Refined diagnostic criteria for the bipolar disorders: phase two of the AREDOC project.

OBJECTIVE: As limitations exist across DSM criteria sets for defining and differentiating the bipolar disorders generally and their component bipolar I (BP-1) and bipolar II (BP-II) sub-types, we sought to generate empirically based criteria. METHOD: We formed an international Task Force (TF) comprising members with bipolar disorder expertise, and who recruited 74 patients with a TF-diagnosed bipolar I and 104 with a bipolar II condition (with patients responding to definitional queries and symptom questionnaires), while 33 unipolar depressed patients recruited by the first author also completed the symptom questionnaire. A factor analysis sought to determine granular hypo/manic constructs. RESULTS: The bipolar disorder subjects strongly affirmed a new general definition of a bipolar disorder (capturing both manic and hypomanic episodes). While DSM-5 requires impaired functioning, we established that a high percentage of individuals with a BP-I or a BP-II disorder reported improved functioning and therefore modified this criterion. Analyses identified syptoms with differential high rates in individuals with bipolar disorder and its sub-types (and thus not simply capturing happiness), while a factor analysis generated seven symptom constructs both linked with and differing from DSM-5 bipolar symptom criteria. CONCLUSION: This second-stage report details a new set of criteria for differentiating the bipolar disorders from unipolar depressive conditions, while arguing for BP-I and BP-II disorders being differentiated principally by the respective presence or absence of psychotic features. Future studies will evaluate whether further modifications are required and examine for differential treatment benefits for those with a BP-I versus a BP-II condition.

Differentiating the bipolar disorders from borderline personality disorder.

OBJECTIVE: To identify features differentiating bipolar disorder (BP) from borderline personality disorder (BPD) and with each condition variably defined. METHOD: Participants were assigned a BP or BPD diagnosis on the basis of DSM criteria and, separately, by clinical judgment, and undertook a diagnostic interview and completed self-report measures. RESULTS: Predictors of BPD status varied according to diagnostic decisions, but with the most consistent items being childhood sexual abuse, childhood depersonalization, personality variables relating to relationship difficulties and sensitivity to criticism, and the absence of any BP family history. Across diagnostic groups, personality measure items alone predicted diagnostic allocation with an accuracy of 81-84%, the refined study variables other than hypo/manic features improved the classification rates to 88%, and when the presence or absence of hypo/manic features was added, classification rates increased to 92-95%. CONCLUSION: Study findings indicate that BPD can be differentiated from BP with a high degree of accuracy.

A randomized controlled trial of mindfulness-based cognitive therapy for bipolar disorder.

OBJECTIVE: To compare the efficacy of mindfulness-based cognitive therapy (MBCT) plus treatment as usual (TAU) to TAU alone for patients with bipolar disorder over a 12-month follow-up period. METHOD: Participants with a DSM-IV diagnosis of bipolar disorder were randomly allocated to either MBCT plus TAU or TAU alone. Primary outcome measures were time to recurrence of a DSM-IV major depressive, hypomanic or manic episode; the Montgomery-Åsberg Depression Rating Scale (MADRS); and Young Mania Rating Scale (YMRS). Secondary outcome measures were number of recurrences, the Depression Anxiety Stress Scales (DASS), and the State Trait Anxiety Inventory (STAI). RESULTS: Ninety-five participants with bipolar disorder were recruited to the study (MBCT = 48; TAU = 47). Intention-to-treat (ITT) analysis found no significant differences between the groups on either time to first recurrence of a mood episode or total number of recurrences over the 12-month period. Furthermore, there were no significant between-group differences on the MADRS or YMRS scales. A significant between-group difference was found in STAI - state anxiety scores. There was a significant treatment by time interaction for the DAS - achievement subscale. CONCLUSION: While MBCT did not lead to significant reductions in time to depressive or hypo/manic relapse, total number of episodes, or mood symptom severity at 12-month follow-up, there was some evidence for an effect on anxiety symptoms. This finding suggests a potential role of MBCT in reducing anxiety comorbid with bipolar disorder.

The superiority of antidepressant medication to cognitive behavior therapy in melancholic depressed patients: a 12-week single-blind randomized study.

OBJECTIVE: To pursue the previously long-standing but formally untested clinical view that melancholia is preferentially responsive to antidepressant medication in comparison with psychotherapy [specifically Cognitive Behavior Therapy (CBT)]. Second, to determine whether a broader action antidepressant medication sequencing regimen is superior to a Selective Serotonin Reuptake Inhibitor (SSRI) alone. METHOD: We sought to recruit a large sample of participants with melancholic depression for a 12-week trial but inclusion criteria compromised recruitment and testing the second hypothesis. The first hypothesis was evaluated by comparing 18 participants receiving antidepressant medication to 11 receiving CBT. Primary study measures were the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Endogenous Subscale (HES), rated blindly, while several secondary measures also evaluated outcome. RESULTS: Participants receiving medication had a superior 12-week outcome to those receiving CBT, with significant differences present on primary measures as early as 4 weeks. At trial conclusion, the percentage improvement in HAM-D scores was 61.1% vs. 34.4%, respectively [Number Needed to Treat (NNT) = 3.7] and with those in receipt of medication returning non-significantly higher HAM-D responder (66.6% vs. 36.4%, NNT = 2.8) and remission (66.7% vs. 45.4%, NNT = 4.7) rates. CONCLUSION: As the sample size was small and participants evidenced only moderate levels of depression severity, the study risked being underpowered and idiosyncratic. Despite the small sample, the superiority of antidepressant medication to CBT in those with a melancholic depression was distinctive in this pilot study.

Depression in general practice attenders. "Caseness", natural history and predictors of outcome.

Assessment of 564 routine attenders of 12 Sydney general practices established that 25% of the women and 17% of the men scored as "potential depressives". Thirty-five agreed to an interview and review over 6 months, with 83% of this group initially rating as a "psychiatric case" on the Present State Examination. The sample could be characterized as being chronically depressed (mean duration of 9 months), as predominantly (86%) female, in having relatively stable but dysfunctional relationships, and by having experienced chronic and acute-on-chronic stressors. The degree of which subjects improved in the following 20 weeks could be predicted by their degree of improvement in the first few weeks and as early as the 6th day after assessment. While overall improvement was minimal, several baseline predictors of a better outcome were suggested: a history of having episodic or recurrent episodes, a more severe depression, lower social class, break-up of an intimate relationship as a precipitant, a neutralizing life event and family support. Married subjects and those with young children had a poor outcome.

Subpopulations of early separation anxiety: relevance to risk of adult anxiety disorders.

BACKGROUND: The present study aims to examine whether discrete subpopulations can be identified according to their levels of early separation anxiety (SA), and if so, whether such a typology of SA influences risk to particular adult anxiety disorders. METHODS: Mixture analysis was applied to early SA scores provided retrospectively by a composite group (n=1800) of adult community and patient samples. The distribution of adult anxiety diagnoses across the SA categories was assessed in a community (n=136) and a clinic (n=74) sample. RESULTS: The mixture analysis yielded two subpopulations according to SA scores. Odds ratios for assignment to the high SA category for the various anxiety disorders ranged from 3.6 to 6.7. A logistic regression analysis revealed that when comorbidity was taken into account, the panic disorder-agoraphobia (PD-Ag) group was the only anxiety disorder to be associated with the high SA category. CONCLUSION: Assignment to a high early SA category appears to increase risk to adult anxiety disorders, particularly PD-Ag. Several possible pathways may account for such a risk including the persistence of separation anxiety disorder into adulthood. LIMITATIONS: Assessment of early SA was made using a retrospective measure and the samples included groups which were known to have high SA scores. CLINICAL RELEVANCE: Only a subpopulation of anxiety sufferers may have elevated levels of SA. Identification of this group may be important for early detection and intervention.

Parent-child concordance for separation anxiety: a clinical study.

There is tentative evidence supporting a familial basis for separation anxiety. The present study aimed to examine parent-child concordance for that subtype of anxiety. Fifty-four children diagnosed with anxiety disorders and their parents (54 mothers and 29 fathers) were recruited from two juvenile anxiety clinics. Sixty-three percent of children diagnosed with juvenile separation anxiety disorder had at least one parent who suffered from the putative adult variant of the disorder (odds ratio = 11.1) (P < 0.001). Affected parents reported high levels of separation anxiety in their own childhoods. Juvenile separation anxiety disorder in children was not associated with any other parental diagnosis. The small sample size and other potential biases caution against definitive conclusions being drawn, but the present data add to existing evidence that separation anxiety may aggregate in families.

Dimensions of trauma associated with posttraumatic stress disorder (PTSD) caseness, severity and functional impairment: a study of Bosnian refugees resettled in Australia.

Refugee survivors of inter-ethnic warfare vary greatly in the extent and range of their trauma experiences. Discerning which experiences are most salient to generating and perpetuating disorders such as posttraumatic stress disorder (PTSD) is critical to the mounting rational strategies for targeted psychosocial interventions. In a sample of Bosnian Muslim refugees (n=126) drawn from a community centre and supplemented by a snowball sampling method, PTSD status and associated disability were measured using the clinician-administered PTSD Scale (CAPS) for DSM-IV. A principal components analysis (PCA) based on a pool of trauma items yielded four coherent trauma dimensions: Human Rights Violations, Threat to Life, Traumatic Loss and Dispossession and Eviction. A cluster analysis identified three subgroupings according to extent of trauma exposure. There were no differences in PTSD risk for the group most exposed to human rights violations (internment in concentration camps, torture) compared to the general war-exposed group. Logistic regression analysis using the dimensions derived from the PCA indicated that Threat to Life alone of the four trauma factors predicted PTSD status, a finding that supports the DSM-IV definition of a trauma. Both Threat to Life and Traumatic Loss contributed to symptom severity and disability associated with PTSD. It may be that human rights violations pose a more general threat to the survivor's future psychosocial adaptation in areas of functioning that extend beyond the confines of PTSD.

The Family Attitude Scale: reliability and validity of a new scale for measuring the emotional climate of families.

Research on outcomes from psychiatric disorders has highlighted the importance of expressed emotion (EE), but its cost-effective measurement remains a challenge. This article describes development of the Family Attitude Scale (FAS), a 30-item instrument that can be completed by any informant. Its psychometric characteristics are reported in parents of undergraduate students and in 70 families with a schizophrenic member. The total FAS had high internal consistency in all samples, and reports of angry behaviour in FAS items showed acceptable inter-rater agreement. The FAS was associated with the reported anger, anger expression and anxiety of respondents. Substantial associations between the parents' FAS and the anger and anger expression of students was also observed. Parents of schizophrenic patients had higher FAS scores than parents of students, and the FAS was higher if disorder duration was longer or patient functioning was poorer. Hostility, high criticism and low warmth on the Camberwell Family Interview (CFI) were associated with a more negative FAS. The highest FAS in the family was a good predictor of a highly critical environment on the CFI. The FAS is a reliable and valid indicator of relationship stress and expressed anger that has wide applicability.

Impact of recounting trauma stories on the emotional state of Cambodian refugees.

Twenty Cambodian refugees with premigration histories of trauma received an average of 16 sessions of individual therapy from a Cambodian bicultural counselor at a trauma treatment center in Sydney, Australia. Nineteen of the 20 patients reported that during treatment they had been willing to talk about their trauma histories, a finding that raises doubts about the commonly held belief that Asians are not psychologically minded and avoid disclosing emotionally sensitive information to health care workers. However, self-disclosing therapy alone did not appear to benefit these patients. Only four patients found talking about their trauma story directly helpful in improving their emotional state, and three of the four found the relief to be transitory.

Satisfaction of Vietnamese patients and their families with refugee and mainstream mental health services.

OBJECTIVE: The study examined levels of satisfaction with mainstream mental health services and specialized mental health services for refugees among Vietnamese psychiatric patients and their relatives. Demographic, diagnostic, symptomatic, and service-related issues that might influence satisfaction were investigated. METHODS: Eighty-six Vietnamese patients were identified from case notes of mainstream inpatient services (N = 31), mainstream community services (N = 7), and a specialized refugee treatment unit (N = 48). During an interview, a scale measuring satisfaction with treatment as well as measures of anxiety, depression, and posttraumatic stress disorder was administered to them. A modified satisfaction scale was administered to 56 relatives. RESULTS: Patients and relatives were, on average, moderately satisfied with treatment. Patients expressed greater satisfaction with the specialized treatment unit for refugees than with mainstream services, a finding that was not influenced by diagnostic differences or symptom levels at the time patients responded. Further analyses controlling for multiple comparisons revealed that the extent of the information provided and the ease of negotiating changes in treatment were the most salient variables in distinguishing satisfaction levels across the two types of treatment centers. Patients' fluency in English and their relatives' level of education were inversely associated with satisfaction scores, tentatively suggesting that the greater the ability of patients and their families to evaluate services, the less likely they were to express satisfaction with treatment. CONCLUSIONS: Specialized mental health services for refugees may be more acceptable to refugee populations than their mainstream counterparts, perhaps because better communication with patients and their families is possible in the specialized services. Patients and families who are in a position to evaluate services fully are more likely to be critical of treatments offered.

Continuities of separation anxiety from early life into adulthood.

The study investigates whether a putative diagnosis of separation anxiety disorder can be identified in adulthood and whether there are continuities between juvenile and adult forms of the disorder. Seventy patients with conventional adult diagnoses of panic disorder and generalized anxiety disorder attending an anxiety clinic were administered an interview and checklist to assess separation anxiety (SA) symptoms in adulthood. Memories of early SA were assessed using the Separation Anxiety Symptom Inventory (SASI). A subsample (n = 31) was used to calibrate the checklist against assignment to a category of adult separation anxiety disorder (ASAD) based on the structured interview. In an expanded sample (n = 70), patients assigned to the ASAD category returned statistically higher scores on the SASI, with the severity of juvenile SA symptoms accounting for 33% of the variance of adult SA scores (p < .001). Assignment of subjects to the putative ASAD category was not associated with any conventional adult anxiety diagnosis and symptoms of SA appeared to predate the onset of the other anxiety disorders. One possible explanation for the data is that, in some individuals, early onset separation anxiety disorder may persist into adulthood, but the symptoms may either be overlooked or, alternatively, obscured by secondary features such as panic.

Compounding of premigration trauma and postmigration stress in asylum seekers.

Unauthorized immigrants arriving in Western countries increasingly are being subjected to stringent restrictions while their residency claims are assessed. The present study was a investigation of premigration exposure to organized violence and postmigration stressors in 40 individuals seeking asylum who were attending a community welfare center in Sydney, Australia. Almost 80% reported exposure to premigration trauma such as witnessing murders, having their lives threatened, being separated from family members, and brainwashing; 25% had been tortured. Asylum seekers reported a marked decline in socioeconomic status. Common ongoing sources of severe stress included fears of being repatriated, barriers to work and social services, separation from family, and issues related to the process of pursuing refugee claims. More than one third had problems obtaining health services in Australia--the same number who reported similar difficulties in their home countries. Although based on a selective and culturally heterogeneous sample, the results suggest that salient aspects of the asylum-seeking process may compound the stressors suffered by an already traumatized group.

Is there an adult form of separation anxiety disorder? A brief clinical report.

OBJECTIVE: The aim of this clinical report is to investigate whether symptoms of separation anxiety disorder can occur in adulthood. CLINICAL PICTURE: Three cases are described to illustrate that adults may experience: wide-ranging separation anxiety symptoms, such as extreme anxiety and fear, when separated from major attachment figures; avoidance of being alone; and fears that harm will befall those close to them. Symptoms of panic appeared to be secondary to separation anxiety, and none of the patients fulfilled criteria for dependent personality disorder. TREATMENT: Group cognitive behavioural treatment focusing on preventing panic attacks and generalised anxiety did not appear to have an impact on core separation anxiety symptoms. OUTCOME: Exacerbations of separation anxiety appeared to be closely linked to actual or threatened ruptures to primary bonds. CONCLUSIONS: Separation anxiety disorder may be a neglected diagnosis in adulthood. Formal nosological systems such as the DSM may need to be revised to incorporate adult manifestations of the disorder.

Childhood bereavement circumstances associated with adult depression.

Seventy-nine women whose mothers had died during the subjects' childhood and whose fathers had remarried were studied to determine how bereavement might dispose to depression in adulthood. Lower social class appeared the most consistent predictor. The sudden death of the mother, the older age of the child, the perception of family support as being deficient in the immediate post-bereavement phase, a longer delay between the mother's death and the stepmother's assuming a maternal role, and the judgement of any replacement mother-figure as being inadequate were associated with adult depression. An important negative finding was that depression in the bereavement phase was neither predictive of a subsequent episode of depression nor of higher levels of state and trait depression in adulthood.

Adults who feared school: is early separation anxiety specific to the pathogenesis of panic disorder?

Although juvenile separation anxiety disorder is maintained to be a predisposing factor to adult panic disorder in DSM-III-R, past research has failed to clarify (a) whether it is separation anxiety per se or school refusal that is the pathogenic risk factor and (b) whether affected youngsters are specifically at risk of developing panic disorder rather than symptoms of general anxiety or phobias in later life. The present study of 74 adults who responded to media publicity found that a measure of early separation anxiety but not a history of school refusal was associated with risk of adult panic disorder according to DSM-III-R criteria. In contrast, separation anxiety scores were not associated with the presence or absence of general anxiety symptoms or phobic-avoidance in adulthood. Subjects with higher separation anxiety scores were more likely to have either a sibling or child with school refusal. Although the present study is limited in its method to mailed survey responses and, in part, to retrospective data, the results do provide additional support for Klein's influential separation anxiety theory of panic disorder.

Is there a false memory syndrome? A review of three cases.

The controversy over recovered memories of childhood sexual abuse (CSA) is whether such experiences can be forgotten for long periods and retrieved later in therapy or in response to cues or triggers from the environment. False memory syndrome (FMS) is caused by memories of a traumatic experience--most frequently CSA--which are objectively false, but in which the person strongly believes. Personality factors often play a role in the development of FMS. Because CSA is such a devastating experience, false accusations of sexual abuse have enormous, if not shattering, consequences for families. We present three case reports to illustrate features of the FMS. FMS should be listed for further study to establish valid criteria for making the diagnosis under the category of "factitious disorders," and a subcategory of "false memories/beliefs of abuse," with a further subdivision of "induced by therapy." The FMS controversy occurred in the context of a general moral panic about sexual abuse in the early 1980s. Psychiatrists should have a high degree of scepticism to moral panics.

Neurotic depression: delineation of symptom profiles and their relation to outcome.

Ninety-one subjects diagnosed clinically as having a 'neurotic depression' were interviewed and then re-assessed at 6 weeks and 20 weeks. Four symptom profiles of clinical features were derived: 'negative cognition', 'lack of drive', 'anxiety', and 'arousal', the last being independent of the other three dimensions and of the severity of depression. Symptom profile scores were then examined against antecedent risk variables and outcome. Links between profile scores and personality variables suggest that personality may colour the clinical presentation of neurotic/reactive depressions, and challenge the assumption that a typology of these depressive disorders based on clinical features is achievable. The break-up of an intimate relationship in the preceding 12 months was a strong predictor of a good outcome. Further analyses suggested, firstly, that there was a distinct subgroup delineated by this life event, with features weighted to the 'arousal' symptom profile, including many symptoms often associated with diagnosis of 'endogenous depression'; and, secondly, that this life event and a good outcome were directly linked, being uninfluenced by personality or other mediating variables.

Perceptions of general and specific therapist behaviors.

In the process of developing a two-part therapist rating scale, we obtained questionnaire responses from a large sample of subjects who had undergone one of a variety of psychotherapies. Our data support the importance of perceived therapist care as a strong correlate of patient satisfaction, and patients seemed able to discriminate clearly between psychodynamic and cognitive-behavioral therapies. In the first (nonspecific) questionnaire, we derived five dimensions (Care-Concern, Directive-Control, Critical-Confronting, Understanding, and Charisma) from principal-components analyses, with the first two dimensions being relatively independent of each other. A multiple-regression analysis revealed that combined scale scores accounted for 50% of the variance of patient satisfaction ratings, with the Care dimension accounting for most of this effect. In the second questionnaire, data were analyzed from respondents who had undergone therapy with known cognitive-behavioral or psychodynamic therapists; but, in a minority of subjects who were recruited through the media, we depended on detailed descriptive vignettes to allocate them to one or another of these "specific" types of psychotherapy. Six scales emerged, three characterizing cognitive-behavioral therapies (Behavioral Task Orientation, Organization, and Cognitive Focus) and three representing psychodynamic therapies (Transference, Inner Conflict, and Relationship). Subjects' ratings on all scales strongly discriminated between the two broad modalities of therapy, suggesting that patient reports may provide valid measures of therapist styles. We conclude that questionnaires such as the one we are developing may provide economical measures for assessing therapist consistency when comparing different modalities of psychotherapy.

Separation anxiety in adulthood: a phenomenological investigation.

Separation anxiety disorder is well recognized as a juvenile psychiatric disorder, but it appears to be rarely diagnosed in adulthood. Drawing on our clinical impressions and a review of the relevant literature, we sought to investigate whether separation anxiety symptoms could be identified in adulthood. Forty-four subjects recruited by a media campaign were administered a semistructured interview and a self-report checklist for adult separation anxiety (ASA) symptoms, as well as the Separation Anxiety Symptom Inventory (SASI), a retrospective measure of early separation anxiety symptoms. Diagnoses of major depressive disorder (MDD), panic disorder (PD), agoraphobia (Ag), and dependent personality disorder were made using the SCID-P and SCID-II. Thirty-six subjects met criteria for a putative diagnosis of ASA based on a global clinical rating and/or endorsement of DSM-IV-derived criteria. Although most subjects dated the separation anxiety symptoms to their juvenile years, it was notable that one third reported the first onset of separation anxiety symptoms in adulthood. Although comorbid lifetime anxiety or depressive disorders were common, the majority of subjects reported that the separation anxiety symptoms predated other axis I disorders. Only six subjects (17%) were diagnosed with dependent personality disorder. Although limited by the method of sampling, this preliminary study suggests the need to examine more systematically whether a form of separation anxiety disorder may occur in adulthood.