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Goldstein Ferber S, Weller A, Hayes AM, Vannorsdall TD, Ajlouni Y, Qudah M, Zalsman G, Shoval G, Jannini TB, Fiedler R, Chen LX, Shayani DR, Kachuki Dory E, Stolowicz-Melman D, Evans C, Trow M, Di Lorenzo G, Rossi R. International study of the Complex Stress Reaction Syndrome: Implications for transdiagnostic clinical practice. World J Psychiatry 2023; 13:803-815. [PMID: 38058684 PMCID: PMC10696285 DOI: 10.5498/wjp.v13.i10.803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/25/2023] [Accepted: 09/11/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND The debate regarding diagnostic classification systems in psychiatry (categorial vs dimensional systems) has essential implications for the diagnosis, prevention and treatment of stress reactions. We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries, and termed it the Complex Stress Reaction Syndrome (CSRS). AIM To investigate CSRS, Type A (psychiatric symptoms, spanning anxiety, depression, stress symptoms, and post-traumatic stress disorder (PTSD)), with or without long-coronavirus disease (COVID) residuals (CSRS, Type B, neuropsychiatric symptoms spanning cognitive deficits and fatigue, excluding systemic symptoms). Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population (Type A) or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals (Type B). METHODS 977 individuals in four continents (North America, Europe, Australia and the Middle East) completed the online study questionnaire in six languages using the Qualtrics platform. The study was managed by six teams in six countries that promoted the study on social media. The questionnaire assessed anxiety, depression, stress symptoms and PTSD (CSRS, Type A), cognitive deficits and fatigue (CSRS, Type B). The data were analyzed using Proportion Analyses, Multivariate Analysis of Co-Variance (MANCOVA), linear regression analyses and validated clinical cutoff points. RESULTS The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety, depression, stress symptoms, and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents, age groups, and gender. This supports the transdiagnostic argument embedded in the CSRS (Type A). The same pattern of results was found in infected/recovered individuals. The prevalence of the 4 psychiatric symptoms combination was significantly greater than that of 5 and 6 symptoms, when adding cognitive deficits and fatigue, respectively. MANCOVA showed a significant three-way interaction (age × gender × continent). Further analyses showed that the sources of this three-way interaction were threefold relating to two sub-populations at-risk: (1) Individuals that self-identified as non-binary gender scored significantly higher on all 4 psychiatric symptoms of the CSRS, Type A at young age groups (< 50 years old) in North America compared to (self-identified) women and men located in the 4 continents studied, and to other ages across the adult life span; and (2) This pattern of results (CSRS, Type A) was found also in women at young ages (< 40 years old) in North America who scored higher compared to men and women in other continents and other ages. Linear regression analyses confirmed the MANCOVA results. CONCLUSION These results show a combined mental health risk factor related to stress reactivity, suggesting that the CSRS is sensitive to populations at risk and may be applied to future identification of other vulnerable sub-populations. It also supports the transdiagnostic approach for more accurate prevention and treatment. Time will tell if such transdiagnostic syndromes will be part of the discussions on the next revisions of the traditional classification systems or whether the crisis in psychiatry further evolves.
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Affiliation(s)
- Sari Goldstein Ferber
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE 19716, United States
- Department of Psychology, Bar Ilan University, Ramat Gan 5290002, Israel
| | - Aron Weller
- Department of Psychology and The Gonda Brain Research Center, Bar Ilan University, Ramat Gan 5290002, Israel
| | - Adele M Hayes
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE 19716, United States
| | - Tracy D Vannorsdall
- Department of Psychiatry and Behavioral Sciences, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | | | - Mo'nes Qudah
- Jordan Health Aid-International, Amman 1234, Jordan
| | - Gil Zalsman
- Geha Mental Health Center, Petah Tiqva, Israel and Faculty of Medicine, Tel Aviv University, Ramat Aviv 6997801, Israel
- Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, NY 10032, United States
| | - Gal Shoval
- Geha Mental Health Center, Petah Tiqva, Israel and Faculty of Medicine, Tel Aviv University, Ramat Aviv 6997801, Israel
- Department of Neuroscience, Princeton University, Princeton, NJ 08544, United States
| | | | - Racquel Fiedler
- Department of Psychology and The Gonda Brain Research Center, Bar Ilan University, Ramat Gan 5290002, Israel
| | - Lily X Chen
- UNSW School of Psychology, UNSW Sydney, Sydney 2052, Australia
| | - Danielle R Shayani
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE 19716, United States
| | - Elin Kachuki Dory
- Department of Psychology and The Gonda Brain Research Center, Bar Ilan University, Ramat Gan 5290002, Israel
| | - Dana Stolowicz-Melman
- Department of Psychology and The Gonda Brain Research Center, Bar Ilan University, Ramat Gan 5290002, Israel
| | - Connor Evans
- Department of Biology, Pacific University, Forest Grove, OR 97116, United States
| | - Megan Trow
- Oregon Chapter of Fulbright Association, Oregon, OR 97045, United States
| | - Giorgio Di Lorenzo
- Department of Systems Medicine, Tor Vergata University of Rome, Rome 00179, Italy
- IRCCS, Fondazione Santa Lucia, Rome 00179, Italy
| | - Rodolfo Rossi
- Department of Systems Medicine, Tor Vergata University of Rome, Rome 00133, Italy
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Goldstein Ferber S, Shoval G, Weller A, Zalsman G. Not one thing at a time: When concomitant multiple stressors produce a transdiagnostic clinical picture. World J Psychiatry 2023; 13:402-408. [PMID: 37547732 PMCID: PMC10401502 DOI: 10.5498/wjp.v13.i7.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/19/2023] [Indexed: 07/17/2023] Open
Abstract
A condition of exposure to multiple stressors resulting in a mixed clinical picture spanning conventional categories without meeting any of them in full, encompasses a risk for a list of comorbidities preventing appropriate prevention and treatment. New transformative transdiagnostic approaches suggest changes spanning conventional categories. They base their systems of classification on biomarkers as well as on brain structural and functional dysregulation as associated with behavioral and emotional symptoms. These new approaches received critiques for not being specific enough and for suggesting a few biomarkers for psychopathology as a whole. Therefore, they put the value of differential diagnosis at risk of avoiding appropriate derived prevention and treatment. Multiplicity of stressors has been considered mostly during and following catastrophes, without considering the resulting mixed clinical picture and life event concomitant stressors. We herewith suggest a new category within the conventional classification systems: The Complex Stress Reaction Syndrome, for a condition of multiplicity of stressors, which showed a mixed clinical picture for daily life in the post coronavirus disease 2019 era, in the general population. We argue that this condition may be relevant to daily, regular life, across the lifespan, and beyond conditions of catastrophes. We further argue that this condition may worsen without professional care and it may develop into a severe mental health disorder, more costly to health systems and the suffering individuals. Means for derived prevention and treatment are discussed.
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Affiliation(s)
- Sari Goldstein Ferber
- Department of Psychology and Brain Sciences, University of Delaware, Newark, DE 19716, United States
- Psychology and Gonda Brain Research Center, Bar Ilan University, Ramat Gan 5317000, Israel
| | - Gal Shoval
- Department of Neuroscience, Princeton University, New Jersey, NJ 08544, United States
- Geha Mental Health Center, Petah Tiqva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 77096, Israel
| | - Aron Weller
- Psychology and Gonda Brain Research Center, Bar Ilan University, Ramat Gan 5317000, Israel
| | - Gil Zalsman
- Geha Mental Health Center, Petah Tiqva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 77096, Israel
- Department of Psychiatry, Columbia University, New York, NY 10032, United States
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Reiss AB, Greene C, Dayaramani C, Rauchman SH, Stecker MM, De Leon J, Pinkhasov A. Long COVID, the Brain, Nerves, and Cognitive Function. Neurol Int 2023; 15:821-841. [PMID: 37489358 PMCID: PMC10366776 DOI: 10.3390/neurolint15030052] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023] Open
Abstract
SARS-CoV-2, a single-stranded RNA coronavirus, causes an illness known as coronavirus disease 2019 (COVID-19). Long-term complications are an increasing issue in patients who have been infected with COVID-19 and may be a result of viral-associated systemic and central nervous system inflammation or may arise from a virus-induced hypercoagulable state. COVID-19 may incite changes in brain function with a wide range of lingering symptoms. Patients often experience fatigue and may note brain fog, sensorimotor symptoms, and sleep disturbances. Prolonged neurological and neuropsychiatric symptoms are prevalent and can interfere substantially in everyday life, leading to a massive public health concern. The mechanistic pathways by which SARS-CoV-2 infection causes neurological sequelae are an important subject of ongoing research. Inflammation- induced blood-brain barrier permeability or viral neuro-invasion and direct nerve damage may be involved. Though the mechanisms are uncertain, the resulting symptoms have been documented from numerous patient reports and studies. This review examines the constellation and spectrum of nervous system symptoms seen in long COVID and incorporates information on the prevalence of these symptoms, contributing factors, and typical course. Although treatment options are generally lacking, potential therapeutic approaches for alleviating symptoms and improving quality of life are explored.
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Affiliation(s)
- Allison B Reiss
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Long Island, NY 11501, USA
| | - Caitriona Greene
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Long Island, NY 11501, USA
| | - Christopher Dayaramani
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Long Island, NY 11501, USA
| | | | | | - Joshua De Leon
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Long Island, NY 11501, USA
| | - Aaron Pinkhasov
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Long Island, NY 11501, USA
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Goldstein Ferber S, Shoval G, Rossi R, Trezza V, Di Lorenzo G, Zalsman G, Weller A, Mann JJ. Transdiagnostic considerations of mental health for the post-COVID era: Lessons from the first surge of the pandemic. World J Clin Cases 2023; 11:809-820. [PMID: 36818632 PMCID: PMC9928692 DOI: 10.12998/wjcc.v11.i4.809] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/28/2022] [Accepted: 01/16/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The Coronavirus disease 19 (COVID-19)-related psychiatric burden partly results from prolonged social stress world-wide. Studies have examined the psychiatric impact of COVID-19 on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) and International Classification of Diseases 11th Revision (ICD-11) categories, implicating multiple diagnoses, complicating clinical management.
AIM To verify whether COVID-19-related psychopathology spans multiple DSM-5 and ICD-11 diagnoses, but not in a random pattern. Consequently, empirical analysis of the multiple associated symptoms will better describe COVID-19-related psychopathology.
METHODS We conducted a bi-national study during the first surge of the pandemic: an Italian sample (n = 21217, studied March-April 2020); and three representative longitudinal samples from Israel (n = 1276, 1189, and 1432 respectively, studied May-July 2020). Data in Italy were collected by a national internet-based survey with an initially approached sample of about one million persons and in Israel by the Israeli Central Bureau of Statistics using probability-based national representative sampling. Data analysis focused on the frequency and patterns of reported multiple mental health symptoms.
RESULTS Combinations with all symptoms were more prevalent than combinations with fewer symptoms, with no majorities-minorities differences in both countries, demonstrating the generalizability of the transdiagnostic pattern of mental health issues in both nations. A history of previous mental disorder (Italian study) and an increase in symptom prevalence over time (Israel study) were associated with an increased number of symptoms. Conclusions: Based on finding correlated symptom diversity spanning conventional diagnostic categories, we suggest that the pattern of mental health issues associated with the COVID-19 pandemic is transdiagnostic.
CONCLUSION The findings have implications for improving prevention and treatment of COVID-19 related psychopathology and for post-pandemic times in conditions resulting from multiplicity of stressors with mixed symptomatology in the clinical picture.
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Affiliation(s)
| | - Gal Shoval
- Department of Neuroscience, Princeton University, Princeton NJ 08544, United States
- Geha Mental Health Center, Petah Tiqva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 77096, Israel
| | - Rodolfo Rossi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome 00133, Italy
| | - Viviana Trezza
- Department of Science, Rome Tre University, Rome 00154, Italy
| | - Giorgio Di Lorenzo
- Department of Psychiatry, Rome University Tor Vergata, Rome 00179, Italy and IRCCS—Fondazione Santa Lucia, Rome 00179, Italy
| | - Gil Zalsman
- Geha Mental Health Center, Petah Tiqva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 77096, Israel
- Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, NY, 10032, United States
| | - Aron Weller
- Department of Psychology, Bar Ilan University, Ramat Gan 5290002, Israel
| | - J John Mann
- Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, NY, 10032, United States
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