Discontinuing involuntary mental health holds for children: Does psychiatrist specialty matter? A pilot study.

BACKGROUND: Involuntary mental health detainments should only be utilized when less restrictive alternatives are unavailable and should be discontinued as soon as safety can be ensured. The study objective was to determine if child and adolescent psychiatrists discontinue a greater proportion of involuntary holds than general psychiatrists for similar pediatric patients. METHODS: Retrospective analysis of consecutive patients under 18 years placed on an involuntary hold in the prehospital setting presenting over a 1-year period to one high-volume emergency department (ED) where youth on involuntary holds are seen by child and adolescent psychiatrists when available and general psychiatrists otherwise. The primary outcome of interest was hold discontinuation after initial psychiatric consultation. The key predictor of interest was psychiatrist specialty (child and adolescent vs. general). We conducted multivariate logistic regression modeling adjusting for patient characteristics and time of arrival. RESULTS: Child and adolescent psychiatrists discontinued 27.4% (51/186) of prehospital holds while general psychiatrists discontinued only 10.6% (22/207). After adjusting for observable confounders, holds were over 3 times as likely to be discontinued in patients evaluated by child and adolescent psychiatrists rather than general emergency psychiatrists (adjusted OR 3.2, 95% CI 1.7-5.9, p < 0.001). CONCLUSIONS: Child and adolescent psychiatrists are much more likely to discontinue prehospital involuntary mental health holds compared with general emergency psychiatrists. While inappropriate hold discontinuation places patients at risk of harm, prolonged hold continuation limits patients' rights and potentially increases psychiatric boarding in EDs. Earlier access to child and adolescent psychiatry may facilitate early hold discontinuation and standardize patient care.

Redefining phenotypes to advance psychiatric genetics: Implications from hierarchical taxonomy of psychopathology.

Genetic discovery in psychiatry and clinical psychology is hindered by suboptimal phenotypic definitions. We argue that the hierarchical, dimensional, and data-driven classification system proposed by the Hierarchical Taxonomy of Psychopathology (HiTOP) consortium provides a more effective approach to identifying genes that underlie mental disorders, and to studying psychiatric etiology, than current diagnostic categories. Specifically, genes are expected to operate at different levels of the HiTOP hierarchy, with some highly pleiotropic genes influencing higher order psychopathology (e.g., the general factor), whereas other genes conferring more specific risk for individual spectra (e.g., internalizing), subfactors (e.g., fear disorders), or narrow symptoms (e.g., mood instability). We propose that the HiTOP model aligns well with the current understanding of the higher order genetic structure of psychopathology that has emerged from a large body of family and twin studies. We also discuss the convergence between the HiTOP model and findings from recent molecular studies of psychopathology indicating broad genetic pleiotropy, such as cross-disorder SNP-based shared genetic covariance and polygenic risk scores, and we highlight molecular genetic studies that have successfully redefined phenotypes to enhance precision and statistical power. Finally, we suggest how to integrate a HiTOP approach into future molecular genetic research, including quantitative and hierarchical assessment tools for future data-collection and recommendations concerning phenotypic analyses. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Controvérsias sobre o uso do DSM para diagnósticos de transtornos mentais / Controversies about the use of DSM for mental disroders diagnoses

Resumo O número de diagnósticos de transtornos mentais cresceu significativamente em paralelo à disseminação das edições do Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM). Neste contexto, desenvolvemos este ensaio com a finalidade de compreender o uso do DSM como instrumento para fundamentar os diagnósticos de transtornos mentais. Para embasar o presente estudo, lançou-se mão de publicações científicas de autores que discutiram as edições do DSM, assim como as classificações psiquiátricas. Constatamos que há controvérsias em relação ao Manual, as quais descrevemos por um lado como conveniências e, por outro, como críticas. Há lugares em que esta lógica do DSM é conveniente, uma vez que gera benefícios a diversos setores, como seguros de saúde e indústria farmacêutica. As principais críticas ao DSM ressaltam o fato de o Manual transformar o sofrimento psíquico em patologias de cunho cerebral.

Abstract The number of diagnoses of mental disorders has grown significantly parallel to the dissemination of the editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In this context, we developed this essay in order to understand the use of DSM as an instrument to support the diagnosis of mental disorders. To do so, we have used scientific publications by authors who have discussed DSM issues, as well as psychiatric classifications. We find that there are controversies regarding the Manual, which we describe on the one hand as conveniences, and on the other, as criticisms. There are places where this logic of the DSM is convenient, since it generates benefits to several sectors, such as health insurance and pharmaceutical industry. The main criticisms of DSM are the fact that the Manual transforms psychic suffering into cerebral pathologies.

Psychiatric comorbidities in autism spectrum disorder: A comparative study between DSM-IV-TR and DSM-5 diagnosis / Comorbilidades psiquiátricas en los trastornos del espectro autista: estudio comparativo entre los criterios DSM-IV-TR y DSM-5

Background/Objective: The heterogeneous clinical presentations of individuals with Autism Spectrum Disorders (ASD) pose a significant challenge for sample characterization. Therefore the main goal of DSM-5 must be to identify subgroups of ASD, including comorbidity disorders and severity. The main goal of this study is to explore the psychiatric comorbidities and the severity of symptoms that could be relevant for the phenotype characterization in ASD and also to compare these results according to the different classification criteria between the DSM-IV-TR and the DSM-5. Method: A comparative study of severity and psychiatric comorbidities was carried out between a sample of participants that only met criteria for Pervasive Developmental Disorder (PDD) according to the DSM-IV-TR and a sample of participants that also met ASD criteria according to DSM-5 classification. The recruitment of children was via educational (N=123). The psychiatric symptoms, comorbid disorders and severity of symptoms were assessed through The Nisonger Child Behavior Rating Form, clinical interview and The Inventory of Autism Spectrum Disorder, respectively. The psychiatric comorbidities considered were: anxiety, eating behavioural problems, self-aggressiveness, hetero-aggressiveness, self-harm, obsessive compulsive disorder and attention deficit and hyperactivity disorder. Results: Statistically significant differences between both groups were found regarding obsessive compulsive disorder, eating behavioural problems and severity. Conclusions: The results support the hypothesis that patients who meet the DSM-5 criteria have more severe symptoms, not only regarding the core autistic symptoms but also in relation with psychiatric comorbidities (AU)

Antecedentes/Objetivo: Los Trastornos del Espectro Autista (TEA) incluyen un grupo heterogéneo en cuanto a su presentación clínica, que supone un desafío a nivel de caracterización diagnóstica. Por consiguiente, el objetivo principal de la clasificación DSM-5 debería de ser identificar subgrupos de TEA incluyendo severidad y comorbilidades psiquiátricas. El objetivo principal de este estudio es explorar las comorbilidades diagnósticas que pueden ser relevantes como descriptores de fenotipos autistas así como la severidad de los síntomas de autismo y comparar los resultados de las diferentes criterios de clasificación entre el DSM-IV-TR y el DSM-5. Método: Se realiza un estudio comparativo de severidad y comorbilidades psiquiátricas entre una muestra con diagnóstico de Trastorno Generalizado del Desarrollo, según criterios DSM-IV-TR, y una muestra que cumplía también criterios para TEA según la clasificación DSM-5. La muestra fue obtenida en centros educativos (N=123). Las comorbilidades psiquiátricas y la severidad de los síntomas se evaluaron a través del The Nisonger Child Behavior Rating Form, entrevista clínica y el Inventario de Trastorno del Espectro Autista, respectivamente. Las comorbilidades estudiadas fueron ansiedad, alteraciones de la conducta alimentaria, auto-agresividad, hetero-agresividad, autolesiones, trastorno obsesivo-compulsivo y déficit de atención e hiperactividad. Resultados: Se encontraron diferencias estadísticamente significativas entre ambos grupos para trastorno obsesivo-compulsivo, alteraciones de la conducta alimentaria y severidad. Conclusiones: Se apoya la hipótesis de que los individuos que cumplen criterios diagnósticos según DSM-5 tienen mayor severidad sintomática, no sólo con respecto a los síntomas autistas centrales, sino también en relación con comorbilidades psiquiátricas (AU)

RDoC and shift of reference.

OBJECTIVE: This paper aims to analyse in a philosophically informed way the recent National Institute of Mental Health proposal for the Research Domain Criteria (RDoC) framework. CONCLUSION: Current classification systems have helped unify psychiatry and the conditions that it is most concerned with. However, by relying too much on syndromes and symptoms, they too often do not define stable constructs. As a result, inclusions and removals from the manuals are not always backed by sound reasons. The RDoC framework is an important move towards ameliorating matters. This paper argues that it improves the current situation by re-referencing constructs to physical properties (biomarkers for disorders, for example), by allowing theoretical levels within the framework, and by treating psychiatry as a special case of the cognitive sciences.

[Historical Development of Symptomatology in Psychosis with Reference to Pathogenesis].

The role of mental symptomatology is to describe various clinical symptoms without refer- ring to their pathogenesis. This may be because of the influence of K. Jasper's General Psycho- pathology. However, from the mid-19th to early 20th century, when modern psychiatry was estab- lished, some excellent hypotheses concerning the pathogenesis of mental symptoms were pro- posed, although it was difficult to verify these hypotheses because of technical limitations. The purpose of this article was to review the historical development of symptomatology in psycho- sis with reference to the pathogenesis. W. Griesinger (1845, 1861) distinguished between the etiology and pathogenesis of a disease, and stated that every mental disease is a manifestation of brain disease. Subsequent investigators elaborated on this view : C. Wernicke (1894, 1906) proposed the disconnection of the association tracts, and P. Flechsig (1894, 1920) regarded the late myelinating "association areas"' (this term was from Flechsig) as the field of the mind. J. H. Jackson (1895) proposed the evolutionary and hierarchical organization of the nervous system. E. Kraepelin (1913) speculated on the hypoactivity of the frontal cortex-the highest cerebral centers according to Jackson's terminology-and hyperactivity of the temporal speech cortex as the pathogenesis of psychotic symptoms in dementia praecox, which were found to be the case based on neuroimaging methods over sixty years later. Currently, the pathogenesis of mental symptoms is being investigated from the viewpoint of the dysfunctions of neural cir- cuits, such as cortico-limbic, cortico-thalamic, or cortico-striatal circuitry.

Is treatment-resistance in psychiatric disorders a trap for polypharmacy?

BACKGROUND: Nowadays, more and more mental health professionals manage patients who fail treatment for major psychiatric disorders. There is not a consensus on how to deal with treatment-resistance patients, but usually psychiatrists result to polypharmacy. METHOD: In reviewing the evidence based clinical research we will try to answer some questions about treatment-resistant psychiatric disorders. Treatment-resistant symptoms complicate the clinical course of all psychiatric disorders especially schizophrenia, causing the patients not to reach the therapeutical goal and enter remission. In consequence, polypharmacy is used to try to deal with the remaining symptoms, raising other issues. SUMMARY: We will try to deal with this problematic issue through clinical studies and major research done to try and answer the question posed.

Psychodynamics and psychopharmacotherapy in the treatment of difficult patients with personality and eating disorders.

The complex inter-relationship between external and internal reality, a source of interest and controversy in psychiatry, has come to the foreground more prominently in the context of more integrative understanding of psychopharmacotherapy. This paper discusses the meaning and clinical applications of the psychodynamic related to psychopharmacotherapy for difficult personality and eating disorders patients. The one of the psychodynamic explanations for patients' being difficult is related to their perceived lack of mentalizing (reflective) capacities. Lack of mentalizing capacity implies disturbed view of psychopharmacotherapy. Therapeutic relationship and optimal alliance offers the frame for acceptance of psychiatric drugs as positive and useful for personality and eating disorder patients. Mentalization and intersubjectivity theories have direct implications for clinical practice, and that the notion of the third is particularly useful in understanding what happens in the patient-doctor relationship.

Almanaques de locos: la representación popular de la locura en la España de posguerra / Almanaques de Locos: Popular depiction of madness in Spain’s postwar period

Los Almanaques de Locos fueron revistas de historieta publicadas en el período 1946-1963. Contaban con una amplia difusión y se trataba de publicaciones de humor cuyo contenido se centraba en una visión cómica de la locura, dando lugar a numerosas representaciones sobre los trastornos mentales, su asistencia y sus profesionales. El análisis de sus contenidos ofrece una interesante visión de las ideas, actitudes y conocimientos que el público general de su época tenía sobre estos temas. El presente trabajo pretende brindar una perspectiva general sobre los contenidos de los Almanaques y resaltar su valor como testimonio histórico (AU)

Almanaque de Locos was a comic book edited in Spain between 1946 and 1963. Had a wide circulation and was humorous publications whose content is focused on a comic vision of madness, resulting in numerous representations about mental disorders, attendance and professional. The analysis of its contents provides an interesting insight into the ideas, attitudes and knowledge that the general public of his day had on these issues. This paper aims to provide an overview of the contents of the Almanacs and highlight their value as historical Testimony (AU)

Aspectos conceptuales sobre el proceso de decisión compartida en salud mental / Conceptual analysis of shared decision-making process in mental health

Uno de los cambios más importantes en la atención sanitaria de las últimas décadas, en lo que a las decisiones terapéuticas se refiere, ha sido la transición desde un modelo centrado en la enfermedad a uno centrado en el paciente. Esto conlleva la progresiva sustitución de una aproximación paternalista por una más deliberativa y, en relación a los tratamientos farmacológicos, del concepto de cumplimiento o adherencia al de concordancia o acuerdo terapéutico. El concepto de concordancia, por su parte, ha sido contemplado como el objetivo final de un proceso de negociación y corresponsabilidad en la decisión de elegir un tratamiento al que se ha denominado proceso de decisión compartida (PDC) (shared decision making). Hasta el momento, el PDC ha sido escasamente implantado en trastornos mentales graves, cuando no contestado como inadecuado dada la presunta alteración de la capacidad del paciente psiquiátrico gravemente enfermo para tomar decisiones. Sin embargo, esta incapacidad no siempre está presente por lo que la decisión compartida debe contemplarse como premisa y no como excepción. El PDC implica la implantación de un procedimiento en etapas (asociación médico paciente, información sobre opciones, pros y contras, deliberación sobre las mismas y su relación con valores y preferencias del paciente, decisión consensuada). Un de las barreras más importantes para la aplicación del proceso de decisión compartida en salud mental es la cuestión de la capacidad del enfermo mental. Por ello, la evaluación de la capacidad debe hacerse central en la práctica clínica psiquiátrica (AU)

One of the most important changes in health care in recent decades, regarding the therapeutic decisions, has been the transition from a model focused on the disease to other one focused on the patient. This entails the progressive replacement of a paternalistic approach by a more deliberative one and, in relation to pharmacological treatments, the concept of compliance or adherence to the therapeutic agreement. The concept of therapeutic agreement, on the other hand, has been referred to as the ultimate goal of a process of negotiation and co-responsibility in the decision to choose a treatment which has been called 'shared decision making process' (SDM). So far, the SDM has been poorly implemented in severe mental disorders, when not answered as inadequate given the alleged alteration of the seriously ill psychiatric patient’s ability to make decisions. However, this inability is not always present so shared decision should be viewed as a premise and not as an exception. SDM involves the introduction of a procedure in stages (doctor-patient partnership, information about options, pros and cons, deliberation about them and their relationship with the values and preferences of the patient, consensual decision). One of the most important barriers for the implementation of the shared mental health decision-making process is the question of the capacity of the mentally ill. Therefore, the evaluation of the capacity must be central in psychiatric clinical practice (AU)

Towards Constructing a New Taxonomy for Psychiatry Using Self-reported Symptoms.

The Diagnostic and Statistical Manual (DSM) has served as the gold standard for psychiatric diagnosis for the past several decades in the USA, and DSM diagnoses mirror mental health and substance abuse diagnoses in ICD-9 and ICD-10. However, DSM diagnoses have severe limitations when used as phenotypes for studies of the pathophysiology underlying mental disorders, as well as for clinical treatment and research. In this paper, we use a novel approach of deconstructing DSM diagnostic criteria, and using expert knowledge to inform feature selection for unsupervised machine learning. We are able to identify clusters of symptoms that stratify subjects with the same DSM disorders into cohorts with increased clinical and biological homogeneity. These findings suggest that itemized self-report symptom data should inform a new taxonomy for psychiatry, and will enhance the bi-directional translation of knowledge from the bench to the clinic through a common terminology.

[The dubious 'reality' of a psychiatric classification]. / De realiteitsaanspraak van het psychiatrisch etiket.

BACKGROUND: The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, incorporates many new classifications, but some of the classifications that appeared in earlier editions have been dropped. The article comments on and clarifies some of the items that have caused controversy. AIM: To investigate whether a psychiatric classification can ever depict reality of whether it is in fact a social construct. METHOD: The article is based on a review of the literature and provides a conceptual analysis of articles and manuals. RESULTS: An attempt has been made to distinguish between different kinds of psychiatric classifications; the 'kinds' can range from natural to artificial and can be practical , interactive or indifferent. This part of the study has led to the conclusion that the way in which we view the type of psychiatric disorders is determined by our entrenched 'subject-object' way of thinking. CONCLUSION: The dichotomy between natural (object) and artificial (subject) should be abandoned and the 'reality' of a psychiatric classification should be seen as a continuum and evolutionary process.

Identification and validation of mixed anxiety-depression.

BACKGROUND: Mixed anxiety-depression (MAD) has been under scrutiny to determine its potential place in psychiatric nosology. The current study sought to investigate its prevalence, clinical characteristics, course and potential validators. METHOD: Restricted latent-class analyses were fit to 12-month self-reports of depression and anxiety symptom criteria in a large population-based sample of twins. Classes were examined across an array of relevant indicators (demographics, co-morbidity, adverse life events, clinical significance and twin concordance). Longitudinal analyses investigated the stability of, and transitions between, these classes for two time periods approximately 1.5 years apart. RESULTS: In all analyses, a class exhibiting levels of MAD symptomatology distinctly above the unaffected subjects yet having low prevalence of either major depression (MD) or generalized anxiety disorder (GAD) was identified. A restricted four-class model, constraining two classes to have no prior disorder history to distinguish residual or recurrent symptoms from new onsets in the last year, provided an interpretable classification: two groups with no prior history that were unaffected or had MAD and two with prior history having relatively low or high symptom levels. Prevalence of MAD was substantial (9-11%), and subjects with MAD differed quantitatively but not qualitatively from those with lifetime MD or GAD across the clinical validators examined. CONCLUSIONS: Our findings suggest that MAD is a commonly occurring, identifiable syndromal subtype that warrants further study and consideration for inclusion in future nosologic systems.