Nosologomania: a disorder of psychiatry

Common Cause Versus Dynamic Mutualism: An Empirical Comparison of Two Theories of Psychopathology in Two Large Longitudinal Cohorts

Mental disorders are among the leading causes of global disease burden. To respond effectively, a strong understanding of the structure of psychopathology is critical. We empirically compared two competing frameworks, dynamic-mutualism theory and common-cause theory, that vie to explain the development of psychopathology. We formalized these theories in statistical models and applied them to explain change in the general factor of psychopathology (p factor) from early to late adolescence (N = 1,482) and major depression in middle adulthood and old age (N = 6,443). Change in the p factor was better explained by mutualism according to model-fit indices. However, a core prediction of mutualism was not supported (i.e., predominantly positive causal interactions among distinct domains). The evidence for change in depression was more ambiguous. Our results support a multicausal approach to understanding psychopathology and showcase the value of translating theories into testable statistical models for understanding developmental processes in clinical sciences.

Validity, reliability and clinical utility of mental disorders: The case of ICD-11 schizophrenia

Diagnostic classification systems categorise mental psychopathology in mental disorders. Although these entities are clinical constructs developed by consensus, it has been pointed out that in practice they are usually managed as natural entities and without evaluating aspects related to their nosological construction. The objectives of the study are to review a) the conceptualisation of mental disorders, b) the indicators of validity, reliability and clinical utility, and c) the values ​​of these indicators in ICD-11 schizophrenia. The results show that mental disorders are conceptualised as discrete entities, like the diseases of other areas of medicine; however, differences are observed between these diagnostic categories in clinical practice. The reliability and clinical utility of mental disorders are adequate; however, the validity is not yet clarified. Similarly, ICD-11 schizophrenia demonstrates adequate reliability and clinical utility, but its validity remains uncertain. The conceptualisation of psychopathology in discrete entities may be inadequate for its study, therefore dimensional and mixed models have been proposed. The indicators of validity, reliability and clinical utility enable us to obtain an accurate view of the nosological state of mental disorders when evaluating different aspects of their nosological construction.

The prevalence, odds and predictors of lifespan comorbid eating disorder among people with a primary diagnosis of bipolar disorders, and vice-versa: Systematic review and meta-analysis

BACKGROUND

There are scarce and discrepant data about the prevalence and correlates of co-occurring eating disorders (EDs) among people with a primary diagnosis of bipolar disorder (BD), and vice-versa, compelling a systematic review and meta-analysis on the matter.

METHODS

MEDLINE/PsycINFO databases were systematically searched for original studies documenting BD⇌ED comorbidity across the lifespan, from inception up until April 20^th, 2020. Random-effects meta-analysis and meta-regression analyses were conducted, accounting for multiple moderators.

RESULTS

Thirty-six studies involved 15,084 primary BD patients. Eleven studies encompassed 15,146 people with primary EDs. Binge eating disorder (BED) occurred in 12.5% (95%C.I.=9.4-16.6%, I²=93.48%) of BDs, while 9.1% (95%C.I.=3.3-22.6%) of BEDs endorsed BD. Bulimia Nervosa (BN) occurred in 7.4% (95%C.I.=6-10%) of people with BD, whereas 6.7% (95%C.I.=12-29.2%) of subjects with BN had a diagnosis of BD. Anorexia Nervosa (AN) occurred in 3.8% (95%C.I.=2-6%) of people with BDs; 2% (95%C.I.=1-2%) of BD patients had a diagnosis of AN. Overall, BD patients with EDs had higher odds of being female vs. non-ED controls. Several moderators yielded statistically significant differences both within- and between different types of BDs and EDs.

LIMITATIONS

Scant longitudinal studies, especially across different EDs and pediatric samples. High heterogeneity despite subgroup comparisons. Limited discrimination of the quality of the evidence.

CONCLUSIONS

The rates of BD⇌ED comorbidity vary across different diagnostic groups, more than they do according to the "direction" of BD⇌ED. Further primary studies should focus on the risks, chronology, clinical impact, and management of the onset of intertwined BD⇌ED across different ages, promoting a continuum approach.

Validity, Reliability and Clinical Utility of Mental Disorders: The Case of ICD-11 Schizophrenia

Diagnostic classification systems categorise mental psychopathology in mental disorders. Although these entities are clinical constructs developed by consensus, it has been pointed out that in practice they are usually managed as natural entities and without evaluating aspects related to their nosological construction. The objectives of the study are to review a) the conceptualisation of mental disorders, b) the indicators of validity, reliability and clinical utility, and c) the values of these indicators in ICD-11 schizophrenia. The results show that mental disorders are conceptualised as discrete entities, like the diseases of other areas of medicine; however, differences are observed between these diagnostic categories in clinical practice. The reliability and clinical utility of mental disorders are adequate; however, the validity is not yet clarified. Similarly, ICD-11 schizophrenia demonstrates adequate reliability and clinical utility, but its validity remains uncertain. The conceptualisation of psychopathology in discrete entities may be inadequate for its study, therefore dimensional and mixed models have been proposed. The indicators of validity, reliability and clinical utility enable us to obtain an accurate view of the nosological state of mental disorders when evaluating different aspects of their nosological construction.

Schizophrenia in ICD-11: Comparison of ICD-10 and DSM-5

The conceptualization of schizophrenia has changed from its initial conception in the 19th century to the recent publication of the ICD-11. The changes incorporated in this latest version were made based on the evaluation of the current ICD, the available scientific evidence, and the consensus reached by its developers. In this paper we describe the conceptualization changes (diagnostic criteria and specifiers) of ICD-11 schizophrenia with respect to those of ICD-10 and DSM-5. The changes found are discussed based on the scientific literature published in Medline, Scopus and Scielo until July 2019 and the information on the Wordl Health Organization and American Psychiatric Association websites. Given that the diagnosis of schizophrenia is based on the diagnostic criteria of the diagnostic classification systems, it is important to know the changes made in its conceptualization and the evidence supporting such modifications.

What are the Key Characteristics of a 'Good' Psychotherapy? Calling for Ethical Patient Involvement

OBJECTIVE

The evidence-based practice movement clearly defines the relevant components of a good treatment. In the present article, we elaborate on how the active involvement of patients within psychotherapy can and should be increased in order to respect ethical considerations. Our arguments complement the requirements of evidence-based practice, and are independent of the actual psychotherapeutic treatment approach being used.

METHOD

Theoretical and ethical analysis.

RESULTS

In order to respect patient autonomy, psychotherapy needs to be transparent and honest when it comes to disclosing the relevant factors for promoting therapeutic change. It has been argued that ethical informed consent needs to include empirically supported patient information. In this paper we go one step further: we outline that fully respecting ethical considerations in psychotherapeutic treatment necessarily calls for acknowledging and strengthening the active role of patients in the course of psychotherapy. Accordingly, patients need not only to be informed openly and transparently about the planned treatment, the treatment rationale, and the expected prognosis of improvement in the course of psychotherapy, but they also need to be actively involved in the decision-making process and during the entire process of psychotherapeutic treatment.

CONCLUSIONS

Our arguments support the tendency that can be observed in health care in recent years towards more active patient involvement across different health-care domains, but also in clinical research. This article offers an ethical perspective on the question what defines a 'good psychotherapy', which, hopefully, will help to leave behind some of the ongoing psychotherapy debates and move the field forward.

A symptom-based continuum of psychosis explains cognitive and real-world functional deficits better than traditional diagnoses

BACKGROUND

Patients with psychotic spectrum disorders share overlapping clinical/biological features, making it often difficult to separate them into a discrete nosology (i.e., Diagnostic and Statistical Manual of Mental Disorders [DSM]).

METHODS

The current study investigated whether a continuum classification scheme based on symptom burden would improve conceptualizations for cognitive and real-world dysfunction relative to traditional DSM nosology. Two independent samples (New Mexico [NM] and Bipolar and Schizophrenia Network on Intermediate Phenotypes [B-SNIP]) of patients with schizophrenia (NM: N = 93; B-SNIP: N = 236), bipolar disorder Type I (NM: N = 42; B-SNIP: N = 195) or schizoaffective disorder (NM: N = 15; B-SNIP: N = 148) and matched healthy controls (NM: N = 64; B-SNIP: N = 717) were examined. Linear regressions examined how variance differed as a function of classification scheme (DSM diagnosis, negative and positive symptom burden, or a three-cluster solution based on symptom burden).

RESULTS

Symptom-based classification schemes (continuous and clustered) accounted for a significantly larger portion of captured variance of real-world functioning relative to DSM diagnoses across both samples. The symptom-based classification schemes accounted for large percentages of variance for general cognitive ability and cognitive domains in the NM sample. However, in the B-SNIP sample, symptom-based classification schemes accounted for roughly equivalent variance as DSM diagnoses. A potential mediating variable across samples was the strength of the relationship between negative symptoms and impaired cognition.

CONCLUSIONS

Current results support suggestions that a continuum perspective of psychopathology may be more powerful for explaining real-world functioning than the DSM diagnostic nosology, whereas results for cognitive dysfunction were sample dependent.

Brain space and time in mental disorders: Paradigm shift in biological psychiatry

Contemporary psychiatry faces serious challenges because it has failed to incorporate accumulated knowledge from basic neuroscience, neurophilosophy, and brain-mind relation studies. As a consequence, it has limited explanatory power, and effective treatment options are hard to come by. A new conceptual framework for understanding mental health based on underlying neurobiological spatial-temporal mechanisms of mental disorders (already gained by the experimental studies) is beginning to emerge.

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.

Psychophysiological science and the research domain criteria: A commentary

The current special issue, devoted to the Research Domain Criteria (RDoC) initiative of the US National Institute of Mental Health, showcases a variety of empirical and review articles that address issues related to this dimensional and multi-method approach to research on mental disorders. Here, we provide an integrative perspective on various aspects of these articles, focused around the primary principles of the RDoC approach and the practical and methodological issues related to conducting RDoC-informed research. The chief point we wish to highlight is that these articles demonstrate the ways in which the field of psychophysiology already thinks along the lines of RDoC in terms of using biobehavioral constructs, looking for convergence among constructs using various methodologies, and utilizing dimensional measurements in studies. In this sense, RDoC is not novel; however, by specifying a formal research platform it provides explicit encouragement and guidance for using such principles in understanding psychiatric phenomena, rather than continuing to focus research efforts on traditional diagnostic categories alone.

Heart rate variability as a transdiagnostic biomarker of psychopathology

The Research Domain Criteria (RDoC), developed by the National Institute of Mental Health as a neuroscience-informed alternative to traditional psychiatric nosology, is an explicitly dimensional system in which classification of psychopathology is derived inductively (i.e., from basic science), across multiple levels of analysis (e.g., genetic, neural, psychophysiological, and behavioral). Although RDoC is often presented as paradigmatically revolutionary, a review of the history of psychophysiology suggests that roots of RDoC thinking extend at least as far back as the mid-20th Century. In this paper, we briefly and selectively review the historical emergence of neurobiologically-informed dimensional trait models of psychopathology, and we summarize our thinking regarding high frequency heart rate variability (HF-HRV) as a transdiagnostic biomarker of self-regulation and cognitive control. When functional interactions between HF-HRV and systems of behavioral approach and avoidance are considered, diverse patterns of behavioral maladjustment can be subsumed into a single model. This model accommodates the general bifactor structure of psychopathology, and suggests that HF-HRV can be viewed as an autonomic, transdiagnostic biomarker of mental illness.

Depression means different things: A qualitative study of psychiatrists' conceptualization of depression in the palliative care setting

OBJECTIVE

Medical practitioners conceptualize depression in different ways, which adds to the challenges of its diagnosis and treatment, as well as research in the palliative care setting. Psychiatric assessment is often considered the "gold standard" for diagnosis, therefore how psychiatrists conceptualize depression in this setting is pertinent. Our study aimed to investigate this issue.

METHOD

Psychiatrists working in palliative care in Australia were individually interviewed using a semistructured approach. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes.

RESULTS

Three overarching themes were identified: (1) depression means different things; (2) depression is conceptualized using different models; and (3) depression is the same concept within and outside of the palliative care setting. Participants explicitly articulated the heterogeneous nature of depression and described a different breadths of concepts, ranging from a narrow construct of a depressive illness to a broader one that encompassed depressive symptoms and emotions. However, depressive illness was a consistent concept, and participants considered this in terms of phenotypic subtypes. Participants used three models (spectral, dichotomous, and mixed) to relate various depressive presentations.

SIGNIFICANCE OF RESULTS

Psychiatrists did not subscribe to a unitary model of depression but understood it as a heterogeneous concept comprised of depressive illness and other less clearly defined depressive presentations. Given the influence of psychiatric opinion in the area of depression, these findings may serve as a platform for further discussions to refine the concepts of depression in the palliative care setting, which in turn may improve diagnostic and treatment outcomes.

A proposal for including nomophobia in the new DSM-V

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered to be the gold standard manual for assessing the psychiatric diseases and is currently in its fourth version (DSM-IV), while a fifth (DSM-V) has just been released in May 2013. The DSM-V Anxiety Work Group has put forward recommendations to modify the criteria for diagnosing specific phobias. In this manuscript, we propose to consider the inclusion of nomophobia in the DSM-V, and we make a comprehensive overview of the existing literature, discussing the clinical relevance of this pathology, its epidemiological features, the available psychometric scales, and the proposed treatment. Even though nomophobia has not been included in the DSM-V, much more attention is paid to the psychopathological effects of the new media, and the interest in this topic will increase in the near future, together with the attention and caution not to hypercodify as pathological normal behaviors.

How do palliative medicine specialists conceptualize depression? Findings from a qualitative in-depth interview study

BACKGROUND AND OBJECTIVE

Different professional conceptualizations of depression may complicate the clinical approach to depression in the palliative care setting. This study aimed to explore and characterize how palliative medicine specialists conceptualize depression.

METHODS

Palliative medicine specialists (i.e., consultants/attending physicians in palliative medicine) practicing in Australia were recruited. Participants were purposively sampled. Individual semi-structured, in-depth interviews were conducted to explore their conceptualizations of depression. Nine participants were interviewed to reach data saturation. Interview transcripts were analyzed for themes.

RESULTS

Four main themes were identified in relation to the conceptualization of depression: (1) depression is a varied concept--it was variously considered as abnormal, a medical problem, an emotional experience, a social product, and an action-oriented construct; (2) depression has unclear boundaries, with differentiation between depression and sadness being especially challenging; (3) depression is different in the palliative care setting--it was seen as more understandable, and distinct from depression that predates life-limiting illnesses; and (4) depression is a challenging issue.

CONCLUSIONS

Depression is conceptualized by palliative medicine specialists in divergent, ontologically heterogeneous and ill-defined ways. A unitary concept of depression was not evident in this study. The concepts of depression need to be actively debated and refined in clinical practice, medical education, and research in order for more sophisticated and consistent models to be developed. The distinction of de novo depression from recurrent or persistent forms of depression also warrants further study.

What is a mental disorder? A perspective from cognitive-affective science

Defining disease and disorder remains a key conceptual question in philosophy of medicine and psychiatry, and is currently a very practical matter for psychiatric nosology, given the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the upcoming International Classification of Diseases, 11th Revision. There have been advances in the cognitive-affective science of human categorization, and it is timely to consider implications for our understanding of the category of psychiatric disorder. The category of mental disorder has graded boundaries, and conditions within this category can be conceptualized using MEDICAL or MORAL metaphors. One key set of constructs used in MEDICAL metaphors relates to the notion of dysfunction, and it may, in turn, be useful to conceptualize such dysfunction in evolutionary terms. For typical disorders, it is relatively easy to agree that dysfunction is present. However, for atypical disorders, there may be considerable debate about the presence and extent of dysfunction. Rational arguments can be brought to bear to help decide whether particular entities should be included in our nosologies, and, if so, what their boundaries should be. However, it is appropriate that there should be ongoing debate on diagnostic validity, clinical utility, and other relevant facts and values, for cases that are difficult to decide. The perspective here can be illustrated using many nosological debates within the anxiety disorders and the obsessive-compulsive and related disorders, including the question of delineating normal from abnormal anxiety, of deciding whether anxiety is psychiatric or medical, and the debate about the optimal meta-structure for anxiety disorders.

Toward the future of psychiatric diagnosis: the seven pillars of RDoC

BACKGROUND

Current diagnostic systems for mental disorders rely upon presenting signs and symptoms, with the result that current definitions do not adequately reflect relevant neurobiological and behavioral systems--impeding not only research on etiology and pathophysiology but also the development of new treatments.

DISCUSSION

The National Institute of Mental Health began the Research Domain Criteria (RDoC) project in 2009 to develop a research classification system for mental disorders based upon dimensions of neurobiology and observable behavior. RDoC supports research to explicate fundamental biobehavioral dimensions that cut across current heterogeneous disorder categories. We summarize the rationale, status and long-term goals of RDoC, outline challenges in developing a research classification system (such as construct validity and a suitable process for updating the framework) and discuss seven distinct differences in conception and emphasis from current psychiatric nosologies.

SUMMARY

Future diagnostic systems cannot reflect ongoing advances in genetics, neuroscience and cognitive science until a literature organized around these disciplines is available to inform the revision efforts. The goal of the RDoC project is to provide a framework for research to transform the approach to the nosology of mental disorders.

Biological indicators of suicide risk in youth with mood disorders: what do we know so far?

Suicidal behaviour in youth is a major public health concern worldwide, and youth in the early stages of a primary mood disorder are an identifiable high-risk population. Neurobiological research in youth at risk for suicidality has sought to investigate the most promising parameters from research in adults. The present paper provides an overview of the current findings of neurobiological research in children and adolescents with mood disorders and suicidality including genetic/epigenetic findings, neuro-hormonal and immunological investigations. Longitudinal research in high-risk youth is a powerful way to investigate the influences and their pathways in determining suicidal risk in the context of a developing mood disorder. In the meantime, there are clear clinical indicators of risk to help identify youth who would benefit from close surveillance and early intervention.

Diagnosis of infectious or inflammatory psychosyndromes

Before an outline of the process of diagnosis and differential diagnosis in infectious and/or inflammatory psy-chosyndromes is given, a more general overview onto the approach to organic psychosyndromes seems useful, because in both entities similar principles of causality conclusion are applied. Correlation does not demonstrate causality. Therefore the principles and consensus recommendations, and limitations of causal inference to categorize psychosyndromes as be-ing 'organic', is to be discussed in detail.

Could the underestimation of bipolarity obstruct the search for novel antidepressant drugs?

INTRODUCTION

Despite the clinical and social relevance of depression, and the availability of numerous antidepressants and non-pharmacological interventions, response rates remain unsatisfactory and novel therapeutic targets are being explored.

AREAS COVERED

This review starts with a brief overview of the evolution of the current antidepressant drug scenario and ends with a focus on the potential influence of the underestimation of bipolarity on the exploration of novel antidepressant drugs.

EXPERT OPINION

The field of antidepressant drug development has suffered from a relative decline recently and, with the exception of agomelatine, innovative non-monoaminergic antidepressants have yet to be developed. The need for more effective compounds is evident. Clinicians and researchers should pay greater attention to the impact of bipolarity in depression. The ultimate goal of this review is not to discourage the use of antidepressants but rather to encourage judicious prescriptions, and also to solicit a better collaboration between clinicians and preclinical researchers so that more reliable diagnostic criteria can be adopted.

Are Psychiatric Diagnoses an Obstacle for Research and Practice? Reliability, Validity and the Problem of Psychiatric Diagnoses. The Case of GAD

The present article focused on the problem of validity, reliability and specificity of psychiatric diagnoses.The authors moved by the concept of syndrome, defined by Sydenham in the 18th century as a constellation of several interrelated symptoms, showing a stable, characteristic structure and a peculiar prognosis, in order to analyse the peculiarity of the current psychiatric nosology. In our opinion, the current nosographic system based on DSM-IV criteria, prevents psychiatry from benefiting of the significant technological progress that has led the rest of medical sciences to important clinical achievements in the last 20 years. The case of Generalized Anxiety Disorder was taken as an example of a disease characterized by unstable diagnostic criteria, high rate of comorbidity and uncertain boundaries. An analysis of the data from the Sesto Fiorentino study was performed to investigate the presence of common mood and anxiety symptoms across the most represented DSM IV diagnoses, in order to evaluate the specificity of these symptoms.The results supported the hypothesis of a low specificity of these symptoms, suggesting the need for psychiatry to find new and more specific markers and instruments.

Kleefstra syndrome in three adult patients: further delineation of the behavioral and neurological phenotype shows aspects of a neurodegenerative course

Kleefstra syndrome (KS), previously known as the 9q subtelomeric deletion syndrome (9qSTDS) is caused by haploinsufficiency of the EHMT1 gene. Both a single mutation and 9q34 microdeletions encompassing the entire gene can be responsible for this syndrome which is characterized by intellectual disability, hypotonia, and typical dysmorphisms, and may be associated with congenital heart and/or renal defects and epilepsy. Its behavioral phenotype has recently been described and comprises particular sleep disturbances and apathy. In this report, the evolution of the behavioral profile of KS is outlined by the description of three female patients aged 19, 33, and 43 years, respectively. In two patients, the syndrome was caused by an intragenic mutation and in the third by a 9q34 microdeletion encompassing the EHMT1 gene. MRI scanning of the brain in the two eldest patients demonstrated multifocal subcortical signal abnormalities. In general, the severity of the behavioral and motor deficiencies increased over time and became apparent after adolescence. It is concluded that the "regressive" phenotype of KS seems to be associated with the EHMT1 gene in particular. In addition, the utility of uncritical use of a classificatory diagnostic approach is discussed in the context of the motor and motivational disturbances that are prominent in this syndrome.

Top-down or bottom-up: Contrasting perspectives on psychiatric diagnoses

Clinical psychiatry is confronted with the expanding knowledge of medical genetics. Most of the research into the genetic underpinnings of major mental disorders as described in the categorical taxonomies, however, did reveal linkage with a variety of chromosomes. This heterogeneity of results is most probably due to the assumption that the nosological categories as used in these studies are disease entities with clear boundaries. If the reverse way of looking, the so-called bottom-up approach, is applied, it becomes clear that genetic abnormalities are in most cases not associated with a single psychiatric disorder but with a certain probability to develop a variety of aspecific psychiatric symptoms. The adequacy of the categorical taxonomy, the so-called top-down approach, seems to be inversely related to the amount of empirical etiological data. This is illustrated by four rather prevalent genetic syndromes, fragile X syndrome, Prader-Willi syndrome, 22q11 deletion syndrome, and Noonan syndrome, as well as by some cases with rare chromosomal abnormalities. From these examples, it becomes clear that psychotic symptoms as well as mood, anxiety, and autistic features can be found in a great variety of different genetic syndromes. A psychiatric phenotype exists, but comprises, apart from the chance to present several psychiatric symptoms, all elements from developmental, neurocognitive, and physical characteristics.

The application of multiplexed assay systems for molecular diagnostics

For decades, the diagnosis of schizophrenia and other psychiatric disorders has relied on subjective assessments such as Diagnostic and Statistical Manual criteria. There is now increasing interest in the identification of altered molecular patterns in blood and other accessible body fluids that can be used to help identify, stratify, and monitor psychiatric patients. Since shorter periods of psychosis are associated with a better prognosis, an accurate molecular test may lead to early intervention and thereby improve patient outcomes. In addition, such a test would open up the possibility to stratify more accurately the disease and could represent a novel translational medicine tool, which is crucial for the discovery and development of more efficacious therapies.

What is a mental/psychiatric disorder? From DSM-IV to DSM-V

The distinction between normality and psychopathology has long been subject to debate. DSM-III and DSM-IV provided a definition of mental disorder to help clinicians address this distinction. As part of the process of developing DSM-V, researchers have reviewed the concept of mental disorder and emphasized the need for additional work in this area. Here we review the DSM-IV definition of mental disorder and propose some changes. The approach taken here arguably takes a middle course through some of the relevant conceptual debates. We agree with the view that no definition perfectly specifies precise boundaries for the concept of mental/psychiatric disorder, but in line with a view that the nomenclature can improve over time, we aim here for a more scientifically valid and more clinically useful definition.

Deconstructing major depression: a validation study of the DSM-IV symptomatic criteria

BACKGROUND

The DSM-IV symptomatic criteria for major depression (MD) derive primarily from clinical experience with modest empirical support.

METHOD

The sample studied included 1015 (518 males, 497 females) Caucasian twins from a population-based registry who met criteria for MD in the year prior to the interview. Logistic regression analyses were conducted to compare the associations of: (1) single symptomatic criterion, (2) two groups of criteria reflecting cognitive and neurovegetative symptoms, with a wide range of potential validators including demographic factors, risk for future episodes, risk of MD in the co-twin, characteristics of the depressive episode, the pattern of co-morbidity and personality traits.

RESULTS

The individual symptomatic criteria showed widely varying associations with the pattern of co-morbidity, personality traits, features of the depressive episode and demographic characteristics. When examined separately, these two criteria groups showed robust differences in their patterns of association, with the validators with the cognitive criteria generally producing stronger associations than the neurovegetative.

CONCLUSIONS

Among depressed individuals, individual DSM-IV symptomatic criteria differ substantially in their predictive relationship with a range of clinical validators. These results challenge the equivalence assumption for the symptomatic criteria for MD and suggest a more than expected degree of 'covert' heterogeneity among these criteria. Part of this heterogeneity is captured by the distinction between cognitive versus neurovegetative symptoms, with cognitive symptoms being more strongly associated with most clinically relevant characteristics. Detailed psychometric evaluation of DSM-IV criteria is overdue.

Does “Psychological Dysfunction” Mean Anything? A Critical Essay on Pathology Versus Agency

Any effort to discuss or study psychopathology (by any name) must decide how to distinguish between psychopathology and narratively comprehensible reactions to adverse circumstances of life. A pathology framework, which views the distressed individual as acted on by impersonal forces, is incompatible with an agential framework, which views the individual as the protagonist in a unique story. Although the Diagnostic and Statistical Manual of Mental Disorders ( DSM) recognizes this issue, it addresses it by postulating that “primary mental disorder” results from a “psychological dysfunction” and non—culturally sanctioned reactions to life events indicate mental disorder. In this essay, the authors examine whether the concept of “psychological dysfunction” can withstand an analogy to that of biological dysfunction. They also examine the DSM’s view that “culture” has already prepared an official evaluation of any reaction to the vicissitudes of life. They conclude that the DSM has failed to convincingly distinguish between psychopathology and reactions to life’s vicissitudes. They suggest that the DSM’s insistence on separating people’s feelings and actions from their own unique circumstances and context amounts to a moral, not scientific enterprise. The study of how people fare in living should abandon the concept of mental disorder and related terms.

Two models of suicide

Objective: The aim of this paper is to present two models of separate but related aspects of suicide, developed with a view to improving understanding and management of this behaviour. Conclusions: First, the predicament model of suicide posits that all suicide represents an escape from a predicament and associated distress. Predicaments are composed of either external (environmental) or internal (mental disorders) factors, or both. Suicide occurs when a threshold is exceeded on a suicide risk ladder, and the degree of movement toward the threshold in response to a particular stressor depends on a range of factors. Second, the suicide pathways model integrates medical and sociological concepts, with distress as the central component, and three run-offs: mental disorder, medicalized and a non-mental disorder (egoistic/anomic; reaction) suicide.

Harmonisation of ICD-11 and DSM-V: opportunities and challenges

BACKGROUND

Differences in the ICD-10 and DSM-IV definitions for the same disorder impede international communication and research efforts. The forthcoming parallel development of DSM-V and ICD-11 offers an opportunity to harmonise the two classifications.

AIMS

This paper aims to facilitate the harmonisation process by identifying diagnostic differences between the two systems.

METHOD

DSM-IV-TR criteria sets and the ICD-10 Diagnostic Criteria for Research were compared and categorised into those with identical definitions, those with conceptually based differences and those in which differences are not conceptually based and appear to be unintentional.

RESULTS

Of the 176 criteria sets in both systems, only one, transient tic disorder, is identical. Twenty-one per cent had conceptually based differences and 78% had non-conceptually based differences.

CONCLUSIONS

Harmonisation of criteria sets, especially those with non-conceptually based differences, should be prioritised in the DSM-V and ICD-11 development process. Prior experience with the DSM-IV and ICD-10 harmonisation effort suggests that for the process to be successful steps should be taken as early as possible.

Nosologomania: DSM & Karl Jaspers' critique of Kraepelin

Emil Kraepelin's nosology has been reinvented, for better or worse. In the United States, the rise of the neo-Kraepelinian nosology of DSM-III resuscitated Kraepelin's work but also differed from many of his ideas, especially his overtly biological ontology. This neo-Kraepelinian system has led to concerns regarding overdiagnosis of psychiatric syndromes ("nosologomania") and perhaps scientifically ill-founded psychopharmacological treatment for presumed neo-Kraepelinian syndromes. In the early 20th century, Karl Jaspers provided unique insights into Kraepelin's work, and Jaspers even proposed an alternate nosology which, though influenced by Kraepelin, also introduced the concept of ideal types. Jaspers' critique of Kraepelin may help us reformulate our current neo-Kraepelinian nosology for the better.

A stubborn behaviour: The failure of antidepressants to reduce suicide rates

Over the past decades the rate of completed suicide has remained quite stable, that of suicide attempts even seems to have increased (to the extent it has been studied in defined regions). These are puzzling observations, since depression is the major suicide precursor and since antidepressants over the years have been increasingly used in the treatment of depression. These observations have not attracted sufficient attention, possibly because they do not accord with consensus opinions about depression treatment in psychiatry today. In this paper a number of possible explanations are discussed. They not only deserve but are definitely in need of systematic investigation.

Does the dexamethasone suppression test reliably discriminate between psychotic and nonpsychotic major depression?: an exploratory analysis of potential confounds

Previous research has shown that psychotic major depression (PMD) is often associated with higher rates of nonsuppression on the dexamethasone suppression test (DST) compared with nonpsychotic major depression (NMD), suggesting the potential importance of cortisol hypersecretion in the psychotic subtype of the disorder. However, these patient groups also are known to differ from one another on a variety of other clinical variables, and there are numerous factors independent of diagnostic status known to affect the DST. Thus, we investigated possible confounds that could help account for the apparent DST abnormalities in PMD sometimes reported in past research. Hospitalized patients with PMD (n = 11) and NMD (n = 58) were compared on the DST and other clinical variables. As expected, PMD patients showed significantly higher rates of DST nonsuppression (55% vs. 24%; p = 0.04). However, PMD patients also had significantly higher levels of anxiety severity (p = 0.01). The higher rates of nonsuppression in the PMD group were attenuated when these patients were compared with a subsample of NMD patients matched on anxiety severity (55% vs. 55%). Implications for future research on biological markers of PMD are discussed.

Suicide and Western culture

OBJECTIVE

The aim of this paper is to examine the cultural roots and transmission of Western suicide and suicidal behaviour.

METHOD

We explored a period of antiquity (mythical Greece-61 CE) and selected accounts of 10 prominent suicides. The precipitating circumstances were tabulated and an assessment made of the most likely attendant emotions. The same process was followed for a recent period (1994-2008), from which 10 suicides were identified. The precipitating circumstances and the attendant emotions were compared. These circumstances and emotions were then compared to statements commonly encountered in clinical practice from people demonstrating suicidal behaviour. Finally, we looked for evidence that these stories (and the response models) had entered Western culture.

RESULTS

Precipitating circumstances, loss of a loved one, actual or imminent execution or imprisonment, other losses and public disgrace, and the negative emotions of shame, guilt, fear, anger, grief and sorrow were common to both historical periods. These circumstances and emotions are similar to those commonly expressed by people who have demonstrated suicidal behaviour. There was a clear record (literature, visual arts) of these stories forming part of our cultural heritage.

CONCLUSION

Models of maladaptive responses to certain adverse circumstances are part of Western culture. Suicide as a response to certain circumstances and negative emotions can be traced back more than 2000 years. Cultural change will be necessary to minimize suicide.

Suicide and reputation damage

AIM

This paper uses the public record to explore the relationship between reputation damage and suicide.

METHOD

The public record of the last 20 years was examined for examples of individuals without evidence of mental disorder who suffered actual or threatened reputation damage and suicided shortly thereafter.

RESULTS

Fifteen individual cases were identified; 18 additional cases, less comprehensively detailed, were mentioned in reports of The Wood Royal Commission and Operation Auxin. All cases were male. Of the 15 individual cases, the average age was 55 years, with a range of 40 to 76 years. The available details of the 18 additional cases were consistent with these findings.

CONCLUSION

Middle-aged males without clear evidence of mental disorder, who suffer actual or threatened reputation damage, may be at increased risk of suicide. Naming and shaming needs to be conducted with caution.

Kraepelin, biological psychiatry, and beyond

One of Kraepelin's major contributions has been the introduction of the nosological principle in psychiatry. Mental pathology, he presumed, is subdividable in discrete entities each based on a specific pathophysiology. Kraepelin provided the diagnostic process in psychiatry with a solid infrastructure. It has been used in biological psychiatric research until this very day. Searching for the biological determinants of categorical entities has been its major goal. The yield of those efforts has been meagre, in that none of the biological findings reported so far seemed to be specific for a particular nosological entity. The question thus arises: is nosology the right model to classify mental disorders. It is suggested that it is not. The disease categories presently delineated are utterly heterogeneous, and therefore cannot be expected to have a well-defined pathophysiology. The nosological system cannot be rejected (as yet), but it has to be upgraded by incorporation of a strong dynamic-functional component. The functional components should become the focus of biological psychiatric research. The question whether an alternative classificatory model, such as the reaction form model, has to be preferred in biological psychiatry should become a matter of serious discussion.

[A reply to Perron regarding the Inserm report "Psychotherapy. The assessment of three approaches"]

The publication of the report by experts from Inserm (France) about the efficacy of psychotherapies (2004) has raised many criticisms, mainly from psychoanalysts. The criticisms of Perron, Brusset, Baruch and Emmanuelli, professors of psychology, published on Internet (www.techniques-psychotherapiques.org) in 2004, attack the methodology that they say introduced numerous biases in favour of cognitive behaviour therapies (CBT) compared to psychodynamic psychotherapies (PP). In order to argue against these criticisms, I have selected ten points raised by this group that seemed to represent the essence of their criticisms. Perron et al. say that the Inserm report is neither objective nor scientific; although this report cannot be fully objective due to its narrative nature, it is, nevertheless, based on empirical studies that satisfy scientific criteria for quality and that are well documented. * Perron et al. suggest that the Inserm report contains numerous biases; it is not possible to avoid all statistical biases so this criticism is an attack on accepted scientific methodology. * Perron et al. do not provide any evidence in favour of their criticism that the meta-analyses included in the report have accumulated biases due to prejudices common among psychotherapy researchers; even if researchers were all subject to therapy allegiance, this would not lead, systematically, to biases in favour of CBT. * Perron et al. state that meta-analyses automatically reinforce biases from randomised controlled trials (RCTs), whereas I argue that biases in RCTs are not systematically accumulated, and that the sensitivity of meta-analyses to doubtful RCTs can be tested by comparing results from analyses with and without these studies. * They also say that, in RCTs, the comparability between groups cannot be complete, however, the aim is not identity, and the comparability can be empirically tested after randomisation. * They also declare that the use of DSM automatically favours CBT, however, despite the fact that DSM is unsatisfactory even for biological psychiatrists and CBT therapists; no unanimously accepted alternative system has yet been identified. * Perron et al. say that the use of quantitative assessment of the psychotherapy outcome favours CBT because of an epistemological split between descriptive-nosological and functional-psychodynamic approaches. However such approaches are not clearly exclusive from each other, and a reduction of psychiatry into only two approaches does not fit with the observed variety of etiological hypotheses. * The statement that the functional-psychodynamic approach is contradictory with quantitative assessment of outcome is challenged by the fact that numerous outcome instruments for psychodynamic assessment exist. Furthermore, I have examined the size of the differences between CBT and PP, by selecting studies and meta-analyses that report the direct comparison of these therapies, but this does not provide evidence of major differences. Therefore, the existence of major bias in favour of CBT, due to either the use of DSM, symptom rating scales or other causes, is not supported by these facts. * The accusation that studies included in the Inserm report did not assess patients from control groups at endpoint has being found to be untrue. * The argument that the various effect size statistics used in the meta-analyses give rise to major bias is very unlikely. However, the authors overlooked the more important problem of pooling different outcome measures. * The allegation that a bias in favour of CBT was induced because there were more studies conducted with CBT than with PP is false, because the number of studies does not influence the effect-sizes. The Inserm report does, however, because of the presentation of results by DSM disorder and emphasis on absolute efficacy studies, find more positive results for CBT than for PP compared with no treatment. In conclusion, Perron's et al. criticisms are, in fact, against the application of scientific methodology to the assessment of the efficacy of psychotherapies as a whole. Nevertheless, the Inserm report has some weaknesses; the low number of studies of PP, the lack of direct comparisons between CBT and PP, the fact that multiple efficacy criteria were not taken into consideration, and the problem of comorbidities which was insufficiently taken into consideration.