Refinement of diagnosis and disease classification in psychiatry

Bridging cognitive, phenomenological and psychodynamic approaches to eating disorders

Cognitive, psychodynamic, and phenomenological scholars converged their attention on abnormal bodily phenomena as the core psychopathological feature of eating disorders (EDs). While cognitive approaches focus their attention on a need for "objective" (i.e., observable, measurable) variables (including behaviours and distorted cognitions), the phenomenological exploration typically targets descriptions of persons' lived experience. According to a new emerging phenomenological perspective, the classic behavioural and cognitive symptoms of EDs should be considered as epiphenomena of a deeper core represented by a disorder of the embodiment. The cognitive-behavioural model is the most studied and, up till now, clinically efficacious treatment for EDs. However, as any coherent and scientifically grounded model, it presents some limitations in its application. Numerous patients report a chronic course, do not respond to treatment and develop a personality structure based on pathological eating behaviours, since "being anorexic" becomes a new identity for the person. Furthermore, the etiopathogenetic trajectory of EDs influences the treatment response: for example, patients reporting childhood abuse or maltreatment respond differently to cognitive-behavioural therapy. To obtain a deeper comprehension of these disorders, it seems important to shift attention from abnormal eating behaviours to more complex and subtle psycho(patho)logical features, especially experiential ones. This characterisation represents the unavoidable premise for the identification of new therapeutic targets and consequently for an improvement of the outcome of these severe disorders. Thus, the present review aims to provide an integrated view of cognitive, psychodynamic, and phenomenological perspectives on EDs, suggesting new therapeutic targets and intervention strategies based on this integrated model. Level of Evidence: Level V.Level of evidence Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Looking into the genetic bases of OCD dimensions: a pilot genome-wide association study

The multidimensional nature of obsessive-compulsive disorder (OCD) has been consistently reported. Clinical and biological characteristics have been associated with OCD dimensions in different ways. Studies suggest the existence of specific genetic bases for the different OCD dimensions. In this study, we analyze the genomic markers, genes, gene ontology and biological pathways associated with the presence of aggressive/checking, symmetry/order, contamination/cleaning, hoarding, and sexual/religious symptoms, as assessed via the Dimensional Yale-Brown Obsessive Compulsive Scale (DY-BOCS) in 399 probands. Logistic regression analyses were performed at the single-nucleotide polymorphism (SNP) level. Gene-based and enrichment analyses were carried out for common (SNPs) and rare variants. No SNP was associated with any dimension at a genome-wide level (p < 5 × 10^-8). Gene-based analyses showed one gene to be associated with hoarding (SETD3, p = 1.89 × 10^-08); a gene highly expressed in the brain and which plays a role in apoptotic processes and transcriptomic changes, and another gene associated with aggressive symptoms (CPE; p = 4.42 × 10^-6), which is involved in neurotrophic functions and the synthesis of peptide hormones and neurotransmitters. Different pathways or biological processes were represented by genes associated with aggressive (zinc ion response and lipid metabolism), order (lipid metabolism), sexual/religious (G protein-mediated processes) and hoarding (metabolic processes and anion transport) symptoms after FDR correction; while no pathway was associated with contamination. Specific genomic bases were found for each dimension assessed, especially in the enrichment analyses. Further research with larger samples and different techniques, such as next-generation sequencing, are needed to better understand the differential genetics of OCD dimensions.

Comorbidity of Physical and Anxiety Symptoms in Adolescent: Functional Impairment, Self-Rated Health and Subjective Well-Being

Physical disorders and anxiety are frequently comorbid. This study investigates the characteristics of physical disorders, self-rated heath, subjective well-being and anxiety in adolescents. Data were drawn from the Saving and Empowering Young Lives in Europe cohort study. From 11 countries 11,230 adolescents, aged 14–16 years were included. Zung Self-Rating Anxiety Scale (SAS), WHO-5 Well-Being Index and five questions prepared for this study to evaluate physical illnesses and self-rated heath were administered. Anxiety levels were significantly higher in adolescents who reported having physical disability (p < 0.001, Cohen’s d = 0.40), suffering from chronic illnesses (p < 0.001, Cohen’s d = 0.40), impairments associated to health conditions (p < 0.001, Cohen’s d = 0.61), or reported poor to very poor self-rated health (p < 0.001, Cohen’s d = 1.11). Mediational analyses revealed no direct effect of having a chronic illness/physical disability on subjective well-being, but the indirect effects through higher levels of anxiety were significant. Functional impairment related to health conditions was both directly and indirectly (through higher levels of anxiety) associated with lower well-being. The co-occurrence of anxiety and physical disorders may confer a greater level of disability and lower levels of subjective well-being. Clinicians have to screen anxiety, even in a subthreshold level in patients with choric physical illness or with medically unexplained physical symptoms.

Attention-deficit hyperactivity disorder and nonsuicidal self-injury in a clinical sample of adolescents: the role of comorbidities and gender

BACKGROUND

The aim of the present study was to investigate the possible association between attention-deficit hyperactivity disorder (ADHD) and non-suicidal self-injury (NSSI) with special focus on the role of comorbidities and gender in a clinical sample of adolescents with both a dimensional and a categorical approach to psychopathology.

METHODS

Using a structured interview, the Mini International Neuropsychiatric Interview Kid and a self-rated questionnaire, the Deliberate Self-Harm Inventory, the authors examined 202 inpatient adolescents (aged: 13-18 years) in the Vadaskert Child and Adolescent Psychiatric Hospital and Outpatient Clinic, Budapest, Hungary. Descriptive statistics, Mann-Whitney U test, chi-square test and mediator model were used.

RESULTS

Fifty-two adolescents met full criteria for ADHD and a further 77 showed symptoms of ADHD at the subthreshold level. From the 52 adolescents diagnosed with ADHD, 35 (67.30%) had NSSI, of whom there were significantly more girls than boys, boys: n = 10 (28.60%), girls: n = 25 (71.40%) ((χ²(1) = 10.643 p < .001 ϕ = .452). Multiple mediation analyses resulted in a moderated mediation model in which the relationship between symptoms of ADHD and the prevalence of current NSSI was fully mediated by the symptoms of comorbid conditions in both sex. Significant mediators were the symptoms of affective and psychotic disorders and suicidality in both sexes and the symptoms of alcohol abuse/dependence disorders in girls.

CONCLUSIONS

ADHD symptoms are associated with an increased risk of NSSI in adolescents, especially in the case of girls. Our findings suggest that clinicians should routinely screen for the symptoms of ADHD and comorbidity, with a special focus on the symptoms of affective disorders and alcohol abuse/dependence psychotic symptoms to prevent NSSI.

Suicidal Risk, Psychopathology, and Quality of Life in a Clinical Population of Adolescents

BACKGROUND

According to literature data, psychopathology is associated with both quality of life (QoL) and suicidal risk in adolescents, but the literature does not fully support a direct association between psychopathology and suicidal thoughts and behaviors. The aim of this study was to investigate the possible mediational role of QoL in the relationship between psychopathology and level of suicidal risk in a clinical sample of adolescents.

METHOD

The authors examined a clinical population of 134 adolescents, aged 13-18 years. Suicidal risk-having any current suicidal ideations and/or previous suicide attempt-was assessed by the Mini International Neuropsychiatric Interview. QoL was evaluated by the adolescent self-rated versions of "Das Intervertar zur Erfassung der Lebensqualität Kindern und Jugendlichen" (ILK: Measure of Quality of Life for Children and Adolescents) and psychopathology was measured by adolescent self-rated versions of the Strengths and Difficulties Questionnaire (SDQ). A mediational model, in which QoL mediated the relationship between psychopathology and suicidal risk controlling for gender and age, was tested by means of regression analyses.

RESULTS

Gender and age were both associated with suicidal risk. Self-reported QoL significantly mediated the relationships between emotional problems (=1.846; 95% BCa CI: 0.731-2.577), as well as peer problems (=0.883; 95% BCa CI: 0.055-1.561) and suicidal risk: more emotional and peer problems were associated with lower QoL, which in turn was related to higher level of suicidal risk.

CONCLUSION

Based on this study, which aims to make further steps in suicidal prevention, our findings suggest that clinicians should routinely screen the QoL of their patients, especially in adolescents with emotional and peer problems. Furthermore, it is important to focus intervention and treatment efforts on improving the QoL of adolescents with emotional and peer problems.

Quantifying dimensional severity of obsessive-compulsive disorder for neurobiological research

Current research to explore genetic susceptibility factors in obsessive-compulsive disorder (OCD) has resulted in the tentative identification of a small number of genes. However, findings have not been readily replicated. It is now broadly accepted that a major limitation to this work is the heterogeneous nature of this disorder, and that an approach incorporating OCD symptom dimensions in a quantitative manner may be more successful in identifying both common as well as dimension-specific vulnerability genetic factors. As most existing genetic datasets did not collect specific dimensional severity ratings, a specific method to reliably extract dimensional ratings from the most widely used severity rating scale, the Yale-Brown Obsessive Compulsive Scale (YBOCS), for OCD is needed. This project aims to develop and validate a novel algorithm to extrapolate specific dimensional symptom severity ratings in OCD from the existing YBOCS for use in genetics and other neurobiological research. To accomplish this goal, we used a large data set comprising adult subjects from three independent sites: the Brazilian OCD Consortium, the Sunnybrook Health Sciences Centre in Toronto, Canada and the Hospital of Bellvitge, in Barcelona, Spain. A multinomial logistic regression was proposed to model and predict the quantitative phenotype [i.e., the severity of each of the five homogeneous symptom dimensions of the Dimensional YBOCS (DYBOCS)] in subjects who have only YBOCS (categorical) data. YBOCS and DYBOCS data obtained from 1183 subjects were used to build the model, which was tested with the leave-one-out cross-validation method. The model's goodness of fit, accepting a deviation of up to three points in the predicted DYBOCS score, varied from 78% (symmetry/order) to 84% (cleaning/contamination and hoarding dimensions). These results suggest that this algorithm may be a valuable tool for extracting dimensional phenotypic data for neurobiological studies in OCD.

Mixed features in bipolar disorder

Mixed affective states, defined as the coexistence of depressive and manic symptoms, are complex presentations of manic-depressive illness that represent a challenge for clinicians at the levels of diagnosis, classification, and pharmacological treatment. The evidence shows that patients with bipolar disorder who have manic/hypomanic or depressive episodes with mixed features tend to have a more severe form of bipolar disorder along with a worse course of illness and higher rates of comorbid conditions than those with non-mixed presentations. In the updated Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), the definition of "mixed episode" has been removed, and subthreshold nonoverlapping symptoms of the opposite pole are captured using a "with mixed features" specifier applied to manic, hypomanic, and major depressive episodes. However, the list of symptoms proposed in the DSM-5 specifier has been widely criticized, because it includes typical manic symptoms (such as elevated mood and grandiosity) that are rare among patients with mixed depression, while excluding symptoms (such as irritability, psychomotor agitation, and distractibility) that are frequently reported in these patients. With the new classification, mixed depressive episodes are three times more common in bipolar II compared with unipolar depression, which partly contributes to the increased risk of suicide observed in bipolar depression compared to unipolar depression. Therefore, a specific diagnostic category would imply an increased diagnostic sensitivity, would help to foster early identification of symptoms and ensure specific treatment, as well as play a role in suicide prevention in this population.

Reliability and validity of the Symptoms of Depression Questionnaire (SDQ)

Current measures for major depressive disorder focus primarily on the assessment of depressive symptoms, while often omitting other common features. However, the presence of comorbid features in the anxiety spectrum influences outcome and may effect treatment. More comprehensive measures of depression are needed that include the assessment of symptoms in the anxiety-depression spectrum. This study examines the reliability and validity of the Symptoms of Depression Questionnaire (SDQ), which assesses irritability, anger attacks, and anxiety symptoms together with the commonly considered symptoms of depression. Analysis of the factor structure of the SDQ identified 5 subscales, including one in the anxiety-depression spectrum, with adequate internal consistency and concurrent validity. The SDQ may be a valuable new tool to better characterize depression and identify and administer more targeted interventions.

Understanding psychopathology in migrants: a mixed categorical-dimensional approach

BACKGROUND

Literature on mental disorders in migrants is constantly increasing. Only a few studies describe psychopathological dimensions in migrants over their nosographic diagnoses; however, there is a growing literature about the greater utility of a categorical-dimensional approach, rather than a solely categorical approach, in the understanding of mental disorders. The aim of this paper is to describe the phenomenology of mental disorders in migrants referred to the Transcultural Psychiatric Team of Bologna (BoTPT), by analysing the psychopathological dimensions that underlie their clinical diagnoses.

METHODS

We recruited all migrants who attended the BoTPT between May 1999 and July 2009. The psychopathological assessment was conducted with the Association for Methodology and Documentation in Psychiatry (AMDP) and clinical diagnoses were formulated according to ICD-10. We proceeded through a two-step analysis: (1) comparing the prevalence rates of psychopathological symptoms across diagnoses; then (2) conducting a factor analysis to assess how those symptoms configure psychopathological dimensions and how these dimensions underlie clinical diagnoses.

RESULTS

As expected, we found significant associations between diagnoses and the prevalence of their core psychopathological symptoms. Factor analysis revealed a strong polymorphism of the psychopathological presentation of mental disorders and unexpectedly showed that in each diagnostic cluster, the first extracted factor was not composed of core symptoms.

CONCLUSIONS

A mixed categorical-dimensional approach seems to improve the description of the psychopathology among migrants, as it adds relevant information regarding psychopathological dimensions useful to the understanding of the peculiar clinical expressivity of our patients.

Attention-deficit hyperactivity disorder and suicidality in a treatment naïve sample of children and adolescents

BACKGROUND

The aim of the present study was to investigate the possible association between attention-deficit/hyperactivity disorder (ADHD) and suicidality.

METHODS

Using a structured interview (Mini International Neuropsychiatric Interview Kid), the authors examined 418 treatment naïve children/adolescents (aged: 3-18 years). Suicidality was defined by the M.I.N.I. Kid as having any current suicidal ideations and/or suicide attempts.

RESULTS

Two hundred and eleven children/adolescents fulfilled the DSM-IV diagnosis of ADHD and a further 105 showed symptoms of ADHD in subthreshold level. Multiple mediation analyses resulted in a moderated meditational model in which the relationship between symptoms of ADHD and current suicidality was fully mediated by the symptoms of comorbid conditions, but this was moderated by age. In children under 12 years, significant mediators were the symptoms of specific anxiety disorders, while in the adolescent group symptoms of major depressive episode and dysthymia and symptoms of substance abuse/dependence approved as significant mediators.

LIMITATIONS

As the study was cross-sectional, it did not reveal any causal relationship among the investigated factors. Furthermore, as the study population included a treatment naïve clinical sample, we can assume that adolescents, who and/or whose family seek for help at the first time in this age belonged to the less sever end of the spectrum.

CONCLUSIONS

ADHD symptoms are associated with an increased risk of suicidality in treatment naïve children/adolescents. The mechanisms of this relationship can be understood only when developmental factors are considered. Our findings suggest that clinicians should screen suicidality and comorbid symptoms routinely in patients with ADHD.

Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk

BACKGROUND

 Subthreshold-depression and anxiety have been associated with significant impairments in adults. This study investigates the characteristics of adolescent subthreshold-depression and anxiety with a focus on suicidality, using both categorical and dimensional diagnostic models.

METHODS

 Data were drawn from the Saving and Empowering Young Lives in Europe (SEYLE) study, comprising 12,395 adolescents from 11 countries. Based on self-report, including Beck Depression Inventory-II (BDI-II), Zung Self-Rating Anxiety Scale (SAS), Strengths and Difficulties Questionnaire (SDQ) and Paykel Suicide Scale (PSS) were administered to students. Based on BDI-II, adolescents were divided into three groups: nondepressed, subthreshold-depressed and depressed; based on the SAS, they were divided into nonanxiety, subthreshold-anxiety and anxiety groups. Analyses of Covariance were conducted on SDQ scores to explore psychopathology of the defined groups. Logistic regression analyses were conducted to explore the relationships between functional impairments, suicidality and subthreshold and full syndromes.

RESULTS

 Thirty-two percent of the adolescents were subthreshold-anxious and 5.8% anxious, 29.2% subthreshold-depressed and 10.5% depressed, with high comorbidity. Mean scores of SDQ of subthreshold-depressed/anxious were significantly higher than the mean scores of the nondepressed/nonanxious groups and significantly lower than those of the depressed/anxious groups. Both subthreshold and threshold-anxiety and depression were related to functional impairment and suicidality.

CONCLUSIONS

Subthreshold-depression and subthreshold-anxiety are associated with an increased burden of disease and suicide risk. These results highlight the importance of early identification of adolescent subthreshold-depression and anxiety to minimize suicide. Incorporating these subthreshold disorders into a diagnosis could provide a bridge between categorical and dimensional diagnostic models.

Mixed states in DSM-5: implications for clinical care, education, and research

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) nomenclature for the co-occurrence of manic and depressive symptoms (mixed states) has been revised in the new DSM-5 version to accommodate a mixed categorical-dimensional concept. The new classification will capture subthreshold non-overlapping symptoms of the opposite pole using a "with mixed features" specifier to be applied to manic episodes in bipolar disorder I (BD I), hypomanic, and major depressive episodes experienced in BD I, BD II, bipolar disorder not otherwise specified, and major depressive disorder. The revision will have a substantial impact in several fields: epidemiology, diagnosis, treatment, research, education, and regulations. The new concept is data-driven and overcomes the problems derived from the extremely narrow definition in the DSM-IV-TR. However, it is unclear how clinicians will deal with the possibility of diagnosing major depression with mixed features and how this may impact the bipolar-unipolar dichotomy and diagnostic reliability. Clinical trials may also need to address treatment effects according to the presence or absence of mixed features. The medications that are effective in treating mixed episodes per the DSM-IV-TR definition may also be effective in treating mixed features per the DSM-5, but new studies are needed to demonstrate it.

BCL9 and C9orf5 are associated with negative symptoms in schizophrenia: meta-analysis of two genome-wide association studies

Schizophrenia is a chronic and debilitating psychiatric condition affecting slightly more than 1% of the population worldwide and it is a multifactorial disorder with a high degree of heritability (80%) based on family and twin studies. Increasing lines of evidence suggest intermediate phenotypes/endophenotypes are more associated with causes of the disease and are less genetically complex than the broader disease spectrum. Negative symptoms in schizophrenia are attractive intermediate phenotypes based on their clinical and treatment response features. Therefore, our objective was to identify genetic variants underlying the negative symptoms of schizophrenia by analyzing two genome-wide association (GWA) data sets consisting of a total of 1,774 European-American patients and 2,726 controls. Logistic regression analysis of negative symptoms as a binary trait (adjusted for age and sex) was performed using PLINK. For meta-analysis of two datasets, the fixed-effect model in PLINK was applied. Through meta-analysis we identified 25 single nucleotide polymorphisms (SNPs) associated with negative symptoms with p<5×10(-5). Especially we detected five SNPs in the first two genes/loci strongly associated with negative symptoms of schizophrenia (P(meta-analysis)<6.22×10(-6)), which included three SNPs in the BCL9 gene: rs583583 showed the strongest association at a P(meta-analysis) of 6.00×10(-7) and two SNPs in the C9orf5 (the top SNP is rs643410 with a p = 1.29 ×10(-6)). Through meta-analysis, we identified several additional negative symptoms associated genes (ST3GAL1, RNF144, CTNNA3 and ZNF385D). This is the first report of the common variants influencing negative symptoms of schizophrenia. These results provide direct evidence of using of negative symptoms as an intermediate phenotype to dissect the complex genetics of schizophrenia. However, additional studies are warranted to examine the underlying mechanisms of these disease-associated SNPs in these genes.

Computational non-linear dynamical psychiatry: a new methodological paradigm for diagnosis and course of illness

The goal of this article is to highlight the significant potential benefits of applying computational mathematical models to the field of psychiatry, specifically in relation to diagnostic conceptualization. The purpose of these models is to augment the current diagnostic categories that utilize a "snapshot" approach to describing mental states. We hope to convey to researchers and clinicians that non-linear dynamics can provide an additional useful longitudinal framework to understand mental illness. Psychiatric phenomena are complex processes that evolve in time, similar to many other processes in nature that have been successfully described and understood within deterministic chaos and non-linear dynamic computational models. Dynamical models describe mental processes and phenomena that change over time, more like a movie than a photograph, with multiple variables interacting over time. The use of these models may help us understand why and how current diagnostic categories are insufficient. They may also provide a new, more descriptive and ultimately more predictive approach leading to better understanding of the interrelationship between psychological, neurobiological, and genetic underpinnings of mental illness.

Animal models of virus-induced neurobehavioral sequelae: recent advances, methodological issues, and future prospects

Converging lines of clinical and epidemiological evidence suggest that viral infections in early developmental stages may be a causal factor in neuropsychiatric disorders such as schizophrenia, bipolar disorder, and autism-spectrum disorders. This etiological link, however, remains controversial in view of the lack of consistent and reproducible associations between viruses and mental illness. Animal models of virus-induced neurobehavioral disturbances afford powerful tools to test etiological hypotheses and explore pathophysiological mechanisms. Prenatal or neonatal inoculations of neurotropic agents (such as herpes-, influenza-, and retroviruses) in rodents result in a broad spectrum of long-term alterations reminiscent of psychiatric abnormalities. Nevertheless, the complexity of these sequelae often poses methodological and interpretational challenges and thwarts their characterization. The recent conceptual advancements in psychiatric nosology and behavioral science may help determine new heuristic criteria to enhance the translational value of these models. A particularly critical issue is the identification of intermediate phenotypes, defined as quantifiable factors representing single neurochemical, neuropsychological, or neuroanatomical aspects of a diagnostic category. In this paper, we examine how the employment of these novel concepts may lead to new methodological refinements in the study of virus-induced neurobehavioral sequelae through animal models.

Changes in clinical trials methodology over time: a systematic review of six decades of research in psychopharmacology

Background

There have been many changes in clinical trials methodology since the introduction of lithium and the beginning of the modern era of psychopharmacology in 1949. The nature and importance of these changes have not been fully addressed to date. As methodological flaws in trials can lead to false-negative or false-positive results, the objective of our study was to evaluate the impact of methodological changes in psychopharmacology clinical research over the past 60 years.

Methodology/Principal Findings

We performed a systematic review from 1949 to 2009 on MEDLINE and Web of Science electronic databases, and a hand search of high impact journals on studies of seven major drugs (chlorpromazine, clozapine, risperidone, lithium, fluoxetine and lamotrigine). All controlled studies published 100 months after the first trial were included. Ninety-one studies met our inclusion criteria. We analyzed the major changes in abstract reporting, study design, participants' assessment and enrollment, methodology and statistical analysis. Our results showed that the methodology of psychiatric clinical trials changed substantially, with quality gains in abstract reporting, results reporting, and statistical methodology. Recent trials use more informed consent, periods of washout, intention-to-treat approach and parametric tests. Placebo use remains high and unchanged over time.

Conclusions/Significance

Clinical trial quality of psychopharmacological studies has changed significantly in most of the aspects we analyzed. There was significant improvement in quality reporting and internal validity. These changes have increased study efficiency; however, there is room for improvement in some aspects such as rating scales, diagnostic criteria and better trial reporting. Therefore, despite the advancements observed, there are still several areas that can be improved in psychopharmacology clinical trials.

Exploring the role of a nicotine quantity-frequency use criterion in the classification of nicotine dependence and the stability of a nicotine dependence continuum over time

INTRODUCTION

This study investigated (a) the utility of a cigarette quantity-frequency (QF) use criterion as an indicator for nicotine dependence (ND) and (b) the stability of the ND continuum of severity over time.

METHOD

Data from individuals who smoked cigarettes in the year prior to both time points of the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed (n = 6,185). The Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV Version (AUDADIS-IV) assessed for DSM-IV ND and nicotine use. Three QF criteria were created to represent daily consumption of > or = 5 cigarettes, > or = 10 cigarettes, or > or = 20 cigarettes. Confirmatory factor analysis and item response theory analysis were used to explore the latent structure of ND. Differential item functioning (DIF) analysis investigated the stability of the ND continuum over time.

RESULTS

A one-factor model, representing the DSM-IV conceptualization of ND, was an acceptable fit to the data at both time points. The inclusion of QF criteria decreased the fit of the one-factor model of ND. DIF in the severity and discrimination parameters of the diagnostic criteria was evident across the time points of the survey.

DISCUSSION

Although QF of cigarette use is related to ND, it appears to be a separate construct. Researchers using the AUDADIS-IV should be aware that the characteristics of the DSM-IV ND criteria do vary slightly across time, even though the changes appear to be relatively small and of minor clinical or practical significance.

Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification

A classification is as good as its theory. As the etiology of psychiatric disorders is still not clearly known, we still define them categorically by their clinical syndrome. There are doubts if they are valid discrete disease entities and if dimensional models are better to study them. We have come a long way till ICD-10 and DSM-IV, but there are shortcomings. With advances in genetics and neurobiology in the future, classification of psychiatric disorders should improve further. The concept, evolution, current status and challenges facing psychiatric classification are discussed in this review.

Creating a map of psychiatric patients based on psychopathological symptom profiles

BACKGROUND

In the current debate about the categorical or dimensional classification of mental disorders many fruitful methods to illustrate one or the other aspect are employed, and suggestions are made to combine the two perspectives.

METHODS

We present such an approach to combine both perspectives at the same time. Based on psychopathological AMDP-symptom profiles, a map of psychiatric patients was calculated by robust nonmetric multidimensional scaling (NMDS).

RESULTS

The sample from the Ludwig-Maximilians University in Munich included the records of patients, who were admitted and discharged in 2002 and 2003 with a diagnosis of either paranoid schizophrenia, (F20.00, N = 24), bipolar affective disorder, current episode manic without psychotic symptoms (F31.1, N = 32) or severe depressive episode without psychotic symptoms (F32.2, N = 78). In the resulting map of patients we found a clear categorical distinction according to the diagnostic groups, but also high regression values of AMDP-syndromes (manic syndrome: r = 0.83, depressive syndrome: r = 0.68, and paranoid-hallucinatory syndrome, r = 0.62).

DISCUSSION

The map of psychiatric patients presents an approach to consider the categorical and dimensional aspects at the same time. We were able to identify meaningful delineations between diagnostic clusters as well as continuous transitions. This method allows the whole psychopathological profile of each individual patient to be considered and also to identify misdiagnosed cases at a glance.

Removing obstacles in neuroscience drug discovery: the future path for animal models

Despite great advances in basic neuroscience knowledge, the improved understanding of brain functioning has not yet led to the introduction of truly novel pharmacological approaches to the treatment of central nervous system (CNS) disorders. This situation has been partly attributed to the difficulty of predicting efficacy in patients based on results from preclinical studies. To address these issues, this review critically discusses the traditional role of animal models in drug discovery, the difficulties encountered, and the reasons why this approach has led to suboptimal utilization of the information animal models provide. The discussion focuses on how animal models can contribute most effectively to translational medicine and drug discovery and the changes needed to increase the probability of achieving clinical benefit. Emphasis is placed on the need to improve the flow of information from the clinical/human domain to the preclinical domain and the benefits of using truly translational measures in both preclinical and clinical testing. Few would dispute the need to move away from the concept of modeling CNS diseases in their entirety using animals. However, the current emphasis on specific dimensions of psychopathology that can be objectively assessed in both clinical populations and animal models has not yet provided concrete examples of successful preclinical-clinical translation in CNS drug discovery. The purpose of this review is to strongly encourage ever more intensive clinical and preclinical interactions to ensure that basic science knowledge gained from improved animal models with good predictive and construct validity readily becomes available to the pharmaceutical industry and clinical researchers to benefit patients as quickly as possible.

Familiality of major depressive disorder and patterns of lifetime comorbidity. The NEMESIS and GenMood studies. A comparison of three samples

BACKGROUND

Major depressive disorder (MDD) aggregates in families and is associated with high rates of lifetime axis-I comorbidity. This study examined whether familiality of MDD is associated with the presence of specific comorbid disorders, which might be an important factor to be taken into account in MDD treatment and research into MDD etiology.

METHODS

A population sample was divided into subjects with familial (f-MDD; n=432) and nonfamilial MDD (nf-MDD; n=454). Since, more comorbidity was expected in clinical cases, a clinical sample with f-MDD (n=120) was also studied. Subjects were assessed with the Composite International Diagnostic Interview and family history methods. Binary logistic regression analyses were carried out to examine the influence of familiality of MDD on comorbidity. Analyses were adjusted for potential confounders, including MDD characteristics such as severity and age of onset.

RESULTS

Dysthymia, anxiety disorders, and alcohol use disorders were significantly more prevalent in subjects with f-MDD than in subjects with nf-MDD. Clinical f-MDD was associated with more anxiety disorders and fewer alcohol use disorders than population f-MDD. After adjustment for MDD characteristics including age at onset, severity, and disease course, comorbid disorders remained more prevalent in f-MDD than in nf-MDD.

LIMITATIONS

The instruments used in the population and the clinical samples were not identical, however, they were comparable to a substantial degree.

CONCLUSIONS

F-MDD, especially in clinical cases, appears to increase the risk of development of comorbid disorders, regardless of MDD characteristics. The link between familiality and comorbidity is important because it will aid a better understanding of the MDD phenotype, and it contributes to planning of effective treatment and to molecular genetic studies.

From categorical to dimensional diagnostics: deficiency-oriented versus person-centred diagnostics

The problem of inhomogeneous categories and the difficulty of drawing boundaries as well as individual progression of the severity of psychopathologic phenomena necessitate a change of paradigm from categorical to dimensional diagnostics. Not only pathogenetic factors but also disorder maintaining factors such as the stigmatization and the significance of the disorder for the patient must be factored into the diagnostic process to ensure therapy relevancy. In addition to this deficiency-oriented approach holistic person-centred diagnostics focuses on the integration of resources, i.e. the abilities and skills, talents and inclinations of the patient, in order to adequately help a patient to resume/live an autonomous life that is as happy as possible.