Beyond clinical staging of psychiatric disorders

Symptom dimensions stability over time in recent onset psychosis: A prospective study

BACKGROUND

The factorial structure of schizophrenia symptoms has been much debated but little is known on its degree of unicity, specificity as well as its dynamic over time. Symptom differentiation is a phenomenon according to which patients' symptoms could differentiate from one another during illness to form more independent, distinct dimensions. On the contrary, symptom dedifferentiation is an increase in the correlations between those symptoms over time. The goal of this study was to investigate symptom differentiation or dedifferentiation over time in recent onset psychosis using the Positive and Negative Syndrome Scale.

METHODS

A confirmatory factor analysis model based on the consensus five-factor model of the Positive and Negative Syndrome Scale for schizophrenia was estimated on seven different time points over a three-year period. A general factor capturing common variance between every symptom was also included. Explained common variance was computed for the general factor and each specific factor.

RESULTS

Three hundred and sixty-two recent onset psychosis patients were assessed. Results showed no evidence for either symptom differentiation or dedifferentiation over time. Specific symptoms accounted for >70 % of the variance suggesting a high degree of specificity of the symptomatology.

CONCLUSIONS

Overall, this study adds support for a highly multidimensional approach to clinical symptom assessment with an explicit focus on depression. The premise behind the staging approach being inherently one-dimensional, implications for further research is discussed.

Questions in Psychiatry (QuiP): Is staging bipolar disorder possible? If so, where to begin?

The prospect of staging psychiatric disorders has been a source of ongoing controversy since the idea was first proposed in the early 1990s, based on the staging models used for cancer. More recently, several staging models have been proposed for bipolar disorder; however, as yet there is no consensus as to which model (or composite) is best, and there is no substantive evidence in support of any one of the models. The fundamental problem is that, unlike cancer, the pathophysiology of psychiatric disorders such as bipolar disorder is essentially unknown. The illness has many neurobiological underpinnings, but whether these are truly causal and if so how they lead to the illness, remains a mystery. As a consequence, there is no way of predicting when the illness will emerge and what trajectory it will take. Its response to treatment and prognosis is equally unpredictable, and therefore, models attempting to stage the disorder on the basis of clinical markers have limited utility. This is especially so, because the clinical presentation of bipolar disorder is particularly complex as it often occurs in the context of comorbidities, which further obscure the clinical picture. Therefore, in this QuiP, we provide insights as to why current methods of staging bipolar disorder are hamstrung and propose a way forward that may yield meaningful insights.

[Has the concept of staging modified treatment of schizophrenia yet ?]

The concept of staging is applied in medicine since many years, in order to better adapt treatment to patients' needs. Some authors have suggested one should also apply this concept to psychiatric disorders. If this approach seems to make sense, concrete progress in the domain are still limited. It is in the field of psychosis that most development have occurred, in the favorable context of early intervention programs. Some very detailed models have recently been proposed where successive stages of psychotic disorders are defined and corresponding treatment options are proposed. However, the limited reliability of clinical diagnoses systems and the absence of biomarkers allowing a more objective delineation of these various stages still hampers the concrete application of such strategies. Despite these limitations, the staging concept has already started to modify the mental health offer, especially for adolescents and young adults, for example through the development of the Headspace centers in Australia and other countries. These centers constitute accessible entry point for help seekers with mental health issues where treatment is defined according to the stage of illness. If such programs seem promising, a better understanding of the mechanisms underlying the development of psychiatric disorders seems important in order to facilitate the identification of stages and define the nature of the treatment needed for each of them, considering such knowledge has been the crucial for the development of the staging model in somatic disorders.

Validity of routine clinical diagnoses in acute psychiatric inpatients

AIM

To examine the validity of diagnoses obtained by clinicians during routine clinical examination on acute psychiatric inpatient wards.

METHODS

N=100 inpatients with a broad spectrum of major mental disorders were randomly selected in a mental hospital's department of general psychiatry. Patients were diagnosed by independent assessors within Md = 5 (Range: 1-18) days of admission using the SCID I in order to examine the validity of the diagnoses given by the clinical staff based on routine assessments.

RESULTS

The commonly used clinical examination technique had good overall agreement with the SCID I assessments regarding primary diagnoses at the level of ICD-10 main categories (F2, F30-31, F32-F33, F4; κ = 0.65). However, agreement between routine clinical diagnoses and the SCID I diagnoses tended to be low for some specific mental disorders (e.g., depressive disorders) and for secondary diagnoses.

CONCLUSIONS

The validity of routine clinical diagnoses established in acute inpatient settings is limited and should be improved.

[Case Formulation in Early Psychosis: What are the Tools for Teamwork?]

First, we briefly feature the TIPP program (Treatment and Early Intervention in Psychosis Program) and early management general concepts in early psychosis. One intervention objective in the early phase of psychotic disorders is proposing specific care adapted to this phase of the illness. From the start, the care team and especially the case manager, the care conductor, are faced with a huge information load in which they have to discern lines of force in order to install an adapted management. This article proposes a model that can constitute a valuable work tool for early intervention teams wanting to produce a case formulation and summarize patient clinical situations, extract from it a meaningful history, and thus facilitate the implementation of a therapeutic project.