and their respective indicators positively associated with cigarettes/day and nicotine withdrawal symptom severity. These findings suggest that shared features of psychological symptoms may be parsimonious explanations of how multiple manifestations of psychological dysfunction play a role in smoking. Implications for research and treatment of co-occurring psychological symptoms and smoking are discussed.

Simultaneous Decomposition of Depression Heterogeneity on the Person-, Symptom- and Time-Level: The Use of Three-Mode Principal Component Analysis

Although heterogeneity of depression hinders research and clinical practice, attempts to reduce it with latent variable models have yielded inconsistent results, probably because these techniques cannot account for all interacting sources of heterogeneity at the same time. Therefore, to simultaneously decompose depression heterogeneity on the person-, symptom and time-level, three-mode Principal Component Analysis (3MPCA) was applied to data of 219 Major Depression patients, who provided Beck Depression Inventory assessments every three months for two years. The resulting person-level components were correlated with external baseline clinical and demographic variables. The 3MPCA extracted two symptom-level components (‘cognitive’, ‘somatic-affective’), two time-level components (‘improving’, ‘persisting’) and three person-level components, characterized by different interaction-patterns between the symptom- and time-components (‘severe non-persisting’, ‘somatic depression’ and ‘cognitive depression’). This model explained 28% of the total variance and 65% when also incorporating the general trend in the data). Correlations with external variables illustrated the content differentiation between the person-components. Severe non-persisting depression was positively correlated with psychopathology (r=0.60) and negatively with quality of life (r=-0.50). Somatic depression was negatively correlated with physical functioning (r=-0.45). Cognitive depression was positively correlated with neuroticism (r=0.38) and negatively with self-esteem (r=-0.47). In conclusion, 3MPCA decomposes depression into homogeneous entities, while accounting for the interactions between different sources of heterogeneity, which shows the utility of the technique to investigate the underlying structure of complex psychopathology data and could help future development of better empirical depression subtypes.

Inhibition-Based Biomarkers for Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a behaviorally defined and heterogeneous disorder. Biomarkers for ASD offer the opportunity to improve prediction, diagnosis, stratification by severity and subtype, monitoring over time and in response to interventions, and overall understanding of the underlying biology of this disorder. A variety of potential biomarkers, from the level of genes and proteins to network-level interactions, is currently being examined. Many of these biomarkers relate to inhibition, which is of particular interest because in many cases ASD is thought to be a disorder of imbalance between excitation and inhibition. Abnormalities in inhibition at the cellular level lead to emergent properties in networks of neurons. These properties take into account a more complete genetic and cellular background than findings at the level of individual genes or cells, and are able to be measured in live humans, offering additional potential as diagnostic biomarkers and predictors of behaviors. In this review we provide examples of how altered inhibition may inform the search for ASD biomarkers at multiple levels, from genes to cells to networks.

Identification of a common neurobiological substrate for mental illness

IMPORTANCE

Psychiatric diagnoses are currently distinguished based on sets of specific symptoms. However, genetic and clinical analyses find similarities across a wide variety of diagnoses, suggesting that a common neurobiological substrate may exist across mental illness.

OBJECTIVE

To conduct a meta-analysis of structural neuroimaging studies across multiple psychiatric diagnoses, followed by parallel analyses of 3 large-scale healthy participant data sets to help interpret structural findings in the meta-analysis.

DATA SOURCES

PubMed was searched to identify voxel-based morphometry studies through July 2012 comparing psychiatric patients to healthy control individuals for the meta-analysis. The 3 parallel healthy participant data sets included resting-state functional magnetic resonance imaging, a database of activation foci across thousands of neuroimaging experiments, and a data set with structural imaging and cognitive task performance data.

DATA EXTRACTION AND SYNTHESIS

Studies were included in the meta-analysis if they reported voxel-based morphometry differences between patients with an Axis I diagnosis and control individuals in stereotactic coordinates across the whole brain, did not present predominantly in childhood, and had at least 10 studies contributing to that diagnosis (or across closely related diagnoses). The meta-analysis was conducted on peak voxel coordinates using an activation likelihood estimation approach.

MAIN OUTCOMES AND MEASURES

We tested for areas of common gray matter volume increase or decrease across Axis I diagnoses, as well as areas differing between diagnoses. Follow-up analyses on other healthy participant data sets tested connectivity related to regions arising from the meta-analysis and the relationship of gray matter volume to cognition.

RESULTS

Based on the voxel-based morphometry meta-analysis of 193 studies comprising 15 892 individuals across 6 diverse diagnostic groups (schizophrenia, bipolar disorder, depression, addiction, obsessive-compulsive disorder, and anxiety), we found that gray matter loss converged across diagnoses in 3 regions: the dorsal anterior cingulate, right insula, and left insula. By contrast, there were few diagnosis-specific effects, distinguishing only schizophrenia and depression from other diagnoses. In the parallel follow-up analyses of the 3 independent healthy participant data sets, we found that the common gray matter loss regions formed a tightly interconnected network during tasks and at resting and that lower gray matter in this network was associated with poor executive functioning.

CONCLUSIONS AND REVELANCE

We identified a concordance across psychiatric diagnoses in terms of integrity of an anterior insula/dorsal anterior cingulate-based network, which may relate to executive function deficits observed across diagnoses. This concordance provides an organizing model that emphasizes the importance of shared neural substrates across psychopathology, despite likely diverse etiologies, which is currently not an explicit component of psychiatric nosology.

Attitudes toward neuroscience education in psychiatry: a national multi-stakeholder survey

OBJECTIVE

The objective of this study is to assess the attitudes of chairs of psychiatry departments, psychiatrists, and psychiatry trainees toward neuroscience education in residency programs and beyond in order to inform future neuroscience education approaches.

METHOD

This multi-stakeholder survey captured data on demographics, self-assessments of neuroscience knowledge, attitudes toward neuroscience education, preferences in learning modalities, and interests in specific neuroscience topics. In 2012, the authors distributed the surveys: by paper to 133 US psychiatry department chairs and electronically through the American Psychiatric Association to 3,563 of its members (1,000 psychiatrists and 2,563 trainees).

RESULTS

The response rates for the chair, psychiatrist, and trainee surveys were 53, 9, and 18 %, respectively. A large majority of respondents agreed with the need for more neuroscience education in general and with respect to their own training. Most respondents believed that neuroscience will help destigmatize mental illness and begin producing new treatments or personalized medicines in 5-10 years. Only a small proportion of trainees and psychiatrists, however, reported a strong knowledge base in neuroscience. Respondents also reported broad enthusiasm for transdiagnostic topics in neuroscience (such as emotion regulation and attention/cognition) and description at the level of neural circuits.

CONCLUSIONS

This study demonstrates the opportunity and enthusiasm for teaching more neuroscience in psychiatry among a broad range of stakeholder groups. A high level of interest was also found for transdiagnostic topics and approaches. We suggest that a transdiagnostic framework may be an effective way to deliver neuroscience education to the psychiatric community and illustrate this through a case example, drawing the similarity between this neuroscience approach and problem-based formulations familiar to clinicians.

The co-occurrence of aggression and self-harm: systematic literature review

BACKGROUND

Epidemiological research supports an association between aggression and self-harm through data on the frequency with which individuals exhibit both behaviours. Unbiased evidence, however, is needed to draw conclusions about the nature and extent of co-occurrence.

METHOD

Systematic review of published studies was undertaken to evaluate whether or not the frequency with which aggression and self-harm co-occur is beyond that which would be expected by chance. Outcome measures included: (a) between-group differences on a standardised aggression/self-harm measure - the groups defined by scores on a measure of the other behaviour; (b) correlations between the two behaviours; (c) co-occurrence rates in populations defined by the presence of either behaviour; (d) co-occurrence rates in populations not defined by either behaviour. Odds ratios were calculated for studies presenting complete frequency data.

RESULTS

123 studies, some yielding more than one type of result, met the inclusion criteria. Most case-control studies found elevated levels of aggression in self-harming populations (or self-harm in aggressive populations) compared to controls. The majority of correlational, co-occurrence rate, and odds ratio data found aggression and self-harm to be associated.

LIMITATIONS

Results were subject to descriptive synthesis only and thus, unable to report an overall effect size.

CONCLUSIONS

Evidence suggests that aggression and self-harm frequently co-occur. Such evidence necessitates more theoretical discussion and associated research on the source and nature of co-occurrence. Nonetheless, individuals who present with one behaviour may be considered an 'at-risk' group in terms of exhibiting the other. Such evidence holds implications for practice (e.g. risk assessment).

Dementia trials and dementia tribulations: methodological and analytical challenges in dementia research

Dementia is a substantial and increasing public health concern. Despite decades of research, a cure or effective preventative treatment for dementia remains elusive. We offer critical review of contemporary dementia research and discuss potential reasons why progress in the field has not been as rapid as in other disciplines. We adopt a broad approach in keeping with the broad nature of the topic. We cover the difficulties inherent in studying dementia from 'bench' to 'bedside' to 'population'. We make particular reference to issues of operationalisation of the dementia syndrome and our evolving understanding of dementia as a research 'outcome'. We discuss contemporary 'hot topics' in dementia research methodology focussing on dementia models, pre-dementia states and biomarkers. Recognising the importance of prospective epidemiological cohorts and large-scale clinical trials we pay particular attention to these approaches and the challenges of generating results that have 'real world' external validity. Based on our thoughts we end with suggestions for future dementia research. Our review is designed to be critical but not unnecessarily negative. There is reason for cautious optimism in dementia research. The recent G8 summit on dementia and subsequent establishment of the World Dementia Council are examples of initiatives that reflect societal and political will to increase research efforts in dementia.

Error-related brain activity in the age of RDoC: A review of the literature

The ability to detect and respond to errors is critical to successful adaptation to a changing environment. The error-related negativity (ERN), an event-related potential (ERP) component, is a well-validated neural response to errors and reflects the error monitoring activity of the anterior cingulate cortex (ACC). Additionally, the ERN is implicated in several processes key to adaptive functioning. Abnormalities in error-related brain activity have been linked to multiple forms of psychopathology and individual differences. As such, the component is likely to be useful in NIMH's Research Domain Criteria (RDoC) initiative to establish biologically-meaningful dimensions of psychological dysfunction, and currently appears as a unit of measurement in three RDoC domains: Positive Valence Systems, Negative Valence Systems, and Cognitive Systems. In this review paper, we introduce the ERN and discuss evidence related to its psychometric properties, as well as important task differences. Following this, we discuss evidence linking the ERN to clinically diverse forms of psychopathology, as well as the implications of one unit of measurement appearing in multiple RDoC dimensions. And finally, we discuss important future directions, as well as research pathways by which the ERN might be leveraged to track the ways in which dysfunctions in multiple neural systems interact to influence psychological well-being.

Psychological symptoms, smoking lapse behavior, and the mediating effects of nicotine withdrawal symptoms: A laboratory study

The influence of psychological symptoms on smoking-lapse behavior is critical to understand. However, this relationship is obscured by comorbidity across multiple forms of psychological symptoms and their overlap with nicotine withdrawal. To address these challenges, we constructed a structural model of latent factors underlying 9 manifest scales of affective and behavioral symptoms and tested relations between latent factors and manifest scale residuals with nicotine withdrawal and smoking lapse in a laboratory analog task. Adult daily smokers (N = 286) completed a baseline session at which several forms of affective and behavioral symptoms were assessed and 2 experimental sessions (i.e., following 16 hr of smoking abstinence and following regular smoking), during which withdrawal symptoms and delay of smoking in exchange for monetary reinforcement, as an analogue for lapse propensity, were measured. A single second-order factor of general psychological maladjustment associated with more severe withdrawal-like symptoms, which in turn associated with shorter delay of smoking. The first-order factors, which tapped qualitatively unique domains of psychological symptoms (low positive affect, negative affect, disinhibition), and the manifest scale residuals provided little predictive power beyond the second-order factor with regard to lapse behavior. Relations among general psychological maladjustment, withdrawal-like symptoms, and lapse were significant in both abstinent and nonabstinent conditions, suggesting that psychological maladjustment, and not nicotine withdrawal per se, accounted for the relation with lapse. These results highlight the potential for smoking-cessation strategies that target general psychological maladjustment processes and have implications for addressing withdrawal-like symptoms among individuals with psychological symptoms.

Classification, assessment, prevalence, and effect of personality disorder

Personality disorders are common and ubiquitous in all medical settings, so every medical practitioner will encounter them frequently. People with personality disorder have problems in interpersonal relationships but often attribute them wrongly to others. No clear threshold exists between types and degrees of personality dysfunction and its pathology is best classified by a single dimension, ranging from normal personality at one extreme through to severe personality disorder at the other. The description of personality disorders has been complicated over the years by undue adherence to overlapping and unvalidated categories that represent specific characteristics rather than the core components of personality disorder. Many people with personality disorder remain undetected in clinical practice and might be given treatments that are ineffective or harmful as a result. Comorbidity with other mental disorders is common, and the presence of personality disorder often has a negative effect on course and treatment outcome. Personality disorder is also associated with premature mortality and suicide, and needs to be identified more often in clinical practice than it is at present.

Depression and Frailty in Late Life: Evidence for a Common Vulnerability

OBJECTIVES

The study purpose is to estimate the correlation between depression and competing models of frailty, and to determine to what degree the comorbidity of these syndromes is determined by shared symptomology.

METHODS

Data come from the 2010 Health and Retirement Study. Analysis was limited to community-dwelling participants 65 and older (N = 3,453). Depressive symptoms were indexed by the 8-item Centers for Epidemiologic Studies Depression (CESD) scale. Frailty was indexed by 3 alternative conceptual models: (a) biological syndrome, (b) frailty index, and (c) functional domains. Confirmatory factor analysis (CFA) was used to estimate the correlation between depression and each model of frailty.

RESULTS

Each of the 3 frailty latent factors was significantly correlated with depression: biological syndrome (ρ = .68, p < .01), functional domains (ρ = .70, p < .01), and frailty index (ρ = .61, p < .01). Substantial correlation remained when accounting for shared symptoms between depression and the biological syndrome (ρ = .45) and frailty index (ρ = .56) models.

DISCUSSION

Results indicate that the correlation of frailty and depression in late life is substantial. The association between the two constructs cannot be fully explained by symptom overlap, suggesting that psychological vulnerability may be an important component of frailty.

Toward a functional definition of a "rare disease" for regulatory authorities and funding agencies

BACKGROUND

The designation of a disease as "rare" is associated with some substantial benefits for companies involved in new drug development, including expedited review by regulatory authorities and relaxed criteria for reimbursement. How "rare disease" is defined therefore has major financial implications, both for pharmaceutical companies and for insurers or public drug reimbursement programs. All existing definitions are based, somewhat arbitrarily, on disease incidence or prevalence.

OBJECTIVES

What is proposed here is a functional definition of rare based on an assessment of the feasibility of measuring the efficacy of a new treatment in conventional randomized controlled trials, to inform regulatory authorities and funding agencies charged with assessing new therapies being considered for public funding.

METHODS

It involves a five-step process, involving significant negotiations between patient advocacy groups, pharmaceutical companies, physicians, and public drug reimbursement programs, designed to establish the feasibility of carrying out a randomized controlled trial with sufficient statistical power to show a clinically significant treatment effect.

RESULTS AND CONCLUSIONS

The steps are as follows: 1) identification of a specific disease, including appropriate genetic definition; 2) identification of clinically relevant outcomes to evaluate efficacy; 3) establishment of the inherent variability of measurements of clinically relevant outcomes; 4) calculation of the sample size required to assess the efficacy of a new treatment with acceptable statistical power; and 5) estimation of the difficulty of recruiting an adequate sample size given the estimated prevalence or incidence of the disorder in the population and the inclusion criteria to be used.

Mechanisms underpinning inattention and hyperactivity: neurocognitive support for ADHD dimensionality

BACKGROUND

Taxometric and behavioral genetic studies suggest that attention deficit hyperactivity disorder (ADHD) is best modeled as a dimension rather than a category. We extended these analyses by testing for the existence of putative ADHD-related deficits in basic information processing (BIP) and inhibitory-based executive function (IB-EF) in individuals in the subclinical and full clinical ranges. Consistent with the dimensional model, we predicted that ADHD-related deficits would be expressed across the full spectrum, with the degree of deficit linearly related to the severity of the clinical presentation.

METHOD

A total of 1547 children (aged 6-12 years) participated in the study. The Development and Well-Being Assessment (DAWBA) was used to classify children into groups according to levels of inattention and hyperactivity independently: (1) asymptomatic, (2) subthreshold minimal, (3) subthreshold moderate and (4) clinical ADHD. Neurocognitive performance was evaluated using a two-choice reaction time task (2C-RT) and a conflict control task (CCT). BIP and IB-EF measures were derived using a diffusion model (DM) for decomposition of reaction time (RT) and error data.

RESULTS

Deficient BIP was found in subjects with minimal, moderate and full ADHD defined in terms of inattention (in both tasks) and hyperactivity/impulsivity dimensions (in the 2C-RT). The size of the deficit increased in a linear manner across increasingly severe presentations of ADHD. IB-EF was unrelated to ADHD.

CONCLUSIONS

Deficits in BIP operate at subclinical and clinical levels of ADHD. The linear nature of this relationship provides support for a dimensional model of ADHD in which diagnostic thresholds are defined in terms of clinical and societal burden rather than representing discrete pathophysiological states.

Shared versus specific features of psychological symptoms and cigarettes per day: structural relations and mediation by negative- and positive-reinforcement smoking

This study examined the extent to which shared versus specific features across multiple manifestations of psychological symptoms (depression, anxiety, ADHD, aggression, alcohol misuse) associated with cigarettes per day. Subsequently, we investigated whether negative- (i.e., withdrawal relief) and positive- (i.e., pleasure enhancement) reinforcement smoking motivations mediated relations. Adult daily smokers (N = 338) completed self-report measures and structural equation modeling was used to construct a 3-factor (low positive affect-negative affect-disinhibition) model of affective and behavioral symptoms and to test relations of each latent factor (shared features) and indicator residual (specific features) to smoking level. Shared dimensions of low positive affect, negative affect, and disinhibition associated with smoking rate. Negative-reinforcement smoking mediated the link between latent negative affect and heavier daily smoking. Specific features of psychological symptoms unique from latent factors were generally not associated with cigarettes per day. Features shared across several forms of psychological symptoms appear to underpin relations between psychological symptoms and smoking rate.

The Arabic Mood and Feelings Questionnaire: psychometrics and validity in a clinical sample

The purpose of this study was to provide clinicians in the Arab World with a child and adolescent depression screening tool. Child and parent versions of the Mood and Feelings Questionnaire (CMFQ and PMFQ respectively) were translated to Arabic and administered along with the Strengths and Difficulties Questionnaire (SDQ) to 30 children and adolescents and with mood disorders and 76 children and adolescents with other psychiatric disorders seeking treatment at a child and adolescent psychiatry clinic. DSM-IV diagnoses were generated through clinical interviews by a psychiatrist blinded to self-reports. Internal consistency for both versions was excellent with moderate inter-informant agreement and good convergent validity with the SDQ emotional symptoms subscales on the child and parent forms. The CMFQ and PMFQ significantly differentiated between currently depressed participants and those with other psychiatric disorders. CMFQ scores were a stronger predictor of categorization into depressed and non-depressed groups than the PMFQ. Two modes of cutoffs were calculated with one favoring sensitivity (a score of 26 for the CMFQ and 22 for the PMFQ) and another favoring specificity (a score of 31 for the CMFQ and 28 for the PMFQ).

The joint structure of major depression, anxiety disorders, and trait negative affect

BACKGROUND

Dimensional models of psychopathology demonstrate that two correlated factors of fear and distress account for the covariation among depressive and anxiety disorders. Nevertheless, these models tend to exclude variables relevant to psychopathology, such as temperament traits. This study examined the joint structure of DSM-IV-based major depression and anxiety disorders along with trait negative affect in a representative sample of adult individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil.

METHODS

The sample consisted of 3,728 individuals who were administered sections D (phobic, anxiety and panic disorders) and E (depressive disorders) of the Composite International Diagnostic Interview (CIDI) 2.1 and a validated version of the Positive and Negative Affect Schedule. Data were analyzed using correlational and structural equation modeling.

RESULTS

Lifetime prevalence ranged from 2.4% for panic disorder to 23.2% for major depression. Most target variables were moderately correlated. A two-factor model specifying correlated fear and distress factors was retained and confirmed for models including only diagnostic variables and diagnostic variables along with trait negative affect.

CONCLUSIONS

This study provides support for characterization of internalizing psychopathology and trait negative affect in terms of correlated dimensions of distress and fear. These results have potential implications for psychiatric taxonomy and for understanding the relationship between temperament and psychopathology.

Beyond the DSM: development of a transdiagnostic psychiatric neuroscience course

OBJECTIVE

Clinical and neurobiological data suggest that psychiatric disorders, as traditionally defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), are (1) more comorbid than expected by chance, (2) often share neurobiological signatures, and (3) reflect alterations across multiple brain systems that mediate particular mental processes. As such, emerging conceptualizations such at the National Institute of Mental Health's Research Domain Criteria Project (RDoC) have suggested that a different way to understand psychopathology may be with respect to the degree of dysfunction in each of these brain systems, seen dimensionally, which both cross traditional diagnostic boundaries and extend to a healthy range of functioning. At present, however, this scientific perspective has not been incorporated into neuroscience education in psychiatry, nor has its relationship to clinical care been made clear.

METHODS

We describe the rationale and implementation of a reformulated neuroscience course given to psychiatric residents at Stanford University centered on the conceptual framework of RDoC. Data are presented on resident feedback before and after revision of the course.

RESULTS

A clear motivation and rationale exists for teaching neuroscience in a transdiagnostic framework. This course was taken up well by the residents, with overall feedback significantly more positive than that prior to the course revision.

CONCLUSION

This "proof of concept" neuroscience course illustrates a potential route for bridging between rapid advances in psychiatric neuroscience and the clinical education for trainees not otherwise versed in neuroscience but who are needed for scientific advances to translate to the clinic. The promise of this approach may be in part related to the similarity between this framework and problem-based approaches common in routine clinical care. In such approaches, clinicians focus on the expressed complaints of their individual patient and identify specific symptoms as the target of treatment--symptoms which are presumably the expression of dysfunction in specific brain systems.

Putative transcriptomic biomarkers in the inflammatory cytokine pathway differentiate major depressive disorder patients from control subjects and bipolar disorder patients

Mood disorders consist of two etiologically related, but distinctly treated illnesses, major depressive disorder (MDD) and bipolar disorder (BPD). These disorders share similarities in their clinical presentation, and thus show high rates of misdiagnosis. Recent research has revealed significant transcriptional differences within the inflammatory cytokine pathway between MDD patients and controls, and between BPD patients and controls, suggesting this pathway may possess important biomarker properties. This exploratory study attempts to identify disorder-specific transcriptional biomarkers within the inflammatory cytokine pathway, which can distinguish between control subjects, MDD patients and BPD patients. This is achieved using RNA extracted from subject blood and applying synthesized complementary DNA to quantitative PCR arrays containing primers for 87 inflammation-related genes. Initially, we use ANOVA to test for transcriptional differences in a 'discovery cohort' (total n = 90) and then we use t-tests to assess the reliability of any identified transcriptional differences in a 'validation cohort' (total n = 35). The two most robust and reliable biomarkers identified across both the discovery and validation cohort were Chemokine (C-C motif) ligand 24 (CCL24) which was consistently transcribed higher amongst MDD patients relative to controls and BPD patients, and C-C chemokine receptor type 6 (CCR6) which was consistently more lowly transcribed amongst MDD patients relative to controls. Results detailed here provide preliminary evidence that transcriptional measures within inflammation-related genes might be useful in aiding clinical diagnostic decision-making processes. Future research should aim to replicate findings detailed in this exploratory study in a larger medication-free sample and examine whether identified biomarkers could be used prospectively to aid clinical diagnosis.

Depression, healthcare utilization, and comorbid psychiatric disorders after spinal cord injury

BACKGROUND

Depression is often comorbid with other psychiatric conditions in the general population, with resultant impact on severity of conditions and healthcare utilization. It is unclear to what degree this is also true among persons with spinal cord injury (SCI).

OBJECTIVE

This study examined rates at which psychiatric conditions were comorbid with depression after SCI, and the association between a depression diagnosis and healthcare and pharmaceutical drug use.

METHODS

Retrospective analysis of data (N = 41 213) abstracted from Veterans Health Administration administrative databases between fiscal years (FYs) 1997 and 2007 to examine overall rates of depression. Administrative data from FY 2007 was used to examine rates of psychiatric disorders comorbid with depression, and to compare veterans with SCI and depression to veterans with SCI but no depression on healthcare and pharmaceutical use.

RESULTS

Twenty-eight percent (n = 11 506) of 41 213 veterans who received SCI care between FY 1997 and FY 2007 were diagnosed with depressive disorders. Among the veterans with SCI and depression diagnoses in 2007 (n = 2615), 70% were also diagnosed with another psychiatric illness, with posttraumatic stress disorder and other anxiety disorders being the most common. Veterans with SCI and depression had more healthcare visits and received more pharmaceutical prescriptions than their counterparts without depression.

CONCLUSIONS

Persons with SCI and depression are likely to experience comorbid psychiatric illnesses, with associated increased healthcare visits and medication use. Research and theory on depression after SCI should develop toward describing and addressing psychiatric and medical co-morbidities that are normative in this population.

The p Factor: One General Psychopathology Factor in the Structure of Psychiatric Disorders?

Mental disorders traditionally have been viewed as distinct, episodic, and categorical conditions. This view has been challenged by evidence that many disorders are sequentially comorbid, recurrent/chronic, and exist on a continuum. Using the Dunedin Multidisciplinary Health and Development Study, we examined the structure of psychopathology, taking into account dimensionality, persistence, co-occurrence, and sequential comorbidity of mental disorders across 20 years, from adolescence to midlife. Psychiatric disorders were initially explained by three higher-order factors (Internalizing, Externalizing, and Thought Disorder) but explained even better with one General Psychopathology dimension. We have called this dimension the p factor because it conceptually parallels a familiar dimension in psychological science: the g factor of general intelligence. Higher p scores are associated with more life impairment, greater familiality, worse developmental histories, and more compromised early-life brain function. The p factor explains why it is challenging to find causes, consequences, biomarkers, and treatments with specificity to individual mental disorders. Transdiagnostic approaches may improve research.