Operational criteria application does not change clinicians' opinion on the diagnosis of mental disorder: a pre- and post-intervention validity study.

Objective: Our objective was to check if the ICD-10 operational criteria application changes non-operational, prototype-based diagnoses obtained in a real-life scenario. Methods: Psychiatry residents applied the diagnostic criteria of the ICD-10 as a "diagnostic test" to five outpatient patients they were already following who had a prototype-based diagnosis. Tests were used to ascertain whether changes in opinion were significant and if any of the diagnostic groups were more prone to change than others. The present paper is part of the study with UTN U1111-1260-1212. Results: Seventeen residents reviewed their last five case files, retrieving 85 diagnostic pairs of non-operational-based vs. operational-based diagnoses. The Stuart-Maxwell test did not indicate a significant opinion change (χ2 = 5.25, p = 0.39; power = 0.94) besides 30% of diagnostic changes. Despite not being statistically significant, 20.2% of all evaluations resulted in a change that would affect treatment choices. Using ICD-10 operational criteria slightly increased the number of observed diagnoses, but probably without clinical relevance. None of the non-operational diagnoses have a higher tendency to change with operational criteria application (χ2 = 11.6, p = 0.07). The female gender was associated with a higher diagnostic change tendency. Conclusion: Applying ICD-10 operational criteria as a diagnostic test does not induce a statistically significant diagnostic opinion change in residents and no diagnostic group seems more sensible to diagnostic change. Gender-related differences in diagnostic opinion changes might be evidence of sunk cost bias. Although not statistically significant, using operational criteria after diagnostic elaboration might help to deal with subjects without adequate treatment response.

Non-standard diagnostic assessment reliability in psychiatry: a study in a Brazilian outpatient setting using Kappa.

The use of Structured Diagnostic Assessments (SDAs) is a solution for unreliability in psychiatry and the gold standard for diagnosis. However, except for studies between the 50 s and 70 s, reliability without the use of Non-SDAs (NSDA) is seldom tested, especially in non-Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. We aim to measure reliability between examiners with NSDAs for psychiatric disorders. We compared diagnostic agreement after clinician change, in an outpatient academic setting. We used inter-rater Kappa measuring 8 diagnostic groups: Depression (DD: F32, F33), Anxiety Related Disorders (ARD: F40-F49, F50-F59), Personality Disorders (PD: F60-F69), Bipolar Disorder (BD: F30, F31, F34.0, F38.1), Organic Mental Disorders (Org: F00-F09), Neurodevelopment Disorders (ND: F70-F99) and Schizophrenia Spectrum Disorders (SSD: F20-F29). Cohen's Kappa measured agreement between groups, and Baphkar's test assessed if any diagnostic group have a higher tendency to change after a new diagnostic assessment. We analyzed 739 reevaluation pairs, from 99 subjects who attended IPUB's outpatient clinic. Overall inter-rater Kappa was moderate, and none of the groups had a different tendency to change. NSDA evaluation was moderately reliable, but the lack of some prevalent hypothesis inside the pairs raised concerns about NSDA sensitivity to some diagnoses. Diagnostic momentum bias (that is, a tendency to keep the last diagnosis observed) may have inflated the observed agreement. This research was approved by IPUB's ethical committee, registered under the CAAE33603220.1.0000.5263, and the UTN-U1111-1260-1212.

Mental State Examination and Its Procedures-Narrative Review of Brazilian Descriptive Psychopathology.

Background: Mental State Examination (MSE) is compared with physical examination as a reliable method of objective data investigation. There is a growing concern with psychiatric clinics, nosology, and the reliability of diagnostic interview methods as a source of valid diagnostic strategy. Efforts to achieve an international diagnosis protocol have been unsuccessful or polemical. This paper focuses on psychopathology, MSE, and mental function development within Brazilian psychiatry over the last few decades. Methods: Searches, interviews, and narrative reviews were done to look for systematic ways in which to conduct MSE, mental functions, symptom clusters, orientations about data observation and records. Brazilian psychopathology textbooks were examined, if they provided access to consolidated knowledge on psychopathology examination. Results: Sixteen textbooks were selected from a 49 year span. Descriptive psychopathology with phenomenological orientation was the primary trend in the MSE. Concepts derived from different traditions, most lacking common terminology, suggested some divergence among authors. Recommendations for patient observation and how to collect objective data was clear, but MSE standardization efforts were missing. A detailed description of mental function abnormalities was the main MSE record strategy, without consensus about ways to summarize and record this data. In an examination summary, mental strata was divided into "mental functions," and MSE subsets were frequent. All authors considered the following mental functions: consciousness, perception, thought, memory, attention, orientation, and volition. Discussion: Psychiatric competence demands MSE proficiency. Official documents are not clear about performance and recording standards. MSE data was usually recorded through descriptive psychopathology. A shift from detailed descriptive findings, to an array of observed pathological elements, described through a mental function checklist was observed over time. Clinical practice and research guidelines should consider the development of reliable MSE practices; however, it has been neglected by modern psychiatry/neuroscience through the excessive emphasis on interview protocols. Better MSE practices, and the improvement of bedside skill in psychiatry are necessary and depend on the recovery of psychopathological debates and semiological reasoning, which will allow the return of phenomenology-oriented "observational" techniques.

Pathological gambling treated with lithium: the role of assessing temperament.

BACKGROUND AND AIMS: Pathological gambling is a condition for which there is still no FDA-approved treatment although some medications seem to be effective at reducing its symptoms. In DSM-V, it is now classified as an addiction disorder. Data show that baseline comorbidities in patients with gambling and substance misuse behavior are frequent. These might include not only major syndromes but also subclinical ones. Bipolar spectrum conditions are often among these comorbidities. Lithium has been showed to be effective in PG subjects with bipolar spectrum comorbidity, and we present a case where assessment of temperament was helpful in treatment selection. CONCLUSIONS: This case illustrates the clinical benefits of how the assessment of temperament and comorbidities in pathological gambling patients may guide the clinician to a successful treatment choice. The case presented also corroborates previous evidence on the efficacy of lithium in patients with pathological gambling and comorbid bipolar spectrum conditions and euphoric temperament. Future clinical trials on pathological gambling pharmacotherapy should include temperament assessment to evaluate its influence on different outcomes.

Morbidade psiquiátrica menor em trabalhadores da área de saúde / Minor psychiatric morbidity in healthcare workers

Sintomas ansiosos, depressivos e somatoformes, comumente referidos como morbidade psiquiátrica menor (MPM), apresentam elevada prevalência na população geral adulta, além de serem diagnosticado s em um terço ou mais das pessoas que procuram atendimentos em serviços primários de saúde. A distribuição dessa categoria de morbidade mostra-se iníqua na população geral, pois há fatores de risco já bem estabelecidos que influenciam a sua ocorrência e persistência. O objetivo do presente estudo foi investigar a prevalência da MPM nos trabalhadores da área de saúde de uma unidade hospitalar e sua associação com características sócio-demográficas, fatores estressores de vida e acidentes de trabalho. Trata-se de um estudo seccional em 404 trabalhadores de saúde, cuja variável dependente foi o instrumento de rastreio epidemiológico General Health Questionnaire (GHQ-12). É um instrumento validado para a língua portuguesa do BrasilA coleta de dados foi realizada por meio de questionário estruturado e de autopreenchimento, aplicado com apoio de pessoal treinado. As variáveis associadas testadas foram: sócio-demográficas; Fatores Estressores de Vida listados no Manual Diagnóstico e Estatísti co dos Transtornos Mentais (DSM-IV) e a ocorrência de ac identes de trabalho. Adicionalmente, os hábitos sociais comumente associados à MPM: uso de álcool, tabagismo e trabalho em turnos de plantão...

Encontrou-se associações no nível de significância 5 por cento na amostra entre MPM e as seguintes características no modelo de regressão logística múltipla: dificuldades financeiras graves OR 2,80 (IC95 por cento 1,37-5,69) e mudança forçada de domicílio nos últimos 12 meses OR 3,32 (IC95 por cento 1,18-9,39); e escolaridade igual ou maior que nível superior OR 3,95 (IC95 por cento1,48-10,59). Conclusão: A prevalência de morbidade psiquiátrica menor detectada neste estudo foi conservadora (13 por cento), provavelmente devido ao ponto de corte mais específico. Consistente com outros estudos nacionais e internacionais, dificuldades financeiras estiveram associadas a morbidade psiquiátrica menor...

Transtorno delirante: a paranóia nos dias de hoje / Delusional disorder: paranoia nowadays

O conceito médico de paranóia começa com Heinroth, na Alemanha, passa por Kraeplin, e chega até os dias de hoje, no DSM-IV e na CID-10, agora com a denominaçäo de transtorno delirante. Este se caracteriza pela presença de delírios näo-bizarros e crônicos, näo associados a outras alteraçöes psicopatológicas importantes. Existem dúvidas quanto à sua validade como uma categoria nosológica independente. A sua prevalência é estimada em 0,03 por cento. Embora os antipsicóticos sejam a opçäo terapêutica de primeira escolha, a sua eficácia ainda näo está comprovad, em funçäo da escassez de ensaios clínicos controlados. Algumas críticas säo levantadas em relaçäo à definiçäo de delírio de Karl Jaspers, e à distinçäo que ele fez entre idéias deliróides. Säo relatados três casos, clínicos: um do subtipo persecutório, outro do erotomaníaco, e outro do de ciúmes, este extraído do romance de Dom Casmurro, de Machado de Assis

Transtorno delirante: a paranoia nos dias de hoje

O conceito medido de paranoia comeca com Heinroth, na Alemanha, passa por Kraepelin, e chega ate os dias de hoje, no DSM-IV e na CID-10, agora com a denominacao de transtorno delirante. Este se caracteriza pela presenca de delirios nao-bizarros e cronicos, nao associados a outras alteracoes psicopatologicas importantes. Existem duvidad quanto a sua validade como uma categoria nosologica independente. A sua prevalencia e estimada em 0,03. Embora os antipsicoticos sejam a opcao terapeutica de primeira escolha, a sua eficacia ainda nao esta comprovada, em funcao da escassez de ensaios clinicos controlados. Algumas criticas sao levantadas em relacao a definicao de deliriode Karl Jaspers, e a distincao que ele fez entre ideias delirantes autenticas e ideias deliroides. Sao relatados tres casos clinicos:; um do subtipo persecutorio, outro do erotomaniaco, e outro do de ciumes, este estraido do romance Dom Casmurro, de Machado de Assis.