Exploring the borders of the schizoaffective spectrum: a categorical and dimensional approach

BACKGROUND: Schizoaffective disorder has long been considered as an intermediate condition between major mood disorders and schizophrenia, however, the nature of the relationship to these diagnoses remains unclear. We aimed at examining the nature of such a relationship in a mixed sample of psychotic disorders by using a dimensional and categorical approach to psychopathology. METHODS: Six-hundred and sixty psychotic inpatients were assessed for lifetime ratings of mania, depression, psychosis and incongruence, diagnosed according to Research Diagnostic Criteria, and classified as having nonaffective psychosis without mood syndromes (n=429), nonaffective psychosis with mood syndromes (n=101), schizoaffective disorder mainly schizophrenic (n=41), schizoaffective disorder mainly affective (n=42) or mood disorder with psychotic symptoms (n=47). We tested for associations of illness-related features including risk factors, premorbid, clinical and outcome variables with classes of disorders and lifetime ratings of psychopathology, and examined the relative contribution of categorical and dimensional representations of psychopathology in explaining disease characteristics. RESULTS: While categories at the extreme end of the psychotic spectrum meaningfully differed across a number of the illness-related variables, no substantial discontinuity was apparent between adjacent categories of psychotic disorders. Risk factors, premorbid adjustment, clinical features and impairment appeared to be present in a mostly monotonic continuous fashion from nonaffective psychoses to mood disorders with psychotic features. The overall association pattern of illness-related variables with mood and psychotic syndromes was largely independent of specific diagnostic categories, and the dimensional approach was neatly superior to the traditional diagnostic approach in explaining the characteristics of the illness. LIMITATIONS: This was a cross-sectional study with retrospective assessment of illness-related-variables and lifetime psychopathology. CONCLUSION: The results are compatible with the notion of the schizoaffective spectrum and with a continuum model of the psychotic illness.     

To what extent does symptomatic improvement result in better outcome in psychotic illness? UK700 Group

BACKGROUND: The effectiveness of therapeutic interventions in psychosis is increasingly reported in terms of reductions in different symptom dimensions. It remains unclear, however, to what degree such symptomatic changes are accompanied by improvement in other measures such as service use, quality of life, and needs for care. METHODS: A sample of 708 patients with chronic psychotic illness was assessed on three occasions over 2 years (baseline, year 1 and year 2). A multilevel analysis was conducted to examine to what degree reduction in psychopathological scores derived from factor analysis of the Comprehensive Psychopathological Rating Scale (CPRS), was associated with improvement in service use, disability, subjective outcomes and measures of self-harm. RESULTS: Reduction in positive, negative, depressive and manic symptoms over the study period were all independently associated with lessening of social disability. Reduction in negative symptoms, and to a lesser extent in positive and manic symptoms, was associated with less time in hospital and more time living independently, whereas changes in positive and manic symptoms resulted in fewer admissions. Subjective outcomes such as improvement in quality of life, perceived needs for care and dissatisfaction with services showed the strongest associations with reduction in depressive symptoms. Reduction in positive symptoms was associated with decreased likelihood of parasuicide. Results did not differ according to diagnostic category. CONCLUSION: The findings suggest that changes in distinct psychopathological dimensions independently and differentially influence outcome. Therapeutic interventions aimed at reducing symptoms of more than one dimension are likely to have more widespread effects.     

Behavioral assessment of psychopathology in children: infantile autism

The utility of a subtest of 14 items from the Children's Psychiatric Rating Scale (CPRS) for evaluating psychopathology in autistic children was examined. A series of 180 autistic children, who satisfied the DSM-III criteria for Infantile Autism, Full Syndrome Present, were rated on the CPRS. A series of children with conduct disorder diagnoses were added to provide a contrast group for investigating specificity of behavioral manifestations with regard to autism. Multivariate analysis was used to elucidate major behavioral dimensions, to identify distinct subtypes, and to evaluate discriminant validity of the CPRS behavioral ratings.     

Taxometric Methods and the Classification and Comorbidity of Mental Disorders: Methodological and Conceptual Considerations

Taxometric methods have become increasingly popular in research on the structure of psychopathology. The majority of this research has entailed study of a single psychopathological construct that differentiates a conjectured taxon group (e.g., persons with the target disorder or vulnerability) from a complement group (e.g., normal controls, persons with disorders other than the target condition). Although indicator and sample selection are important in these endeavors, these issues are more critical to the extension of taxometrics to the study of comorbidity (simultaneous taxometric evaluation of multiple psychopathological constructs). Selected methodological and conceptual issues in the application of taxometrics to the understanding of comorbidity are discussed, as well as the implications of taxometric and comorbidity research on the categorical versus dimensional classification of mental disorders.     

Dimensional versus categorical classification of prototypic and nonprototypic cases of personality disorder

This study examined interrater reliability and ratings of confidence and clinical utility (professional communication, case conceptualization, treatment planning) of categorical and dimensional approaches to diagnosing prototypic and nonprototypic personality disorder cases. Two national samples of psychologists (n = 93, n = 92) participated. Interrater reliability was higher for prototypic cases than nonprototypic cases for the categorical system, but similar for prototypic and nonprototypic cases using dimensional ratings. Across cases, interrater reliability and confidence were highest for the categorical model, hybrid models, and the five-factor model. However, ratings of clinical utility were highest for the categorical and the hybrid models, even when interrater reliability was inadequate, suggesting clinician preference for a classification based on the existing categories. Mean ratings for the prototypic cases supported the theorized relationships between the dimensional models and the personality disorders. Reasons for these findings and implications for moving towards a dimensional model of personality disorder are discussed.     

Interactive effect of substance abuse and depression on adolescent social competence.

This study explored the interactive effect of substance abuse and depression on social competence among 106 adolescent inpatients (57% female, 86% Caucasian). Substance abuse and depression were conceptualized using dimensional ratings of illness severity based on adolescent interviews, whereas social competence was conceptualized using parent ratings of adolescent behavior. Cross-sectional analyses revealed that substance abuse and depression had a negative interactive effect on adolescent social competence: Higher severity levels of both dimensions were associated with lower levels of competence than accounted for by the additive effects of the two dimensions. These findings persisted when controlling for gender, race, and other common dimensions of psychopathology. Significant impairment in social competence occurred at subdiagnostic levels of substance abuse when depression severity was high, highlighting the value of assessing outcomes across the full range of severity.     

Disguise and the structured self-report assessment of psychopathology: II. A clinical replication

Previous research on the use of disguise in structured tests of psychopathology is extended to a clinical population. Based on a sample of 112 adult psychiatric patients for whom clinical criterion ratings were obtained, psychopathological test item validities were calculated and related to indices of test item disguise. Data contraindicated the use of disguise and were interpreted in terms of the various philosophies of test construction that underlie the structured assessment of psychopathology. In particular, results suggested the merit of a rational test construction strategy that emphasizes the use of relevant test item content.     

Confidence in one-self and confidence in one's own body: The revival of an old paradigm for anorexia nervosa

Impaired interoceptive function represents an important variable in the psychopathology of anorexia nervosa (AN) and is thought to be influenced by maladaptive schemas grounded on early intimate interactions. However, the role of the different psychological processes involved in the interoceptive function has been poorly assessed in AN. We aimed to investigate the associations between adult insecure attachment, interoceptive processes, and psychopathology. One hundred and fifty participants with AN completed self-report questionnaires: the Multidimensional Assessment of Interoceptive Awareness, which measures interoception dimensions; the Attachment Style Questionnaire, assessing adult attachment styles, and the Eating Disorder Inventory-2, exploring eating-related core symptoms. Pearson's correlations were employed to assess the relationships between MAIA and EDI-2 subscores. Structural equation models (SEM) were performed to investigate the relationships between insecure attachment dimensions, interoception, and AN core symptoms as latent variables. Body listening, self-regulating, and trusting were interoceptive dimensions associated with eating psychopathology. As confirmed by an exploratory factor analysis, these interoceptive dimensions are included in a latent variable which points to “confidence” in body sensations. SEM showed that insecure, in particular anxious, attachment predicts body “confidence” and, in turn, AN core symptoms. Confidence in body sensations as a trustworthy source of knowledge represents the specific interoceptive dimension associated with psychopathology in AN. In accordance with Bruch's model of AN, insecure attachment patterns may promote a need to validate inner experiences by external sources conferring vulnerability to symptomatology. These psychopathological pathways could be addressed in clinical interventions.     

Comorbidity among anxiety disorders: implications for treatment and DSM-IV.

Research on comorbidity among psychological disorders is relatively new. Yet, comorbidity data have fundamental significance for classification and treatment. This significance is particularly apparent in the anxiety disorders, which, prior to DSM-III-R, were subsumed under disorders considered more significant (e.g., psychotic and depressive disorders). After considering definitional, methodological, and theoretical issues of comorbidity, data on comorbidity among the anxiety disorders are reviewed as well as data on comorbidity of anxiety disorders with the depressive, personality, and substance use disorders. Treatment implications are presented with preliminary data on the effects of psychosocial treatment of panic disorder on co-morbid generalized anxiety disorder. Implications of comorbidity for research on the nature of psychopathology and the ultimate integration of dimensional and categorical features in our nosology are considered.     

Natural categories or fundamental dimensions: on carving nature at the joints and the rearticulation of psychopathology

The question of whether to view psychopathology as categorical or dimensional continues to provoke debate. We review the many facets of this argument. These include the pragmatics of measurement; the needs of clinical practice; our ability to distinguish categories from dimensions empirically; methods of analysis appropriate to each and how they relate; and the potential theoretical biases associated with each approach. We conclude that much of the debate is misconceived in that we do not observe pathology directly; rather, we observe its properties. The same pathology can have some properties that are most easily understood using a dimensional conceptualization while at the same time having other properties that are best understood categorically. We suggest replacing Meehl's analogy involving qualitatively distinct species with an alternative analogy with the "duality" of light, a phenomenon with both wave- and particle-like properties.     

A re-introduction of the psychodynamic approach to the standard clinical psychology curriculum

Objective

There is a strong evidence-base for a psychodynamic approach, supporting primary theoretical tenets as well as the treatment effectiveness. Additionally, there are increasing calls from the field for more individualized treatment for clients, and the lack of training in multiple orientations limits the ability of students in clinical psychology Ph.D. programs in the United States to personalize their treatments. The accumulated evidence-base for contemporary relational psychodynamic theory and therapy places it in good standing to return to the standard clinical psychology curriculum, along with other evidence-based approaches.

Methods

We use data from the Insider's Guide (which describes clinical Ph.D. programs in the United States) from three time points over 20 years to document the waning psychodynamic approach in clinical psychology programs. We review the scientific evidence for four primary tenets of a contemporary psychodynamic approach: three related to development—from healthy to psychopathological: (1) unconscious processes; (2) internal representations of self and other; (3) dimensional model of psychopathology, and a fourth tenet that builds on these three and is the foundation for a contemporary psychodynamic approach to psychotherapy: (4) therapeutic relationship as a primary mechanism of change.

Results/Conclusions

Based on the review of the evidence, we make specific recommendations for clinical psychology training programs about how to include a psychodynamic approach in the curriculum.     

The feasibility and need for dimensional psychiatric diagnoses

BACKGROUND: It is our contention that both categorical and dimensional approaches to diagnosis are important for clinical work and research alike, and that each approach has its drawbacks and advantages. As the processes toward developing DSM-V and ICD-11 progress, we suggest that another exclusively categorical revision of psychiatric taxonomies will no longer be sufficient and that adding a dimensional component is a necessary step if these taxonomies are to continue serving the future clinical and research needs of psychiatry as they have so effectively done in the past. METHOD: We begin the paper with a review of terminology related to categories and dimensions and briefly review literature on advantages and disadvantages of both approaches. RESULTS: A review of relevant literature supports both the need for and feasibility of augmenting traditional categorical diagnoses with dimensional information. CONCLUSION: We conclude with a proposal for preserving traditional categorical diagnostic definitions, but adding a dimensional component that would be reflective of and directly referable back to the categorical definitions. We also offer a specific proposal for adding a dimensional component to official taxonomies such as the DSM and the ICD in a way that fully preserves the traditional categorical approach.     

Denosologization of biological psychiatry or the specificity of 5-HT disturbances in psychiatric disorders

5-Hydroxytryptamine (5-HT) disorders have been reported to occur in a variety of psychiatric disorders. The situation has been called chaotic, the disturbances non-specific. We reject this viewpoint. 5-HT disturbances are non-specific only from a nosological/categorical viewpoint; they seem rather specific from a functional/dimensional point of view, correlating as they do with particular psychopathological dimensions, i.e. aggression-, anxiety- and possibly mood-disregulation, across diagnosis. The evolution of 5-HT research in psychiatry illustrates the importance of what we have called the functional approach, implying dissection of a given psychopathological syndrome in its component parts, i.e., the psychological dysfunctions, and searching for correlations between biological and psychological dysfunctions. The rigid preoccupation of biological psychiatry with the search for markers of disease entities has hampered progress. The functional approach should be incorporated in biological psychiatry, not as an alternative for the nosological approach but as its complement.     

Can a Developmental Psychopathology Perspective Facilitate a Paradigm Shift Toward a Mixed Categorical–Dimensional Classification System?

Maser et al. (2009 ) identify several problems with the categorical DSM , and suggest that a shift to a mixed categorical–dimensional system is warranted. Maser et al. support their argument by citing evidence related to mood and anxiety disorders, among other conditions. In this commentary, I consider the applicability of several issues raised by Maser et al. to two disruptive behavior disorders in youth, oppositional defiant disorder (ODD) and conduct disorder (CD). The issues include paradigm shifts concerning (a) the diagnostic threshold, (b) symptoms, and (c) distress/psychosocial impairment. Within each topic, several developmental psychopathology principles that parallel and extend the Maser et al. issues are presented and described. This commentary also provides examples of dimensions that could be useful for conceptualizing ODD and CD within a mixed categorical–dimensional classification system.     

Integrating theory-driven and empirically-derived models of personality development and psychopathology: a proposal for DSM V

Although there is growing consensus that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) should replace the categorical view of mental disorders with a dimensional approach rooted in personality theory, no consensus has emerged about the dimensions that should be the basis of the new classification system. Moreover, recent attempts to bridge the gap between psychiatric nosology and personality theories have primarily relied on empirically-derived dimensional personality models. While this focus on empirically-derived personality theories may result in a psychometrically valid classification system, it may create a classification system that lacks theoretical and empirical comprehensiveness and has limited clinical utility. In this paper, we first argue that research findings increasingly suggest that an integration of theory-driven and empirically-derived models of personality development is not only possible, but also has the potential to provide a more comprehensive and clinically-relevant approach to classification and diagnosis than either approach alone. Next, we propose a comprehensive model of personality development and psychopathology based on an integration of contemporary theory-driven and empirically-derived models of personality. Finally, we outline the implications of this approach for the future development of DSM, and especially its potential for developing research that addresses the interactions between psychosocial and neurobiological processes implicated in personality development and psychopathology.     

External correlates of the SPECTRA: Indices of psychopathology (SPECTRA) in a clinical sample

The SPECTRA: Indices of Psychopathology is a broadband assessment inventory compatible with contemporary hierarchical models of psychopathology (internalizing, externalizing, reality impairing dimensions and global psychopathology factor). This study explored the SPECTRA's construct validity using a wide range of life event (extra-test) variables in a clinical sample. The life event variables included the following: education level, school failure, childhood adversity, suicide attempts, psychiatric hospitalizations, depression, psychotic symptoms, self-injury, substance abuse, arrests, physical violence, marital status, employment status and current medications. Results showed that all SPECTRA clinical scales had significant life event correlations. For the higher-order Spectra scales, the global index of psychopathology had the greatest number and range of life event correlations. Correlations for the externalizing and reality impairing Spectra scales provided solid validity evidence, while correlations for the internalizing Spectra scale were more diffuse. These findings provide the first non-test-based evidence of construct validity for the SPECTRA.     

Psychopathic personality traits: heritability and genetic overlap with internalizing and externalizing psychopathology

BACKGROUND: Little research has examined genetic and environmental contributions to psychopathic personality traits. Additionally, no studies have examined etiological connections between psychopathic traits and the broad psychopathological domains of internalizing (mood and anxiety) and externalizing (antisocial behavior, substance abuse). The current study was designed to fill these gaps in the literature. METHOD: Participants were 626 pairs of 17-year-old male and female twins from the community. Psychopathic traits were indexed using scores on the Multidimensional Personality Questionnaire (MPQ). Symptoms of internalizing and externalizing psychopathology were obtained via structured clinical interviews. Structural equation modeling was used to estimate genetic and environmental influences on psychopathic personality traits as well as the degree of genetic overlap between these traits and composites of internalizing and externalizing. RESULTS: Twin analyses revealed significant genetic influence on distinct psychopathic traits (Fearless Dominance and Impulsive Antisociality). Moreover, Fearless Dominance was associated with reduced genetic risk for internalizing psychopathology, and Impulsive Antisociality was associated with increased genetic risk for externalizing psychopathology. CONCLUSIONS: These results indicate that different psychopathic traits as measured by the MPQ show distinct genetically based relations with broad dimensions of DSM psychopathology.     

The Nurses Evaluation Rating Scale (NERS)

The Nurses Evaluation Rating Scale (NERS) consists of 16 items designed to capture salient dimensions of psychopathology and nursing care requirements for psychiatric patients. Reliability and validity of the NERS were evaluated by using a total of 3,052 sets of ratings accomplished by 19 staff nurses on a total of 235 adult psychiatric inpatients. All items of the NERS were utilized in describing psychopathology in this sample of patients, although no patient was positive on all items. Factor analysis revealed four distinct clusters of items, which represented higher-order constructs of thinking disturbance, depression, anxiety, and psychomotor retardation. Test-retest reliability was found to be comparable to the reliability of most other clinical assessments of psychopathology. Scoring for the four factors was defined, and analysis of change during first 10 days of hospital stay revealed statistically significant improvement. The NERS appears to be a promising instrument for longitudinal, daily evaluations of inpatient psychopathology as seen in the routine clinical practice of psychiatric nurses.     

When's a story a story? Determining interpretability of Social Cognition and Object Relations Scale‐Global ratings on Thematic Apperception Test narratives

The Social Cognition and Object Relations Scale‐Global Rating Method (SCORS‐G) measures the quality of object relations in narrative material. The reliability and validity of this measure have been well established. However, a psychometric oddity of this scale is that default ratings are given to select dimensions when the relevant construct is not present. This can result in narrative ‘blandness’ and may impact clinical findings. The aim of these two studies is to understand these phenomena both psychometrically and clinically. In the first study, we identified 276 outpatients who had SCORS‐G ratings for TAT Cards 1, 2, 3BM, and 14, set criteria for narrative ‘blandness’ across all eight dimensions, and examined group differences. In Study 2, we used a subset (N = 99) of Study 1 and examined how percentage of formal default ratings for Emotional Investment in Values and Moral Standards (EIM), Experience and Management of Aggressive Impulses (AGG), Self‐Esteem(SE), and Identify and Coherence of Self (ICS) impacted robustness of correlations across tests of intelligence, psychopathology, and normal personality functioning. Taken together, we identified clinical characteristics of patients who are more likely to produce ‘bland’ narratives and increased percentages of formal default ratings. Also, an excess of default ratings per protocol impacts robustness of correlations and weakens significant correlations. As cut‐off scores increase (>25% and >28.12%), the likelihood of being able to interpret EIM, AGG, SE, and ICS decreases. Psychometric and clinical implications are discussed.     

Comparison of alternative models for personality disorders

BACKGROUND: The categorical classification system for personality disorder (PD) has been frequently criticized and several alternative dimensional models have been proposed. METHOD: Antecedent, concurrent and predictive markers of construct validity were examined for three models of PDs: the Five-Factor Model (FFM), the Schedule for Nonadaptive and Adaptive Personality (SNAP) model and the DSM-IV in the Collaborative Study of Personality Disorders (CLPS) sample. RESULTS: All models showed substantial validity across a variety of marker variables over time. Dimensional models (including dimensionalized DSM-IV) consistently outperformed the conventional categorical diagnosis in predicting external variables, such as subsequent suicidal gestures and hospitalizations. FFM facets failed to improve upon the validity of higher-order factors upon cross-validation. Data demonstrated the importance of both stable trait and dynamic psychopathological influences in predicting external criteria over time. CONCLUSIONS: The results support a dimensional representation of PDs that assesses both stable traits and dynamic processes.