Much more than just shyness: the impact of social anxiety disorder on educational performance across the lifespan.

BACKGROUND: Social anxiety disorder (SAD) has been linked to academic underachievement, but previous studies had methodological limitations. We investigated the association between SAD and objective indicators of educational performance, controlling for a number of covariates and unmeasured confounders shared between siblings. METHODS: This population-based birth cohort study included 2 238 837 individuals born in Sweden between 1973 and 1997, followed-up until 2013. Within the cohort, 15 755 individuals had a recorded ICD-10 diagnosis of SAD in the Swedish National Patient Register. Logistic regression models tested the association between SAD and educational performance. We also identified 6488 families with full siblings discordant for SAD. RESULTS: Compared to unexposed individuals, individuals diagnosed with SAD were less likely to pass all subjects in the last year of compulsory education [adjusted odds ratios (aOR) ranging from 0.19 to 0.44] and less likely to be eligible for a vocational or academic programme in upper secondary education [aOR = 0.31 (95% confidence interval [CI] 0.30-0.33) and aOR = 0.52 (95% CI 0.50-0.55), respectively], finish upper secondary education [aOR = 0.19 (95% CI 0.19-0.20)], start a university degree [aOR = 0.47 (95% CI 0.45-0.49)], obtain a university degree [aOR = 0.35 (95% CI 0.33-0.37)], and finish postgraduate education [aOR = 0.58 (95% CI 0.43-0.80)]. Results were attenuated but remained statistically significant in adjusted sibling comparison models. When psychiatric comorbidities were taken into account, the results were largely unchanged. CONCLUSIONS: Treatment-seeking individuals with SAD have substantially impaired academic performance throughout the formative years. Early detection and intervention are warranted to minimise the long-term socioeconomic impact of the disorder.

Validity and reliability of social anxiety disorder diagnoses in the Swedish National Patient Register.

BACKGROUND: Population-based administrative registers are often used for research purposes. However, their potential usefulness depends on the validity of the registered information. This study assessed the validity of the recorded codes for social anxiety disorder (SAD), also known as social phobia, in the Swedish National Patient Register (NPR). METHODS: The personal identification numbers of 300 randomly selected individuals with a diagnosis of SAD recorded in the NPR were obtained from the Swedish National Board of Health and Welfare. The medical files of these individuals were then requested from clinics nationally. A total of 117 files were received and two independent raters reviewed each file to assess the presence or absence of SAD, according to the definition of the International Classification of Diseases, Tenth Edition (ICD-10) and the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). When disagreements between the two raters were found, a third rater reviewed the file to establish a best estimate diagnosis. Positive predictive values (PPV) and agreement between the two initial raters (using Cohen's kappa) were calculated. Additionally, raters completed the Clinical Global Impression - Severity (CGI-S) and the Global Assessment of Functioning (GAF) rating scales for each file. Inter-rater agreement for the CGI-S and the GAF was assessed using intraclass correlation coefficients (ICC). RESULTS: After exclusion of files not containing sufficient information, 95 files were included in the analyses. Of these, 77 files (81.05%) were considered to be 'true positive' cases (PPV = 0.81, 95% confidence interval = 0.72-0.88). Inter-rater agreement regarding the presence or absence of SAD was substantial (κ = 0.72). CGI-S and GAF scores indicated that patients were in the moderate range of severity and functional impairment. Inter-rater agreement for the CGI-S and the GAF was moderate to good (ICC = 0.72 and ICC = 0.82, respectively). CONCLUSIONS: The ICD-10 codes for SAD in the Swedish NPR are generally valid and reliable, but we recommend sensitivity analyses in future register-based studies to minimise the impact of potential diagnostic misclassification. Most patients were moderately severe and impaired, suggesting that results from register-based studies of SAD may be generalizable.

Validity and reliability of the diagnostic codes for hypochondriasis and dysmorphophobia in the Swedish National Patient Register: a retrospective chart review.

OBJECTIVES: In the International Classification of Diseases, Tenth Edition (ICD-10), hypochondriasis (illness anxiety disorder) and dysmorphophobia (body dysmorphic disorder) share the same diagnostic code (F45.2). However, the Swedish ICD-10 allows for these disorders to be coded separately (F45.2 and F45.2A, respectively), potentially offering unique opportunities for register-based research on these conditions. We assessed the validity and reliability of their ICD-10 codes in the Swedish National Patient Register (NPR). DESIGN: Retrospective chart review. METHODS: Six hundred individuals with a diagnosis of hypochondriasis or dysmorphophobia (300 each) were randomly selected from the NPR. Their medical files were requested from the corresponding clinics, located anywhere in Sweden. Two independent raters assessed each file according to ICD-10 definitions and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and Fifth Edition criteria. Raters also completed the Clinical Global Impression-Severity (CGI-S) and the Global Assessment of Functioning (GAF). PRIMARY OUTCOME MEASURE: Per cent between-rater agreement and positive predictive value (PPV). Intraclass correlation coefficients for the CGI-S and the GAF. RESULTS: Eighty-four hypochondriasis and 122 dysmorphophobia files were received and analysed. The inter-rater agreement rate regarding the presence or absence of a diagnosis was 95.2% for hypochondriasis and 92.6% for dysmorphophobia. Sixty-seven hypochondriasis files (79.8%) and 111 dysmorphophobia files (91.0%) were considered 'true positive' cases (PPV=0.80 and PPV=0.91, respectively). CGI-S scores indicated that symptoms were moderately to markedly severe, while GAF scores suggested moderate impairment for hypochondriasis cases and moderate to serious impairment for dysmorphophobia cases. CGI-S and GAF inter-rater agreement were good for hypochondriasis and moderate for dysmorphophobia. CONCLUSIONS: The Swedish ICD-10 codes for hypochondriasis and dysmorphophobia are sufficiently valid and reliable for register-based studies. The results of such studies should be interpreted in the context of a possible over-representation of severe and highly impaired cases in the register, particularly for dysmorphophobia.

Insomnia in obsessive-compulsive disorder: A Swedish population-based cohort study.

BACKGROUND: The association between specific psychiatric disorders and insomnia is well established, but the prevalence of insomnia in obsessive-compulsive disorder (OCD) is unknown. This population-based study examined the prevalence of insomnia in patients with OCD compared to unaffected individuals from the general population and to their unaffected full siblings, and evaluated the contribution of psychiatric comorbidities to this association. METHODS: Individuals diagnosed with OCD (31,856) were identified from a cohort of 13,017,902 individuals living in Sweden anytime during 1973 and 2013. Logistic regression analyses were used to investigate the odds of insomnia in individuals with OCD, compared to the general population and their unaffected full siblings. Sensitivity analyses were performed in subgroups from which all individuals with comorbid psychiatric conditions were excluded, one at a time. RESULTS: Individuals with OCD had almost 7-fold increased odds of receiving an insomnia diagnosis or being dispensed a drug with specific indication for insomnia, compared to unaffected individuals from the general population (42.2% vs. 11.0%, respectively; OR=6.92 [95% CI, 6.76-7.08]). Familiar factors shared with siblings and comorbid conditions did not fully explain this association, but when individuals with comorbid depression and anxiety disorders were excluded, the odds of insomnia were significantly reduced (OR=4.97 [95% CI, 4.81-5.14] and OR=4.51 [95% CI, 4.33-4.69], respectively). LIMITATIONS: Due to the intrinsic coverage issues of the registers, results may not be generalizable to milder forms of the disorder and to individuals who do not seek help. CONCLUSIONS: Insomnia should be systematically evaluated and managed in individuals with OCD, particularly in those with comorbid anxiety and depression.

Assessment of Posttraumatic Stress Disorder and Educational Achievement in Sweden.

Importance: Posttraumatic stress disorder (PTSD) has been associated with impaired educational performance. Previous studies on the disorder could not control for important measured and unmeasured confounders. Objective: To prospectively investigate the association between PTSD and objective indicators of educational attainment across the life span, controlling for familial factors shared by full siblings, psychiatric comorbidity, and general cognitive ability. Design, Setting, and Participants: This population-based cohort study included 2 244 193 individuals born in Sweden between January 1, 1973, and December 31, 1997, who were followed-up until December 31, 2013. Clusters of full siblings were used to account for familial factors. Data analyses were conducted between December 2018 and May 2020. Exposure: International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnoses of PTSD in the Swedish National Patient Register. Main Outcomes and Measures: Eligibility to access upper secondary education after finishing compulsory education, finishing upper secondary education, starting a university degree, and finishing a university degree. Results: Of the final cohort of 2 244 193 individuals (1 151 414 [51.3%] men) included in the analysis, 1 425 326 were assessed for finishing compulsory education (919 with PTSD), 2 001 944 for finishing upper secondary education (2013 with PTSD), and 1 796 407 and 1 356 741 for starting and finishing a university degree (2243 and 2254 with PTSD, respectively). Posttraumatic stress disorder was associated with lower odds of achieving each of the educational milestones during the study period, including 82% lower odds of finishing compulsory education (adjusted odds ratio [aOR], 0.18; 95% CI, 0.15-0.20), 87% lower odds of finishing upper secondary education (aOR, 0.13; 95% CI, 0.12-0.14), 68% lower odds of starting a university degree (aOR, 0.32; 95% CI, 0.28-0.35), and 73% lower odds of finishing a university degree (aOR, 0.27; 95% CI, 0.23-0.31). Estimates in the sibling comparison were attenuated (aOR range, 0.22-0.53) but remained statistically significant. Overall, excluding psychiatric comorbidities and adjusting for the successful completion of the previous milestone and general cognitive ability did not statistically significantly alter the magnitude of the associations. Conclusions and Relevance: Posttraumatic stress disorder was associated with educational impairment across the life span, and the associations were not entirely explained by shared familial factors, psychiatric comorbidity, or general cognitive ability. This finding highlights the importance of implementing early trauma-informed interventions in schools and universities to minimize the long-term socioeconomic consequences of academic failure in individuals with PTSD.

Association of Cesarean Delivery With Risk of Neurodevelopmental and Psychiatric Disorders in the Offspring: A Systematic Review and Meta-analysis.

Importance: Birth by cesarean delivery is increasing globally, particularly cesarean deliveries without medical indication. Children born via cesarean delivery may have an increased risk of negative health outcomes, but the evidence for psychiatric disorders is incomplete. Objective: To evaluate the association between cesarean delivery and risk of neurodevelopmental and psychiatric disorders in the offspring. Data Sources: Ovid MEDLINE, Embase, Web of Science, and PsycINFO were searched from inception to December 19, 2018. Search terms included all main mental disorders in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Study Selection: Two researchers independently selected observational studies that examined the association between cesarean delivery and neurodevelopmental and psychiatric disorders in the offspring. Data Extraction and Synthesis: Two researchers independently extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines and assessed study quality using the Newcastle-Ottawa Scale. Random-effects meta-analyses were used to pool odds ratios (ORs) with 95% CIs for each outcome. Sensitivity and influence analyses tested the robustness of the results. Main Outcomes and Measures: The ORs for the offspring with any neurodevelopmental or psychiatric disorder who were born via cesarean delivery compared with those were born via vaginal delivery. Results: A total of 6953 articles were identified, of which 61 studies comprising 67 independent samples were included, totaling 20 607 935 deliveries. Compared with offspring born by vaginal delivery, offspring born via cesarean delivery had increased odds of autism spectrum disorders (OR, 1.33; 95% CI, 1.25-1.41; I2 = 69.5%) and attention-deficit/hyperactivity disorder (OR, 1.17; 95% CI, 1.07-1.26; I2 = 79.2%). Estimates were less precise for intellectual disabilities (OR, 1.83; 95% CI, 0.90-3.70; I2 = 88.2%), obsessive-compulsive disorder (OR, 1.49; 95% CI, 0.87-2.56; I2 = 67.3%), tic disorders (OR, 1.31; 95% CI, 0.98-1.76; I2 = 75.6%), and eating disorders (OR, 1.18; 95% CI, 0.96-1.47; I2 = 92.7%). No significant associations were found with depression/affective psychoses or nonaffective psychoses. Estimates were comparable for emergency and elective cesarean delivery. Study quality was high for 82% of the cohort studies and 50% of the case-control studies. Conclusions and Relevance: The findings suggest that cesarean delivery births are associated with an increased risk of autism spectrum disorder and attention-deficit/hyperactivity disorder, irrespective of cesarean delivery modality, compared with vaginal delivery. Future studies on the mechanisms behind these associations appear to be warranted.

Insight, sintomatología y funcionamiento neurocognitivo en pacientes con psicosis / Insight, symptomatology, and neurocognitive functioning in patients with psychosis

Introducción: Se estudia la relación entre insight, sintomatologia y funcionamiento cognitivo en una muestra de pacientes con trastornos psicóticos. Materiales y métodos: Se evaluaron 55 pacientes ingresados en una unidad de hospitalización psiquiátrica con diagnóstico de psicosis no afectiva. La evaluación se llevó a cabo con las siguientes escalas: para evaluar el insight clínico, se utilizó la Scale to Assess Unawareness of Mental Disorder (SUMD); para evaluar el insight cognitivo, la Escala de Insight Cognitivo de Beck (la EICB); para evaluar la clínica psicótica, la Positive and Negative Syndrome Scale (PANSS); y la sintomatología depresiva se evaluó con el Beck Depression Inventory (BDI). Las funciones ejecutivas neurocognitivas se valoraron con el Wisconsin Card Sorting Test (WCST) y el deterioro cognitivo con el Screen for Cognitive Impairment in Psychiatry (SCIP). Resultados: Un menor insight clínico se relaciona con una mayor presencia de síntomas psicóticos positivos y una menor presencia de síntomas negativos y depresivos. No se observó relación entre insight y funciones ejecutivas, pero sí con el deterioro cognitivo. Conclusiones: Un menor insight en pacientes con trastorno psicótico se relaciona con la presencia de más sintomatología psicótica positiva y menor sintomatología psicótica negativa y depresiva. El insight clínico aumenta cuanto mayor deterioro cognitivo se aprecia

Introduction: The aim of this paper is to study the degree of insight in patients with psychotic disorders and its possible relationship with psychotic and depressive symptoms. Materials and methods: The sample consisted of 55 patients hospitalized in a psychiatric inpatient unit with a diagnosis of non-affective psychosis. In order to assess the patients, we used the Scale to Assess Unawareness of Mental Disorder (SUMD) for clinical insight; the Beck Cognitive Insight Scale (BCIS) for cognitive insight; the Positive And Negative Syndrome Scale (PANSS) for psychotic symptoms; and the Beck Depression Inventory (BDI) for depressive symptoms. The Wisconsin Card Sorting Test (WCST) was used to assess executive functions and the Screen for Cognitive Impairment in Psychiatry (SCIP) was used to assess cognitive impairment. Results: A lower clinical insight is related to more positive psychotic symptoms and to less negative and depressive symptoms. There was no relationship between insight and executive functions; however, we found a relationship between insight and cognitive impairment. Conclusions: A lower insight in patients with psychotic disorders is related to higher scores in the PANNS positive subscale and to lower scores in the PANSS negative subscale and the BDI. Clinical insight was higher in cognitively impaired patients

Trastorno psicótico: clave para el diagnóstico de esclerosis múltiple / Psychotic disorder as key clue in the diagnosis of multiple sclerosis

La comorbilidad de los síntomas psicóticos con la esclerosis múltiple (EM) no es frecuente. Si bien es relativamente común la aparición de sintomatología psiquiátrica como son los trastornos afectivos (detectados en dos tercios de los pacientes con EM), los trastornos del contenido del pensamiento se presentan con una prevalencia menor al 5%, y bastante más aisladamente se han observado alteraciones sensoperceptivas en relación con estos cuadros. Menos frecuente es todavía que sean estas alteraciones sensoperceptivas las que se presenten sin otra sintomatología acompañante, sirviendo de llave para el diagnóstico de EM, sin que exista apenas literatura en relación con esta forma de presentación. En el presente artículo se aporta el caso clínico de una paciente de 36 años que ingresa por la presentación de un primer brote psicótico a estudio, sin antecedentes psiquiátricos personales ni familiares, y a la que, de manera protocolizada, se le realizan las pruebas complementarias pertinentes. En la resonancia magnética se identifican por primera vez lesiones desmielinizantes compatibles con EM (AU)

Comorbidity of psychotic symptoms with multiple sclerosis (MS) is quite rare. It is relatively common to observe some psychiatric symptoms such as mood disorders (detected in two thirds of patients with MS). Otherwise, symptoms like disordered thinking have a prevalence lower than 5%, and a few isolated sensory processing disorders have been observed in relation to these symptoms. Still less common are these sensory processing disorders with no other symptoms, giving a clue for the diagnosis of MS. Furthermore, there is practically nothing in the literature on this way of presentation. In this article, the case is presented of a 36-year-old woman who was hospitalized in order to study her first-episode psychoses. She had no personal or family psychiatric history. Demyelinating lesions consistent with MS were identified for the first time on magnetic resonance (AU)