DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem?

Exploring sub-threshold food addiction in adult patients with severe obesity: a cross-sectional analysis

BACKGROUND

Most studies on Food Addiction (FA) used the strict classical diagnosis approach without quantifying sub-threshold symptoms (i.e. uncontrolled/excessive food intake, negative affect, craving, tolerance, withdrawal, and continued use despite harm) nor indicating where they stand on the "three-stage addiction cycle" modeling the transition from substance use to addiction.

OBJECTIVES

(1) to estimate the proportion of clinically significant episodes of distress/impairment in severely obese patients without FA, and (2) to assess their associations with FA symptoms at the subthreshold level.

METHODS

The modified Yale Food Addiction Scale 2.0 (mYFAS 2.0) assesses 11 symptoms (diagnostic criteria) plus clinically significant impairment and distress (clinical significance criterion). We used this tool to diagnose FA (≥ 2 criteria plus clinical significance) in adult patients with severe obesity, but included only those below the threshold in the analyses. Demographics, clinical features, and obesity complications were collected.

RESULTS

Only 18% of the 192 participants (women n = 148, 77.1%; mean age: 43.0 ± 13.2) reported a total absence of FA symptoms, while one in four reported recurrent episodes of clinically significant distress (24%) or impairment (25%) in social, occupational, or other important areas of functioning. The most common recurrent symptoms were first-stage symptoms (binge/intoxication), while second- (withdrawal/negative affect) and third-stage (preoccupation/anticipation) symptoms affected nearly one patient in five for tolerance and craving, and one in ten for withdrawal. In multivariate analysis, impairment was positively related to withdrawal and tolerance, while distress was positively related to failure in role obligations.

CONCLUSION

Many patients with severe obesity experience recurrent episodes of FA symptoms at the subthreshold level. Prospective studies will examine whether these symptoms may play a causal role in symptoms progression toward a full-blown FA and obesity outcomes.

A close look at sociality in DSM criteria

PURPOSE

The importance of sociality in psychology and psychotherapy is quite undisputed; however, this construct risks being underestimated in psychiatric nosography. The aim of the review was to assess the relevance of sociality in DSM 5 criteria.

METHOD

Sociality-laden criteria of 192 selected DSM categories have been identified through a textual grid. Second, the criteria have been classified into 6 categories, i.e., (1) Affiliation and Attachment (AA), (2) Social Communication (SC), (3) Perception and Understanding of Others (PUO), (4) Culture, (5) Clinical Significance Criterion (CSC) (6), and No Specific Construct (NSC).

RESULTS

13% of all mental disorders mention AA in their criteria. 8.8% of all mental disorders mention SC; 8.8% of all mental disorders mention PUO in their criteria. 15% of all mental disorders mention culture in their criteria (exclusively ex negativo though). 40% of mental disorders mention non-specific sociality (NSC) in their criteria. CSC is mentioned in 85% of mental disorders. Personality disorders have the highest "concentration" of sociality mentions throughout the DSM categories.

CONCLUSIONS

The overall results suggest that DSM criteria offer a confused account of sociality. We believe that the descriptive approach is the underlying reason. We suggest that in the long run a theory-laden approach to sociality, informed by evolutionary insights about motivations, could be of help.

Untroubled Pullers: An Examination of Nonclinical Hair-Pulling

Nonclinical hair-pulling is much more prevalent than hair pulling associated with a diagnosis of trichotillomania (TTM). However, little is known about nonclinical pulling. The purpose of this exploratory research was to begin characterizing a subset of nonclinical hair pullers we refer to as "untroubled pullers," people who engage in recurrent, noncosmetic hair-pulling without associated distress or impairment. In a secondary analysis of two studies conducted online, untroubled pullers reported significantly lower symptom severity than did those diagnosed with TTM. The Big Five personality dimensions did not differentiate the groups in Study 1, but untroubled pullers endorsed significantly less disability, focused and automatic pulling, social anxiety, perceived risk in intimacy, and perfectionism in Study 2. These findings remained significant after controlling for symptom severity. Age and race resulted in mixed findings between the two studies, but no differences arose in other demographics. These findings suggest that symptom severity may not sufficiently explain differences in associated distress and impairment. Future studies are needed on how other constructs related to distress and impairment interact with hair-pulling behavior to provide insight into when pulling is associated with clinically significant distress or impairment.

The Relationship between Orthorexia Nervosa and Obsessive Compulsive Disorder

Orthorexia nervosa (ON) is characterized by an intense avoidance of foods considered unhealthy, obsession with healthy eating behaviors, and pathological fixation on healthy foods. Although there are still debates in the literature about the psychological factors and symptoms of ON, it should be noted that many of the symptoms share common features with obsessive compulsive disorder (OCD). The aim of the present study was to investigate the relationship between ON and OCD with its subtypes. In this framework, the cross-sectional study was conducted with an opportunistic sample of 587 participants (86% women and 14% men), with an average age of 29.32 (s.d. = 11.29; age range = 15-74). Our work showed that almost all OCD subtypes were largely correlated with ON. The lowest correlation was for "Checking" and the highest for "Obsession". Overall, the OCD subtypes (i.e., Indecisiveness, Just Right, Obsession, and Hoarding) were more strongly associated with ON measures, while subtypes Checking and Contamination, although positively associated, had lower correlation coefficients.

Values in mental and medical disorder concepts: Their presence is not the point, being aware of them is

BACKGROUND

Both in medicine and in psychiatry, it's essential to find a general definition for medical and mental disorders. For this we have to analyze the concepts behind these definitions. In this article, we intend to review the proximity between the concepts of mental and medical disorders regarding the presence of values, and to propose a way to deal with the different kinds of values that might be present.

METHODS

The method used in this paper was a conceptual review/analysis.

RESULTS

Regarding the concept of medical disorder, it has resorted to different sub-concepts such as dysfunction and harm (distress disability). The concept of dysfunction, apparently being less value-laden, has been prioritized in relation to the harm component although several authors have already proved that implicitly and explicitly this concept is value laden. In medical-surgical disorder it is very unlikely to find any diagnostic information that includes moral values. In this type of disorder, the values in question are universally non-moral: pain, disability, distress (or risk for these) and risk of death. On the other hand, in several mental disorders, moral values have often been included in their diagnostic criteria.

CONCLUSION

It is concluded that values are present in the main concepts that have been used to define medical or mental disorder. What is essential is to understand what is descriptive and what is value and to try to avoid moral values in this context.

Impact of Psychotherapy for Children and Adolescents with Anxiety Disorders on Global and Domain-Specific Functioning: A Systematic Review and Meta-analysis

A substantial empirical base supports the use of psychotherapy to alleviate anxiety symptoms and diagnoses in children and adolescents. However, focusing only on symptom or diagnostic reduction provides an incomplete picture of clinically meaningful efficacy given that anxiety disorders in this age group are integrally associated with problems in functioning. A systematic review and meta-analysis (N studies = 40, N participants = 3094) evaluating the impacts of psychotherapy for anxiety was conducted on the following outcomes: global functioning, social functioning, academic functioning, and school attendance. Randomised controlled trials with a passive control condition, a child and/or adolescent sample (7–17 years) with a primary anxiety diagnosis, and receiving anxiety-focused psychotherapy were eligible for inclusion if they reported suitable outcome data. Results from the meta-analysis indicated that from pre- to post-treatment, psychotherapy led to significant improvements in global functioning according to clinician (d = 1.55), parent (d = 0.67), and child (d = 0.31) reports and on social functioning according to parent (d = 0.51), but not child (d = 0.31) reports. The qualitative review provided preliminary support psychotherapy’s efficacy in increasing family functioning and school attendance, but not so much in enhancing academic performance. These results indicate that psychotherapy improves daily functioning in anxious children and adolescents. The study also highlighted the limited attention paid to measures of functioning in the empirical literature on treatment of childhood anxiety.

Trial Registry: This study is registered with PROSPERO under the identification number CRD42021246565.

A Systematic Review of Sleep–Wake Disorder Diagnostic Criteria Reliability Studies

The aim of this article is to provide a systematic review of reliability studies of the sleep–wake disorder diagnostic criteria of the international classifications used in sleep medicine. Electronic databases (ubMed (1946–2021) and Web of Science (—2021)) were searched up to December 2021 for studies computing the Cohen’s kappa coefficient of diagnostic criteria for the main sleep–wake disorder categories described in the principal classifications. Cohen’s kappa coefficients were extracted for each main sleep–wake disorder category, for each classification subtype, and for the different types of methods used to test the degree of agreement about a diagnosis. The database search identified 383 studies. Fifteen studies were analyzed in this systematic review. Insomnia disorder (10/15) and parasomnia disorder (7/15) diagnostic criteria were the most studied. The reliability of all sleep–wake disorders presented a Cohen’s kappa with substantial agreement (Cohen’s kappa mean = 0.66). The two main reliability methods identified were “test–retest reliability” (11/15), principally used for International Classification of Sleep Disorders (ICSD), and “joint interrater reliability” (4/15), principally used for Diagnostic and Statistical Manual of Mental Disorders (DSM) subtype diagnostic criteria, in particularl, the DSM-5. The implications in terms of the design of the methods used to test the degree of agreement about a diagnosis in sleep medicine are discussed.

Examining impairment and distress from food addiction across demographic and weight groups

Rates of food addiction (FA) vary across weight and demographic groups. Factors influencing discrepant prevalence rates are largely unknown. Rates of clinically significant distress or impairment also vary across demographic groups, yet prior studies have overlooked the diagnostic significance of distress/impairment in heterogenous groups. We tested if weight and demographic groups differed in their likelihood of endorsing distress/impairment from FA. Participants (N = 1832) recruited from Amazon Mechanical Turk completed the modified Yale Food Addiction Scale 2.0 (mYFAS). The mYFAS includes 11 dichotomous symptom indicators and one dichotomous distress/impairment indicator. Differences in distress/impairment were tested across weight, sex, racial/ethnic, and educational groups using logistic regression. FA severity was controlled for using FA symptom count. There were no differences among racial/ethnic and educational groups (p > 0.05). Compared to men, women were more likely to report distress/impairment (aOR = 1.96, 95% CI = 1.28-3.03). People with obesity were more likely to report distress/impairment compared to people with overweight (aOR = 2.20, 95% CI = 1.39-3.49) or normal weight (aOR = 1.99, 95% CI = 1.26-3.13). Individual characteristics (i.e., sex, weight) may influence reporting of distress/impairment from FA. Further inquiry may be appropriate for men and people with normal weight or overweight presenting with FA symptoms who otherwise deny distress/impairment.

Cognitive Behavior Therapy for Depression From an Evolutionary Perspective

Evolutionary medicine attempts to solve a problem with which traditional medicine has struggled historically; how do we distinguish between diseased states and "healthy" responses to disease states? Fever and diarrhea represent classic examples of evolved adaptations that increase the likelihood of survival in response to the presence of pathogens in the body. Whereas, the severe mental disorders like psychotic mania or the schizophrenias may involve true "disease" states best treated pharmacologically, most non-psychotic "disorders" that revolve around negative affects like depression or anxiety are likely adaptations that evolved to serve a function that increased inclusive fitness in our ancestral past. What this likely means is that the proximal mechanisms underlying the non-psychotic "disorders" are "species typical" and neither diseases nor disorders. Rather, they are coordinated "whole body" responses that prepare the individual to respond in a maximally functional fashion to the variety of different challenges that our ancestors faced. A case can be made that depression evolved to facilitate a deliberate cognitive style (rumination) in response to complex (often social) problems. What this further suggests is that those interventions that best facilitate the functions that those adaptations evolved to serve (such as rumination) are likely to be preferred over those like medications that simply anesthetize the distress. We consider the mechanisms that evolved to generate depression and the processes utilized in cognitive behavior therapy to facilitate those functions from an adaptationist evolutionary perspective.

Crossover between diagnostic and empirical categorizations of full and subthreshold PTSD

BACKGROUND

Most of the work on understanding subthreshold PTSD has focused on inconsistencies in defining subthreshold PTSD and how those inconsistencies impact prevalence rates. The present study distinguishes between full and subthreshold PTSD using empirical categorization and assesses the circumstances under which empirical categorization is discordant with full and subthreshold PTSD diagnoses.

METHODS

Using data from the NIDA CTN Women and Trauma Study (N = 353), we use a modernized adaptation of the Jacobson and Truax (1991) framework, assessing whether patients were above or below an empirical threshold on latent PTSD severity scores estimated under categorical confirmatory factor analysis; the empirical categorizations were then crossed with the diagnoses to form four diagnostic by empirical categorization groupings.

RESULTS

Compared to a reference group (full PTSD diagnosis and empirical categorization), patients who had a full PTSD diagnosis but a subthreshold empirical categorization had lower symptom endorsement rates on 15 PTSD symptoms, were more likely to be married, ethnic minorities with fewer lifetime traumas. Conversely, patients with a subthreshold PTSD diagnosis and a full PTSD empirical grouping looked similar to "Full/Fulls", only differing on avoidance symptoms.

LIMITATIONS

Alternative definitions of subthreshold PTSD and coding of symptom endorsement may impact results. The use of DSM-IV symptoms (though reconciled against overlapping symptoms from DSM-5) is also a key limitation.

CONCLUSIONS

Empirical categorization can be a useful supplement to diagnosis in distinguishing subthreshold PTSD from full PTSD, using a methodology that could provide a platform for melding dimensional and categorical nosology approaches in the DSM.

Toward a Dimensional Assessment of Externalizing Disorders in Children: Reliability and Validity of a Semi-Structured Parent Interview

OBJECTIVE

This study assesses the reliability and validity of the DSM-5-based, semi-structured Clinical Parent Interview for Externalizing Disorders in Children and Adolescents (ILF-EXTERNAL).

METHOD

Participant data were drawn from the ongoing ESCAschool intervention study. The ILF-EXTERNAL was evaluated in a clinical sample of 474 children and adolescents (aged 6-12 years, 92 females) with symptoms of attention-deficit/hyperactivity disorder (ADHD). To obtain interrater reliability, the one-way random-effects, absolute agreement models of the intraclass correlation (ICC) for single ICC(1,1) and average measurements ICC(1,3) were computed between the interviewers and two independent raters for 45 randomly selected interviews involving ten interviewers. Overall agreement on DSM-5 diagnoses was assessed using Fleiss' kappa. Further analyses evaluated internal consistencies, item-total correlations as well as correlations between symptom severity and the degree of functional impairment. Additionally, parents completed the German version of the Child Behavior Checklist (CBCL) and two DSM-5-based parent questionnaires for the assessment of ADHD symptoms and symptoms of disruptive behavior disorders (FBB-ADHS; FBB-SSV), which were used to evaluate convergent and divergent validity.

RESULTS

ICC coefficients demonstrated very good to excellent interrater reliability on the item and scale level of the ILF-EXTERNAL [scale level: ICC(1,1) = 0.83-0.95; ICC(1,3) = 0.94-0.98]. Overall kappa agreement on DSM-5 diagnoses was substantial to almost perfect for most disorders (0.38 ≤ κ ≤ 0.94). With some exceptions, internal consistencies (0.60 ≤ α ≤ 0.86) and item-total correlations (0.21 ≤ r it ≤ 0.71) were generally satisfactory to good. Furthermore, higher symptom severity was associated with a higher degree of functional impairment. The evaluation of convergent validity revealed positive results regarding clinical judgment and parent ratings (FBB-ADHS; FBB-SSV). Correlations between the ILF-EXTERNAL scales and the CBCL Externalizing Problems were moderate to high. Finally, the ILF-EXTERNAL scales were significantly more strongly associated with the CBCL Externalizing Problems than with the Internalizing Problems, indicating divergent validity.

CONCLUSION

In clinically referred, school-age children, the ILF-EXTERNAL demonstrates sound psychometric properties. The ILF-EXTERNAL is a promising clinical interview and contributes to high-quality diagnostics of externalizing disorders in children and adolescents.

Normal Versus Pathological Mood: Implications for Diagnosis

Is there a clear line between normal and abnormal mood? Studies of manifest and latent structure provide strong support for a continuum that extends from asymptomatic to subsyndromal to syndromal cases of increasing severity. Subsyndromal symptoms are impairing, predict syndrome onset and relapse, and account for more doctor's visits and suicide attempts than the full syndromes, yet they are not recognized in the current classification. For most research and some clinical activities, dimensional diagnoses are recommended, and examples are offered for how such diagnoses could be made. For clinical activities requiring decisions, a multithreshold model is proposed in which both lower (e.g., mild depression, capturing subsyndromal cases) and upper (e.g., major depression, capturing clinically significant cases) diagnostic categories are used to inform clinical care. Beyond its implications for diagnosis, the dimensionality of depression and anxiety has implications for etiology and for research aimed at understanding how emotions become disrupted in psychopathology.

Revisiting ADHD age-of-onset in adults: to what extent should we rely on the recall of childhood symptoms?

BACKGROUND

ADHD diagnosis requires the presence of symptoms before the age of twelve. In clinical assessment of adults, the most frequent strategy to check this criterion is investigating self-report recall of symptoms, despite little evidence on the validity of this approach. We aim to evaluate the recall accuracy and factors associated with its reliability in a large population-based sample of adults.

METHODS

Individuals from the 1993 Pelotas Birth Cohort were followed-up from childhood to adulthood. At the age of 22, 3810 individuals were assessed through structured interviews by trained psychologists regarding mental health outcomes, including ADHD diagnosis and ADHD symptoms in childhood. The retrospective recall was compared with available information on ADHD childhood symptoms at the age of eleven. We also assessed factors related to recall accuracy through multiple regression analyses.

RESULTS

Self-reported recall of childhood symptoms at 22 years of age had an accuracy of only 55.4%, with sensitivity of 32.8% and positive predictive value of 40.7%. Current inattention symptoms were associated with lower risk and social phobia with higher risk for false-positive endorsement, while higher levels of schooling correlated with lower risk and male gender with higher risk for false-negative endorsement.

CONCLUSIONS

Clinicians treating male patients with social phobia and ADHD symptoms should assess even more carefully retrospective recall of ADHD childhood symptoms. Moreover, characteristics associated with recall improvement do not impact accuracy robustly. In this context, the recall of childhood ADHD symptoms seems an unreliable method to characterize the neurodevelopmental trajectory in adults with currently-impairing ADHD symptomatology.

Invariance of ADHD Symptoms Across Sex and Age: a Latent Analysis of ADHD and Impairment Ratings from Early Childhood into Adolescence

A population-based longitudinal sample of 489 twin pairs was assessed at six time points over ten years to examine the measurement invariance and stability of attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as the developmental relations between inattention (IN), hyperactivity-impulsivity (HI), and multiple aspects of functional impairment. Parent ratings of ADHD symptoms and functional impairment were obtained in preschool and after the completion of kindergarten, first, second, fourth, and ninth grades. Results of the temporal and sex invariance models indicated that parent ratings of the 18 ADHD symptoms function in the same manner for females and males from early childhood into adolescence. In addition to establishing this prerequisite condition for the interpretation of longitudinal and between-sex differences in the IN and HI symptom dimensions, cross-lagged models indicated that both IN and HI were associated with increased risk for both concurrent and future overall, social, and recreational impairment, whereas only IN was uniquely associated with later academic impairment. Taken together, the current results demonstrate that IN and HI are highly stable from preschool through ninth grade, invariant between females and males, and indicative of risk for impairment in multiple areas, thereby providing strong support for the validity of the symptom dimensions among both sexes.

Depressive role impairment and subthreshold depression in older black and white women: race differences in the clinical significance criterion

OBJECTIVES

We examined race differences in the DSM-IV clinical significance criterion (CSC), an indicator of depressive role impairment, and its impact on assessment outcomes in older white and black women with diagnosed and subthreshold depression.

DESIGN

We conducted a secondary analysis of a community-based interview study, using group comparisons and logistic regression.

SETTING

Lower-income neighborhoods in a Midwestern city.

PARTICIPANTS

411 community-dwelling depressed and non-depressed women ≥ 65 years (45.3% Black; mean age = 75.2, SD = 7.2) recruited through census tract-based telephone screening.

MEASUREMENTS

SCID interview for DSM-IV to assess major depression and dysthymia; Center for Epidemiologic Studies-Depression Scale to define subthreshold depression (≥16 points); Mini-Mental State Examination, count of medical conditions, activities of daily living, and mental health treatment to assess health factors.

RESULTS

Black participants were less likely than Whites to endorse the CSC (11.8% vs. 24.1%; p = .002). There were few race differences in depressive symptom type, severity, or count. Blacks with subthreshold depression endorsed more symptoms, though this comparison was not significant after adjustments. Health factors did not account for race differences in CSC endorsement. Disregarding the CSC-eliminated differences in diagnosis rate, race was a significant predictor of CSC endorsement in a logistic regression.

CONCLUSIONS

Race differences in CSC endorsement are not due to depressive symptom presentations or health factors. The use of the CSC may lead to underdiagnosis of depression among black older adults. Subthreshold depression among Blacks may be more severe compared to Whites, thus requiring tailored assessment and treatment approaches.

Integrating the Hierarchical Taxonomy of Psychopathology (HiTOP) into clinical practice

OBJECTIVE

Diagnosis is a cornerstone of clinical practice for mental health care providers, yet traditional diagnostic systems have well-known shortcomings, including inadequate reliability, high comorbidity, and marked within-diagnosis heterogeneity. The Hierarchical Taxonomy of Psychopathology (HiTOP) is a data-driven, hierarchically based alternative to traditional classifications that conceptualizes psychopathology as a set of dimensions organized into increasingly broad, transdiagnostic spectra. Prior work has shown that using a dimensional approach improves reliability and validity, but translating a model like HiTOP into a workable system that is useful for health care providers remains a major challenge.

METHOD

The present work outlines the HiTOP model and describes the core principles to guide its integration into clinical practice.

RESULTS

Potential advantages and limitations of the HiTOP model for clinical utility are reviewed, including with respect to case conceptualization and treatment planning. A HiTOP approach to practice is illustrated and contrasted with an approach based on traditional nosology. Common barriers to using HiTOP in real-world health care settings and solutions to these barriers are discussed.

CONCLUSIONS

HiTOP represents a viable alternative to classifying mental illness that can be integrated into practice today, although research is needed to further establish its utility. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Harm should not be a necessary criterion for mental disorder: some reflections on the DSM-5 definition of mental disorder

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the presence of distress or disability, which may be bracketed as the presence of harm, is taken to be merely usual, and thus not a necessary requirement: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for defining the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others pertaining to the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be (provisionally) maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified.

High-frequency repetitive transcranial magnetic stimulation (rTMS) improves neurocognitive function in bipolar disorder

BACKGROUND

Patients with bipolar disorder (BD) present widespread and significant neurocognitive impairments during all stages of the disorder. Repetitive transcranial magnetic stimulation (rTMS) has been used to improve clinical outcomes in common psychiatric diseases, such as depression, anxiety disorders, schizophrenia, and BD. Whether rTMS can improve cognitive function in BD patients remains unclear. The present study explored the regulatory effects of rTMS on cognitive function in patients with BD.

METHODS

Fifty-two eligible subjects with BD were randomly assigned to receive active or sham rTMS via high-speed magnetic stimulator with a figure-of-eight coil for 10 consecutive days. In the active rTMS group, a total of 25,000 stimuli were applied over the left dorsolateral prefrontal cortex at 110% of the motor threshold. The sham group received corresponding sham stimulation. Clinical manifestations and cognitive functions were assessed using a modified 24-item Hamilton Depression Rating Scale (HDRS), the Young Mania Rating Scale (YMRS), and the MATRICS Consensus Cognitive Battery (MCCB).

RESULTS

Ten consecutive days of high-frequency active rTMS improved scores on the Wechsler Memory Scale-III Spatial Span, and the MCCB Category Fluency subtest, without intolerable adverse effects. No significant differences in HDRS or YMRS scores were found between groups.

LIMITATIONS

No follow-up after the intervention. The effect of the drug on cognitive function in subjects was not excluded.

CONCLUSIONS

Short-term rTMS can improve cognitive function in BD patients.

Mental disorder: Are we moving away from distress and disability?

The first time that formally a definition of mental disorder was presented was in DSM-III. This resulted from a complex conceptual analysis carried out by Spitzer, chair of the committee on nomenclature and statistics. The criteria of harm (distress-disability) arise as main defining characteristics for mental illness, being added that "there is an inference" that there is a dysfunction. The distress-disability model was later developed by Wakefield. This author argued that in a medical or psychiatric disorder there had to be a dysfunctional component (value free) and another one of harm (value laden). In this article, we intend to review the emergence and evolution of the definition of mental disorder and the importance that the criteria of distress and disability always had in this definition. This happened until the advent of DSM-5 when these criteria came to play a secondary role.

Toward valid and reliable brain imaging results in eating disorders

Human brain imaging can help improve our understanding of mechanisms underlying brain function and how they drive behavior in health and disease. Such knowledge may eventually help us to devise better treatments for psychiatric disorders. However, the brain imaging literature in psychiatry and especially eating disorders has been inconsistent, and studies are often difficult to replicate. The extent or severity of extremes of eating and state of illness, which are often associated with differences in, for instance hormonal status, comorbidity, and medication use, commonly differ between studies and likely add to variation across study results. Those effects are in addition to the well-described problems arising from differences in task designs, data quality control procedures, image data preprocessing and analysis or statistical thresholds applied across studies. Which of those factors are most relevant to improve reproducibility is still a question for debate and further research. Here we propose guidelines for brain imaging research in eating disorders to acquire valid results that are more reliable and clinically useful.

Adjustment disorder: A diagnosis whose time has come

BACKGROUND

Adjustment disorder is among the most frequently diagnosed mental disorders in clinical practice although it has received little academic attention and been the subject of substantial criticism over the past decades. While those suffering with adjustment disorders are often treated by mental health professionals, research interest in the origin of the disorder or the effectiveness of psychotherapeutic and medical interventions has only recently begun to emerge. This article summarizes the empirical literature published on adjustment disorder and points out current diagnostic developments in DSM-5 and ICD-11.

METHODS

Literature for this review was identified through established online search tools, including publications in English, German, and Spanish.

RESULTS

This paper reviews literature on the evolution of adjustment disorder, and highlights the current state of research with regard to genesis and treatment. Importantly, for the first time ICD-11 intends to define adjustment disorder by explicit symptom groups, unlike DSM-5.

LIMITATIONS

Publications without an English abstract were not included.

CONCLUSIONS

Key directions for future research include investigating the concordance of the ICD-11 and DSM-5 concepts and the effect that the diverging conceptualizations may have. Risk and protective factors specific to AD should be identified and the biological underpinnings of the disorder should be explored. Finally, given the high prevalence of AD in certain clinical settings effective disorder-specific interventions should be developed and evaluated.

Mental Disorder-The Need for an Accurate Definition

There are several reasons why a definition for mental disorder is essential. Among these are not only reasons linked to psychiatry itself as a science (nosology, research) but also to ethical, legal, and financial issues. The first formal definition of mental disorder resulted from a deep conceptual analysis led by Robert Spitzer. It emerged to address several challenges that psychiatry faced at the time, namely to serve as the starting point for an atheoretical and evidence-based classification of mental disorders, to justify the removal of homosexuality from classifications, and to counter the arguments of antipsychiatry. This definition has been updated, with some conceptual changes that make it depart from the main assumptions of Spitzer's original definition. In this article, we intend to review the factors that substantiated the emergence of the first formal definition of mental disorder that based all its later versions.

Reviewing the Assumptions About Men's Mental Health: An Exploration of the Gender Binary

Many researchers take for granted that men's mental health can be explained in the same terms as women's or can be gauged using the same measures. Women tend to have higher rates of internalizing disorders (i.e., depression, anxiety), while men experience more externalizing symptoms (i.e., violence, substance abuse). These patterns are often attributed to gender differences in socialization (including the acquisition of expectations associated with traditional gender roles), help seeking, coping, and socioeconomic status. However, measurement bias (inadequate survey assessment of men's experiences) and clinician bias (practitioner's subconscious tendency to overlook male distress) may lead to underestimates of the prevalence of depression and anxiety among men. Continuing to focus on gender differences in mental health may obscure significant within-gender group differences in men's symptomatology. In order to better understand men's lived experiences and their psychological well-being, it is crucial for scholars to focus exclusively on men's mental health.

Classifying child and adolescent psychiatric disorder by problem checklists and standardized interviews

This paper discusses the need for research on the psychometric adequacy of self-completed problem checklists to classify child and adolescent psychiatric disorder based on proxy assessments by parents and self-assessments by adolescents. We put forward six theoretical arguments for expecting checklists to achieve comparable levels of reliability and validity with standardized diagnostic interviews for identifying child psychiatric disorder in epidemiological studies and clinical research. Empirically, the modest levels of test-retest reliability exhibited by standardized diagnostic interviews - 0.40 to 0.60 based on kappa - should be achievable by checklists when thresholds or cut-points are applied to scale scores to identify a child with disorder. The few studies to conduct head-to-head comparisons of checklists and interviews in the 1990s concurred that no construct validity differences existed between checklist and interview classifications of disorder, even though the classifications of youth with psychiatric disorder only partially overlapped across instruments. Demonstrating that self-completed problem checklists can classify disorder with similar reliability and validity as standardized diagnostic interviews would provide a simple, brief, flexible way to measuring psychiatric disorder as both a categorical or dimensional phenomenon as well as dramatically lowering the burden and cost of assessments in epidemiological studies and clinical research.

Interpersonal dysfunction in personality disorders: A meta-analytic review

Personality disorders are defined in the current psychiatric diagnostic system as pervasive, inflexible, and stable patterns of thinking, feeling, behaving, and interacting with others. Questions regarding the validity and reliability of the current personality disorder diagnoses prompted a reconceptualization of personality pathology in the most recent edition of the psychiatric diagnostic manual, in an appendix of emerging models for future study. To evaluate the construct and discriminant validity of the current personality disorder diagnoses, we conducted a quantitative synthesis of the existing empirical research on associations between personality disorders and interpersonal functioning, defined using the interpersonal circumplex model (comprising orthogonal dimensions of agency and communion), as well as functioning in specific relationship domains (parent-child, family, peer, romantic). A comprehensive literature search yielded 127 published and unpublished studies, comprising 2,579 effect sizes. Average effect sizes from 120 separate meta-analyses, corrected for sampling error and measurement unreliability, and aggregated using a random-effects model, indicated that each personality disorder showed a distinct profile of interpersonal style consistent with its characteristic pattern of symptomatic dysfunction; specific relationship domains affected and strength of associations varied for each personality disorder. Overall, results support the construct and discriminant validity of the personality disorders in the current diagnostic manual, as well as the proposed conceptualization that disturbances in self and interpersonal functioning constitute the core of personality pathology. Importantly, however, contradicting both the current and proposed conceptualizations, there was not evidence for pervasive dysfunction across interpersonal situations and relationships. (PsycINFO Database Record

Comparisons of Subthreshold Versus Full Posttraumatic Stress Disorder Distinguished by Subjective Functional Impairment Among Train Drivers: A Population-Based Nationwide Study in South Korea

OBJECTIVE

Subthreshold posttraumatic stress disorder (SPTSD), a condition that meets the full symptomatic criteria of posttraumatic stress disorder (PTSD) without subjective functional impairment, has yet to be fully investigated. In this study, we aimed to determine the prevalence and characteristics of SPTSD.

METHODS

The web-based survey including psychiatric diagnosis and experience of human error was conducted in actively working train drivers in South Korea.

RESULTS

Of the 4,634 subjects, 103 (2.23%) were categorized as full PTSD and 322 (6.96%) were categorized as having SPTSD. Individuals with full PTSD showed higher impulsivity and anxiety compared to those with SPTSD and those without PTSD, while those with SPTSD had more frequent clinically meaningful depression, posttraumatic stress, and alcohol and nicotine dependence and significant human error.

CONCLUSION

Despite not qualifying as a subjective functional disability, SPTSD still had significant psychiatric symptoms. More clinical attentions need to be given to the diagnosis and treatment of SPTSD.

Co-morbid psychological dysfunction is associated with a higher risk of asthma exacerbations: a systematic review and meta-analysis

BACKGROUND

The longitudinal associations between psychological dysfunction (PD) and asthma exacerbations (AE) have not been adequately addressed. This study aimed to systematically assess the influence of PD on AE, and to determine whether different PD affects AE differentially.

METHODS

Electronic databases (PubMed, Cochrane library, Web of Science, Embase, and Ovid) were searched for prospective cohort studies on the influence of PD on AE in individuals with asthma. Relative risk (RR) and adjusted RR (RRadj) were pooled across studies. Subgroup analyses assessed the effects of different types of PD and the time-dependent response to the duration of PD exposure.

RESULTS

Ten articles that involved 31,432 adults with asthma with follow-up of 6.0-86.4 months were included. PD significantly increased the risk of AE [RRadj =1.06, 95% confidence interval (95%CI): 1.04-1.09, P<0.001], presenting as hospitalizations (RRadj =1.22, 95% CI: 1.12-1.34, P<0.001), unscheduled doctor visits (RR =4.26, 95% CI: 2.52-7.19), and emergency department (ED) visits (RRadj =1.06, 95% CI: 1.01-1.10, P=0.009) because of asthma. Depression significantly increased the risk of AE (RRadj =1.07, 95% CI: 1.04-1.11, P<0.001), presenting as hospitalizations (RRadj =1.26, 95% CI: 1.07-1.49, P=0.007) and ED visits (RRadj =1.06, 95% CI: 1.02-1.11, P=0.007) because of asthma. Anxiety was only associated with an increased risk of AE in pregnant women (RR =1.05, 95% CI: 1.01-1.08), possibly due to the small amount of data available on anxiety. The influence of PD on AE was only significant when the PD exposure time exceeded one year.

CONCLUSIONS

Co-morbid PD adversely affects AE, and there are differential effects of depression and anxiety. Asthmatic subjects with PD may benefit from more attention when establishing a treatment regimen in clinical practice.

Using Evolutionary Theory to Guide Mental Health Research

Evolutionary approaches to medicine can shed light on the origins and etiology of disease. Such an approach may be especially useful in psychiatry, which frequently addresses conditions with heterogeneous presentation and unknown causes. We review several previous applications of evolutionary theory that highlight the ways in which psychiatric conditions may persist despite and because of natural selection. One lesson from the evolutionary approach is that some conditions currently classified as disorders (because they cause distress and impairment) may actually be caused by functioning adaptations operating "normally" (as designed by natural selection). Such conditions suggest an alternative illness model that may generate alternative intervention strategies. Thus, the evolutionary approach suggests that psychiatry should sometimes think differently about distress and impairment. The complexity of the human brain, including normal functioning and potential for dysfunctions, has developed over evolutionary time and has been shaped by natural selection. Understanding the evolutionary origins of psychiatric conditions is therefore a crucial component to a complete understanding of etiology.

Homosexuality and scientific evidence: On suspect anecdotes, antiquated data, and broad generalizations

The American Psychiatric Association and the American Psychological Association have suggested for many years now that there is significant empirical evidence supporting the claim that homosexuality is a normal variant of human sexual orientation as opposed to a mental disorder. This paper summarizes and analyzes that purported scientific evidence and explains that much (if not all) of the evidence is irrelevant and does not support the homosexuality-is-not-a-mental-disorder claim. As a result of their deficiencies and arbitrariness, the credibility those two groups that are typically deemed authoritative and trustworthy is called into question. Lay summary: At one time, homosexuality was considered to be mentally disordered. Since the 1970s, however, major medical associations in the U.S. have labeled homosexuality as a normal counterpart of heterosexuality. Those medical associations have proposed that their homosexuality-is-normal claim is based on "scientific evidence." This article critically reviews that "scientific evidence" and finds that much of their literature does not support the claim that homosexuality is normal. This article suggests that instead of supporting their claim with scientific evidence, those major medical associations arbitrarily label homosexuality as normal.

DSM-5, psychiatric epidemiology and the false positives problem

The revision effort leading to the publication of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was flawed in process, goals and outcome. The revision process suffered from lack of an adequate public record of the rationale for changes, thus shortchanging future scholarship. The goals, such as dimensionalising diagnosis, incorporating biomarkers and separating impairment from diagnosis, were ill-considered and mostly abandoned. However, DSM-5's greatest problem, and the target of the most vigorous and sustained criticism, was its failure to take seriously the false positives problem. By expanding diagnosis beyond plausible boundaries in ways inconsistent with DSM-5's own definition of disorder, DSM-5 threatened the validity of psychiatric research, including especially psychiatric epidemiology. I present four examples: increasing the symptom options while decreasing the diagnostic threshold for substance use disorder, elimination of the bereavement exclusion from major depression, allowing verbal arguments as evidence of intermittent explosive disorder and expanding attention-deficit/hyperactivity disorder to adults before addressing its manifest false positives problems.

Prevalence of DSM-IV disorders in a population-based sample of 5- to 8-year-old children: the impact of impairment criteria

This study determined the impact of impairment criteria on the prevalence and patterns of comorbidity of child DSM-IV disorders. The validity of these impairment criteria was tested against different measures of mental health care referral and utilization. We interviewed parents of 1,154 children aged 5-8 years in-depth using the Diagnostic Interview Schedule for Children in Rotterdam, the Netherlands, to establish DSM-IV diagnosis. These children were randomly selected or oversampled based on Child Behavior Checklist ratings from a large population-based study (N = 6,172). Referral data were extracted from the psychiatric interview as well as from a follow-up questionnaire. The results showed an overall prevalence of DSM-IV disorders of 31.1 % when impairment was not considered. This rate declined to 22.9 % when mild impairment was required and declined even further, to 10.3 %, for more severe levels of impairment. Similarly, the overall comorbidity rate declined from 8.5 to 6.7 and 2.7 % when mild and severe impairment were required, respectively. Virtually all children who attained symptom thresholds for a specific disorder, and had been referred to a mental health care professional because of the associated symptoms, also had mild impairment. The requirement of severe impairment criteria significantly increased diagnostic thresholds, but for most disorders, this definition captured only half of the clinically referred cases. In conclusion, prevalence was highly dependent upon the criteria used to define impairment. If severe impairment is made a diagnostic requirement, many children with psychiatric symptoms and mild impairment seeking mental health care will be undiagnosed and possibly untreated.

How Many People have Alcohol Use Disorders? Using the Harmful Dysfunction Analysis to Reconcile Prevalence Estimates in Two Community Surveys

Community prevalence rates of alcohol use disorders (AUDs) provided by epidemiological studies using DSM-based diagnostic criteria pose several challenges: the rates appear implausibly high to many epidemiologists; they do not converge across similar studies; and, due to low service utilization by those diagnosed as disordered, they yield estimates of unmet need for services so high that credibility for planning purposes is jeopardized. For example, two early community studies using DSM diagnostic criteria, the Epidemiologic Catchment Area Study (ECA) and the National Comorbidity Survey (NCS), yielded lifetime AUD prevalence rates of 14 and 24%, respectively, with NCS unmet need for services 19% of the entire population. Attempts to address these challenges by adding clinical significance requirements to diagnostic criteria have proven unsuccessful. Hypothesizing that these challenges are due to high rates of false-positive diagnoses of problem drinking as AUDs, we test an alternative approach. We use the harmful dysfunction (HD) analysis of the concept of mental disorder as a guide to construct more valid criteria within the framework of the standard out-of-control model of AUD. The proposed HD criteria require harm and dysfunction, where harm can be any negative social, personal, or physical outcome, and dysfunction requires either withdrawal symptoms or inability to stop drinking. Using HD criteria, ECA and NCS lifetime prevalences converge to much-reduced rates of 6 and 6.8%, respectively. Due to higher service utilization rates, NCS lifetime unmet need is reduced to 3.4%. Service use and duration comparisons suggest that HD criteria possess increased diagnostic validity. Moreover, HD criteria eliminate 90% of transient teenage drinking from disorder status. The HD version of the out-of-control model thus potentially resolves the three classic prevalence challenges while offering a more rigorous approach to distinguishing AUDs from problematic drinking.

Diagnostic criteria as dysfunction indicators: bridging the chasm between the definition of mental disorder and diagnostic criteria for specific disorders

According to the introduction to the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, each disorder must satisfy the definition of mental disorder, which requires the presence of both harm and dysfunction. Constructing criteria sets to require harm is relatively straightforward. However, establishing the presence of dysfunction is necessarily inferential because of the lack of knowledge of internal psychological and biological processes and their functions and dysfunctions. Given that virtually every psychiatric symptom characteristic of a DSM disorder can occur under some circumstances in a normally functioning person, diagnostic criteria based on symptoms must be constructed so that the symptoms indicate an internal dysfunction, and are thus inherently pathosuggestive. In this paper, we review strategies used in DSM criteria sets for increasing the pathosuggestiveness of symptoms to ensure that the disorder meets the requirements of the definition of mental disorder. Strategies include the following: requiring a minimum duration and persistence; requiring that the frequency or intensity of a symptom exceed that seen in normal people; requiring disproportionality of symptoms, given the context; requiring pervasiveness of symptom expression across contexts; adding specific exclusions for contextual scenarios in which symptoms are best understood as normal reactions; combining symptoms to increase cumulative pathosuggestiveness; and requiring enough symptoms from an overall syndrome to meet a minimum threshold of pathosuggestiveness. We propose that future revisions of the DSM consider systematic implementation of these strategies in the construction and revision of criteria sets, with the goal of maximizing the pathosuggestiveness of diagnostic criteria to reduce the potential for diagnostic false positives.

Enhanced antisaccade abilities in children with Tourette syndrome: the Gap-effect Reversal

Tourette Syndrome (TS) is a childhood onset disorder of motor and vocal tics. The neural networks underlying TS overlap with those of saccade eye movements. Thus, deviations on saccadic tasks can provide important information about psychopathology of TS. Tourette syndrome often coexists with Attention Deficit Hyperactivity Disorder (ADHD) and Obsessive Compulsive Disorder (OCD). Hence, we manipulated various components of a saccade task to measure its effects on saccades of children with TS-only, TS+ADHD, TS+ADHD+OCD and healthy controls. Children looked toward (prosaccade) or in the opposite direction (antisaccade) of a peripheral target as soon as it appeared. The prosaccade and antisaccade tasks were presented in three conditions. In the Gap200 condition, the fixation dot disappeared 200 ms prior to the appearance of the peripheral target, In the Gap800 condition, the fixation dot disappeared 800 ms prior to the appearance of the peripheral target and in Overlap200 the fixation dot disappeared 200 ms after the appearance of the peripheral target. Fixation-offset manipulations had different effects on each group's antisaccades. The TS+ADHD+OCD group's antisaccade latencies and error rates remained relatively unchanged in the three conditions and displayed a pattern of eye movements that can be interpreted as enhanced. Alternatively, the TS+ADHD group displayed an overall pattern of longer saccadic latencies. Findings corroborate the hypothesis that the combination of tic disorder and ADHD results in unique behavioral profiles. It is plausible that a subgroup of children with TS develop an adaptive ability to control their tics which generalizes to enhanced volitional control of saccadic behavior as well. Supporting evidence and other findings are discussed.

Family influences on the long term post-disaster recovery of Puerto Rican youth

This study focused on characteristics of the family environment that may mediate the relationship between disaster exposure and the presence of symptoms that met DSM-IV diagnostic criteria for symptom count and duration for an internalizing disorder in children and youth. We also explored how parental history of mental health problems may moderate this mediational model. Approximately 18 months after Hurricane Georges hit Puerto Rico in 1998, participants were randomly selected based on a probability household sample using 1990 US Census block groups. Caregivers and children (N = 1,886 dyads) were interviewed with the Diagnostic Interview Schedule for Children and other questionnaires in Spanish. Areas of the family environment assessed include parent-child relationship quality, parent-child involvement, parental monitoring, discipline, parents' relationship quality and parental mental health. SEM models were estimated for parents and children, and by age group. For children (4-10 years old), parenting variables were related to internalizing psychopathology, but did not mediate the exposure-psychopathology relationship. Exposure had a direct relationship to internalizing psychopathology. For youth (11-17 years old), some parenting variables attenuated the relation between exposure and internalizing psychopathology. Family environment factors may play a mediational role in psychopathology post-disaster among youth, compared to an additive role for children. Hurricane exposure had a significant relation to family environment for families without parental history of mental health problems, but no influence for families with a parental history of mental health problems.

When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds

High community prevalence estimates of DSM-defined major depressive disorder (MDD) have led to proposals to raise MDD's diagnostic threshold to more validly distinguish pathology from normal-range distress. However, such proposals lack empirical validation. We used MDD recurrence rates in the longitudinal 2-wave Epidemiologic Catchment Area Study to test the predictive validity of three proposals to narrow MDD diagnosis: a) excluding "uncomplicated" episodes (i.e., episodes that last no longer than 2 months and do not include suicidal ideation, psychotic ideation, psychomotor retardation, or feelings of worthlessness); b) excluding mild episodes (i.e., episodes with only five to six symptoms); and c) excluding nonmelancholic episodes. For each proposal, we used lifetime MDD diagnoses at wave 1 to distinguish the group proposed for exclusion, other MDD, and those with no MDD history. We then compared these groups' 1-year MDD rates at wave 2. A proposal was considered strongly supported if at wave 2 the excluded group's MDD rate was not only significantly lower than the rate for other MDD but also not significantly greater than the no-MDD-history group. Results indicated that all three excluded groups had significantly lower recurrence rates than other MDD (uncomplicated vs. complicated, 3.4% vs. 14.6%; mild vs. severe, 9.6% vs. 20.7%; nonmelancholic vs. melancholic, 10.6% vs. 19.2%, respectively). However, only uncomplicated MDD's recurrence rate was also not significantly greater than the MDD occurrence rate for the no-MDD-history group (3.4% vs. 1.7%, respectively). This low recurrence rate resulted from an interaction between uncomplicated duration and symptom criteria. Multiple-episode uncomplicated MDD did not entail significantly elevated recurrence over single-episode cases (3.7% vs. 3.0%, respectively). Uncomplicated MDD's general-distress symptoms, transient duration, and lack of elevated recurrence suggest it may generally represent nonpathologic intense sadness that should be addressed in treatment guidelines and considered for exclusion from MDD diagnosis to increase the validity of the MDD/normal sadness boundary.

Peer deviance, social support, and symptoms of internalizing disorders among youth exposed to Hurricane Georges

This study examined the influence of peers in meeting DSM-IV symptom criteria for an internalizing disorder in adolescents exposed to Hurricane Georges. Participants included a representative community sample of 905 youth (n = 476 boys) ages 11-17, residing in Puerto Rico. Data were gathered on hurricane exposure, symptoms of internalizing disorders, peer social support, peer violence, and peer substance use through in-person structured interviews with adolescents and caretakers from 1999 to 2000 in Puerto Rico, 12-27 months after Hurricane Georges. Hurricane exposure, peer violence, and peer substance use predicted whether adolescents met DSM-IV symptom criteria for a measured internalizing disorder. An interaction was found between hurricane exposure and peer violence, which indicated that hurricane exposure was significantly related to meeting DSM-IV symptom criteria for an internalizing disorder among adolescents who do not report associating with violent peers. However, for participants who reported high levels of peer violence, hurricane exposure did not convey additional risk for meeting DSM-IV symptom criteria for an internalizing disorder. With the increasing role peers play in adolescents' lives, understanding the influence of peers on the development of internalizing symptoms following hurricane exposure may assist in planning developmentally sensitive response plans.

Classification of bulimic-type eating disorders: from DSM-IV to DSM-5

Proposed changes to the classification of bulimic-type eating disorders in the lead up to the publication of DSM-5 are reviewed. Several of the proposed changes, including according formal diagnostic status to binge eating disorder (BED), removing the separation of bulimia nervosa (BN) into purging and non-purging subtypes, and reducing the binge frequency threshold from twice per week to once per week for both BN and (BED), have considerable empirical evidence to support them and will likely have the effect of facilitating clinical practice, improving access to care, improving public and professional awareness and understanding of these disorders and stimulating the additional research needed to address at least some problematic issues. However, the omission of any reference to variants of BN characterized by subjective, but not objective, binge eating episodes, and to the undue influence of weight or shape on self-evaluation or similar cognitive criterion in relation to the diagnosis of BED, is regrettable, given their potential to inform clinical and research practice and given that there is considerable evidence to support specific reference to these distinctions. Other aspects of the proposed criteria, such as retention of behavioral indicators of impaired control associated with binge eating and the presence of marked distress regarding binge eating among the diagnostic for BED, appear anomalous in that there is little or no evidence to support their validity or clinical utility. It is hoped that these issues will be addressed in final phase of the DSM-5 development process.

Validity of DSM-IV attention deficit/hyperactivity disorder symptom dimensions and subtypes

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for attention deficit/hyperactivity disorder (ADHD) specify two dimensions of inattention and hyperactivity-impulsivity symptoms that are used to define three nominal subtypes: predominantly hyperactive-impulsive type (ADHD-H), predominantly inattentive type (ADHD-I), and combined type (ADHD-C). To aid decision making for DSM-5 and other future diagnostic systems, a comprehensive literature review and meta-analysis of 546 studies was completed to evaluate the validity of the DSM-IV model of ADHD. Results indicated that DSM-IV criteria identify individuals with significant and persistent impairment in social, academic, occupational, and adaptive functioning when intelligence, demographic factors, and concurrent psychopathology are controlled. Available data overwhelmingly support the concurrent, predictive, and discriminant validity of the distinction between inattention and hyperactivity-impulsivity symptoms, and indicate that nearly all differences among the nominal subtypes are consistent with the relative levels of inattention and hyperactivity-impulsivity symptoms that define the subtypes. In contrast, the DSM-IV subtype model is compromised by weak evidence for the validity of ADHD-H after first grade, minimal support for the distinction between ADHD-I and ADHD-C in studies of etiological influences, academic and cognitive functioning, and treatment response, and the marked longitudinal instability of all three subtypes. Overall, we conclude that the DSM-IV ADHD subtypes provide a convenient clinical shorthand to describe the functional and behavioral correlates of current levels of inattention and hyperactivity-impulsivity symptoms, but do not identify discrete subgroups with sufficient long-term stability to justify the classification of distinct forms of the disorder. Empirical support is stronger for an alternative model that would replace the subtypes with dimensional modifiers that reflect the number of inattention and hyperactivity-impulsivity symptoms at the time of assessment. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

Bereavement and the diagnosis of major depressive episode in the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

Bereavement-related depression is excluded from a diagnosis of major depressive episode (MDE) in DSM-IV, unless the syndrome is prolonged or complicated. The objective of this study is to assess the validity of the bereavement exclusion by comparing characteristics of bereavement-related episodes that are excluded from a diagnosis and bereavement-related episodes that qualify for a diagnosis (complicated bereavement) to MDE.

METHOD

We used data from 2 waves of the National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093) to compare bereavement-excluded depression and complicated bereavement to MDE with respect to indicators of preexisting risk for psychopathology (antecedent indicators) and indicators of disorder severity measured at baseline and at the study's 3-year follow-up interview (consequent indicators). The primary outcome measure was the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV.

RESULTS

Compared to individuals with MDE, individuals with bereavement-excluded depression had lower risks of preexisting psychiatric disorders (eg, 0.44 lower odds of social phobia, P = .006), fewer depressive episodes (recurrence rate 0.37 times lower, P < .001), less psychosocial impairment (P < .001), a 0.18 times lower odds of seeking treatment (P < .001), and a lower risk of psychiatric disorders during a 3-year follow-up period. Unexpectedly, this same pattern of differences was observed between individuals with complicated bereavement and MDE.

CONCLUSIONS

Despite the presence of a clinically significant depressive episode, bereavement-excluded depression is in many ways less indicative of psychopathology than MDE. However, complicated bereavement was more similar to bereavement-excluded depression than to MDE. We therefore question whether the DSM-IV criteria validly distinguish between nondisordered loss reactions (bereavement-excluded depression), pathological loss reactions (complicated bereavement), and nonloss-related MDE.

Does GP training in depression care affect patient outcome? - A systematic review and meta-analysis

Background

Primary care practices provide a gate-keeping function in many health care systems. Since depressive disorders are highly prevalent in primary care settings, reliable detection and diagnoses are a first step to enhance depression care for patients. Provider training is a self-evident approach to enhance detection, diagnoses and treatment options and might even lead to improved patient outcomes.

Methods

A systematic literature search was conducted reviewing research studies providing training of general practitioners, published from 1999 until May 2011, available on the electronic databases Medline, Web of Science, PsycINFO and the Cochrane Library as well as national guidelines and health technology assessments (HTA).

Results

108 articles were fully assessed and 11 articles met the inclusion criteria and were included. Training of providers alone (even in a specific interventional method) did not result in improved patient outcomes. The additional implementation of guidelines and the use of more complex interventions in primary care yield a significant reduction in depressive symptomatology. The number of studies examining sole provider training is limited, and studies include different patient samples (new on-set cases vs. chronically depressed patients), which reduce comparability.

Conclusions

This is the first overview of randomized controlled trials introducing GP training for depression care. Provider training by itself does not seem to improve depression care; however, if combined with additional guidelines implementation, results are promising for new-onset depression patient samples. Additional organizational structure changes in form of collaborative care models are more likely to show effects on depression care.

Blue again: perturbational effects of antidepressants suggest monoaminergic homeostasis in major depression

Some evolutionary researchers have argued that current diagnostic criteria for major depressive disorder (MDD) may not accurately distinguish true instances of disorder from a normal, adaptive stress response. According to disorder advocates, neurochemicals like the monoamine neurotransmitters (serotonin, norepinephrine, and dopamine) are dysregulated in major depression. Monoamines are normally under homeostatic control, so the monoamine disorder hypothesis implies a breakdown in homeostatic mechanisms. In contrast, adaptationist hypotheses propose that homeostatic mechanisms are properly functioning in most patients meeting current criteria for MDD. If the homeostatic mechanisms regulating monoamines are functioning properly in these patients, then oppositional tolerance should develop with prolonged antidepressant medication (ADM) therapy. Oppositional tolerance refers to the forces that develop when a homeostatic mechanism has been subject to prolonged pharmacological perturbation that attempt to bring the system back to equilibrium. When pharmacological intervention is discontinued, the oppositional forces cause monoamine levels to overshoot their equilibrium levels. Since depressive symptoms are under monoaminergic control, this overshoot should cause a resurgence of depressive symptoms that is proportional to the perturbational effect of the ADM. We test this prediction by conducting a meta-analysis of ADM discontinuation studies. We find that the risk of relapse after ADM discontinuation is positively associated with the degree to which ADMs enhance serotonin and norepinephrine in prefrontal cortex, after controlling for covariates. The results are consistent with oppositional tolerance, and provide no evidence of malfunction in the monoaminergic regulatory mechanisms in patients meeting current diagnostic criteria for MDD. We discuss the evolutionary and clinical implications of our findings.

The impact of DSM-IV symptom and clinical significance criteria on the prevalence estimates of subthreshold and threshold anxiety in the older adult population

OBJECTIVES

Subthreshold anxiety refers to a condition where individuals do not meet the full symptom criteria (i.e., the number of symptoms required for a formal diagnosis is not reached) and/or do not report significant impairment or distress in functioning (i.e., the clinical significance criterion is not met). The purpose of this study was to examine how the symptom and the clinical significance criteria may affect the prevalence estimates of anxiety problems in the older adult population and whether applying these criteria results in an identifiable older group showing more severe anxiety.

SETTING AND PARTICIPANTS

Data came from a large representative sample of community-dwelling older adults age 65 years and older (N = 2,784).

RESULTS

Results showed that the 12-month prevalence rate of any anxiety problem varied from 5.6% when DSM-IV criteria for anxiety disorders were used to 26.2% when all subthreshold manifestations of anxiety were considered. Findings also indicated that when compared with respondents without anxiety, older adults presenting different manifestations of subthreshold or threshold anxiety appear to be more similar than different in their health and health behavior characteristics.

CONCLUSIONS

Subthreshold anxiety has a high prevalence and may cause significant impairment. Both symptom and clinical significance criteria do not perfectly discriminate between older adults with or without a severe anxiety problem presenting comorbid disorders and needing psychiatric help.