Familial concordance in schizophrenia: a comparative study of pairs of sibs.

Intrafamilial resemblance in psychiatric clinical features may provide a powerful tool to the search for an explanation of the distheis-stress duality. Family studies of schizophrenia have emphasized the role of familial concordance for subtype diagnosis,^1,2 symptomatology,^2,3,5 mode,² and age of onset,^2,5,7 outcome,⁸ and sex^9–14 in psychiatric research. Most of these studies have failed, however, to apply uniform criteria for the selection of patients and were based on retrospective and non-blind evaluation of family members.An attempt has been made in this study to apply updated research criteria for the diagnosis of schizophrenia and to evaluate probands in a blind fashion as regards their relatives. Combined variables have been analyzed in order to further elucidate the issue of familial homogeneity in schizophrenia. Efforts to correlate between the results of this study and certain biologic derangements are currently being made (Baron, et al.: Tissue-Serum Affinity in Schizophrenia: Clinical and Familial Determinants, in preparation), aimed at achieving a better understanding of the “nature-nurture” duality.     

Ego-dystonic Homosexuality

Section 302.01 of the new Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III) carries the title of Ego-dystonic Homosexuality.¹ The two necessary and sufficient diagnostic criteria are: (A) The individual complains that a persistent pattern of absent or weak heterosexual arousal significantly interferes with initiating or maintaining wanted heterosexual relationships and (B) There is a sustained pattern of homosexual arousal that the individual explicitly complains is unwanted and a source of distress.In his forward to the January 1978 draft of the new manual, Robert L. Spitzer, Chairman of the Task Force on Nomenclature and Statistics of the APA writes “It is suggested that the diagnostic categories included in this manual be seen as the best current approximation available for describing mental disorders”.The achievement of a “best current approximation” in an area which is as controversial as human sexual variation cannot have been an easy task. Groups of clinicians are still in disagreement over whether and in what circumstances homosexual behavior should be regarded as psychopathologic. The very name of the category itself was the subject of controversy in the preparation of the manual. Alternative headings such as “Sexual Orientation Dysphoria” were suggested by some members of the Task Force. “Ego-dystonic Homosexuality” was chosen as a compromise solution, acceptable to most, but without much enthusiasm.²It must be noted that the new DSM-III approach, although it reintroduces the word “homosexuality” into the nomenclature, is even more restricted in diagnostic criteria than was the modified DSM-II category of “Sexual Orientation Disturbance.”³ The essential difference is that in addition to disturbance and conflict, in order to apply the diagnosis of ego-dystonic homosexuality there must also be a strong desire by the patient to alter his or her sexual orientation.     

Diagnostic errors in psychiatry

Although the importance of nosology has been derided as “pigeonholing” by some American psychiatrists, the science of diagnosis has lately enjoyed a renaissance. Actually, whether or not a psychiatrist possessed diagnostic acumen had little effect on the outcome of treatment until the past two decades, because so much of treatment was nonspecific. But the increasing use of drugs, particularly neuroleptics, antidepressants, and lithium, has made precise diagnosis a necessity.In recent years, several authors have commented upon the misdiagnosis of manic-depressive patients—particularly catatonics¹—as schizophrenics² and a multihospital cross-national study³ has suggested that American psychiatrists overdiagnose schizophrenia and underdiagnose affective disorder. The Iowa group⁴ has demonstrated that strict criteria result in a much lower rate of diagnosed schizophrenia than does the “agreement of experienced clinicians” so often set as the standard. With the compilation of diagnostic criteria for psychiatric disorder by Feighner et al.,⁵ it became clear that 80% or more of psychiatric patients can be definitely classified according to standards that permit accurate prediction of treatment and prognosis. But today, the vast majority of psychiatric diagnoses still are not made on the basis of scientific criteria, and the category of “undiagnosed psychiatric disorder,” at least as used by clinicians, is virtually an empty set.To what extent strict criteria are used no one knows, but from anecdotal case reports in the literature they are probably not overutilized. The resulting margin for disagreement and for downright error is probably enormous. We propose now to review the kinds of erroneous diagnoses commonly made, the reasons for these errors, and their possible consequences. This report, based upon the experience of psychiatrists in private practice, deals with the diagnostic pitfalls encountered despite, or in some cases because of, the use of scientific diagnostic criteria.     

Presenting problems and diagnosis.

As an object of widespread criticism, psychiatric diagnosis has amassed a voluminous body of literature, most of it being focused on questions of validity, reliability, and consistency. Even though germane to the issue, less attention has been directed to the process of diagnostic decision making, i.e., how such assessments are made, what identifiable factors they are based on, and so forth. The work of Gauron and Dickinson,⁶ Petzel and Gynther,⁴ Sandifer et al.,⁵ and Kendall⁷ are among the few studies addressed to these questions.This paper continues this line of inquiry by exploring psychiatric diagnosis in relation to presenting problems. At times a presenting problem is simply a short-hand verbal account of a person's “story”. Generally, however, it is a composite presentation that also includes accounts about his condition made by “significant others” acting as complainant and/or concerned party, as well as the clinician's gross observations.Except for the work of a few investigators,^8–10 presenting problems remain a relatively unexplored area. Taken at face value, without interpretation or inference, presenting problems provide a unique body of information. As such, they constitute one of the few variables that stand at the interfaces of demographic, psychosocial, and clinical data and can thus provide a fruitful, empirically-grounded research tool.Accordingly, data and findings are presented from a recent community-wide survey of psychiatric utilization,¹¹ i.e., specifically, the presenting problems of a 1-year adult population of applicants (unduplicated count) who sought psychiatric care from either a large urban mental health center or from the private sector (i.e., the office and hospital clientele of psychiatrists in private practice; 86% of the private psychiatrists cooperated and participated in the study).     

Time-limited treatment of hospitalized borderline patients: Considerations

Patients with a diagnosis in the spectrum of “borderline personality organization” represent a significant proportion of inpatient hospital admissions. An intensive, psychodynamically-oriented treatment environment may induce further behavioral disturbances and regressions in such patients.^1,2 Among iatrogenic elements in the therapeutic milieu, which promote ego dedifferentiation and regression, are overgratification of pathologic dependency needs by a permissive supportive staff or inexperienced trainee therapists enmeshed in a quagmire of transference-countertransference difficulties. Borderline patients are often unable to keep a part of their ego available for observation in a therapeutic or working alliance, show marked senses of entitlement, and, by primitive projective mechanisms, protect themselves from seeing the implications of their actions on others. On admission and during a hospitalization, they often present difficult diagnostic and management problems, precipitate endemic psychotic regressions among other patients, or provoke critical staff conflicts.The literature on the “borderline patient”, though clarifying dynamic issues, has tended to emphasize chronicity of the condition and the need for intensive long-term psychotherapy by highly experienced analytically oriented therapists.^3,4 However, limited hospitalization funds and an unavailability of the prescribed outpatient treatment are often issues which generate an atmosphere of therapeutic nihilism. This atmosphere should be metabolized by treatment designs that integrate theory with reality constraints, and allow borderline patients to return to the community in a more functional mode than when they entered the hospital.It is the purpose of this article to identify features important for time-limited hospital treatment of patients with borderline character pathology.     

Diagnostic criteria for amyotrophic lateral sclerosis: A multicentre study of inter-rater variation and sensitivity

ObjectiveThis study assesses inter-rater agreement and sensitivity of diagnostic criteria for amyotrophic lateral sclerosis (ALS).MethodsClinical and electrophysiological data of 399 patients with suspected ALS were collected by eleven experienced physicians from ten different countries. Eight physicians classified patients independently and blinded according to the revised El Escorial Criteria (rEEC) and to the Awaji Criteria (AC). Inter-rater agreement was assessed by Kappa coefficients, sensitivity by majority diagnosis on 350 patients with follow-up data.ResultsInter-rater agreement was generally low both for rEEC and AC. Agreement was best on the categories “Not-ALS”, “Definite”, and “Probable”, and poorest for “Possible” and “Probable Laboratory-supported”.Sensitivity was equal for rEEC (64%) and AC (63%), probably due to downgrading of “Probable Laboratory-supported” patients by AC. However, AC was significantly more effective in classifying patients as “ALS” versus “Not-ALS” (p < 0.0001).ConclusionsInter-rater variation is high both for rEEC and for AC probably due to a high complexity of the rEEC inherent in the AC.The gain of AC on diagnostic sensitivity is reduced by the omission of the “Probable Laboratory-supported” category.SignificanceThe results highlight a need for initiatives to develop simpler and more reproducible diagnostic criteria for ALS in clinical practice and research.     

Dangerous headaches

Abstract Headache is a critical problem in the emergency department (ED). The main aim for the ED doctor is to distinguish primary forms of headache from secondary forms. In this paper we will briefly review epidemiological data regarding headache in ED, consider the role of diagnostic alarms and “warning symptoms” in differential diagnosis and describe some “dangerous headaches”.

     

Prevalence of tardive dyskinesia in an outpatient population

Tardive dyskinesia (TD) is a disorder of abnormal involuntary choreothetotic movements associated with the use of neuroleptic drugs. The reported prevalence of TD among patients taking antipsychotic agents varies markedly, from 3% to 56%,^1–8 accounted for, in part, by the use of different diagnostic criteria. Although most investigators use the Abnormal Involuntary Movement Scale (AIMS) to assess signs of TD, the methods of analyzing resulting data have varied widely, and there is disagreement as to the severity of abnormal movements needed to qualify for a diagnosis of TD. This divergence in severity criteria is further complicated by the heterogeneous nature of this disorder and by the effects of drugs on the appearance of the movements. For example, abnormal movements can develop temporarily when antipsychotic medication is withdrawn, but may fade over time—a syndrome more properly termed “withdrawal dyskinesias” rather than true TD. Antipsychotics can also “mask” the movements of TD. Gardos⁹ has coined the term “covert dyskinesia” to describe movements that only become apparent when a neuroleptic dose is lowered, but that persist over time. In other patients, TD “breaks through” a stable neuropleptic dose, but may be controlled by increasing the dose.Over the past 3 yr we have conducted a study of the prevalence of TD within our mental health system. This article presents data from the study and prevalence data based on four different severity criteria for the diagnosis of TD. In addition, epidemiological correlations are presented and their possible implications discussed. Finally, we will present a new scale, Targeting Abnormal Kinetic Effects (TAKE), which rates extrapyramidal signs and forms a natural companion piece to the AIMS (see Appendix 1).     

Nonconvulsive psychogenic attacks investigated for temporal lobe epilepsy

Slater and Roth recognize the occasional diagnostic problem due to the “overlap between the symptomatology of temporal lobe epilepsy and neurotic disturbance…”¹ Harper and Roth² compared the clinical features of patients with phobic anxiety-depersonalization syndrome with temporal lobe epileptics and found that the psychogenic group had significantly more family histories of neurosis, childhood and adult phobias, anxiety and depressive syndromes, hypochondriacal symptoms, and personality traits of immaturity and dependence. This study examined this subject using rating scales.     

The experience of healthcare professionals treating adolescents with eating disorders in psychiatric and pediatric inpatient units for adolescents: A qualitative study

ObjectivesThe recommended treatment for Eating Disorders (EDs) is multidisciplinary and multimodal. Nonetheless, the complex linkage of the different disciplines involved is not necessarily simple. We analyzed the experience of healthcare professionals faced with psychiatric and psychological symptoms in adolescents with EDs in two “multidisciplinary” inpatient units embedded predominantly in different paradigms — one pediatric and one psychiatric.MethodsQualitative analysis of 20 healthcare staff members’ interviews from different professional backgrounds working in inpatient units for EDs in Montreal (Canada) and Paris (France).ResultsThe “Complex patients” theme discusses the need for a global approach to the multiplicity of symptoms presented by these patients. “Management and its limits” describes the daily management of psychiatric symptoms in both units. “Psychiatry and Adolescent medicine: from opposition to collaboration” describes the different levels at which these disciplines work together and how this cooperation may be evolving.ConclusionsThe complex entanglement intrinsic in EDs of the patients’ somatic, psychosocial, psychiatric, and adolescent problems requires collaboration between disciplines, but the modalities of this collaboration are multiple and evolve non-linearly in specialized treatment units. A multilevel approach must be offered, with the degree of collaboration (multidisciplinary, interdisciplinary and transdisciplinary) appropriate to the complexity of each adolescent's issues.     

Psychosomatic Symptoms as Physical Dreams: Emotional Experiences Given Expression through the Body

This article offers a view of psychosomatic symptoms as experiential phenomena that function as “physical dreams.” The author suggests a way of perceiving psychosomatic symptoms either as "undreamt" dreams or as "interrupted" dreams, reflecting the various ways in which patients are able to utilize their symptoms in undertaking unconscious psychological work. For this work to be carried out, patients, as well as their analysts, need to have some ability to engage in intersubjective “dream-work” with the patient’s symptomatology. In the tradition of Bion's conception of the dual function of the contact-barrier, I propose viewing psychosomatic symptoms as constructions by which aspects of the psyche-soma are rendered conscious or unconscious in the service of psychological work. With the analyst's aid, the analysand may restart his or her interrupted “physical” dreaming and/or (re)form an “undreamt” dream, transferring and transforming “physical” into “psychical” material and verse versa.     

Behavioral precipitants of restraint in the modern milieu

Physical restraint of the psychiatric patient is a persisting reality in the acute management of uncontrolled, disruptive, or violent behavior. Depite advances in pharmacologic and milieu management, the “quiet room”, locked seclusion, or mechanical restraint often remain the last resort in control of the acutely disturbed patient. In this era of nonrestraint, little is taught or written of the practice of restraint. The literature contains few systematic studies of its persistence in modern milieu wards. The practice of restraint is viewed in resident education as an embarrassing anachronism, yet persists in some form in most clinical settings. This incongruity between teaching and practice led us to systematically survey our own use of physical restraint in an acute inpatient milieu. The diagnosis of patients restrained and the behavioral precipitants of restraint are the focus of this report.The modern therapeutic milieu stands in philosophic opposition to physical restraint by virtue of widespread acceptance of dynamic management of violent patients and confidence in the efficacy of pharmacologic treatment. The clinical belief that dynamic understanding in experienced hands can render a potential combatant “quickly cooperative”¹ is widely held. Following Connolly's famous admonition that “restraint and neglect are synonymous,”² the milieu staff shares responsibility for the patient's disruptive behavior. Violence and impulsive behavior are not so much the product of autistic process as they are defensive responses to “ambiguous, confusing, belligerent or threatening treatment.”¹ A violent outcome and resort to physical restraint implies staff failure and a punitive response to fear of the threatening patient. In his study of factors sustaining the practice of locked seclusion at the Boston Psychopathic Hospital, Greenblatt identified the “evils” of “overroutinization of use, lack of knowledge concerning the patient's feelings, poor communication about these feelings among the staff and lack of adequate motivation for serving the basic psychologic needs of the patient.”³ Attention to these dynamic considerations in a therapeutic milieu augmented by the use of potent pharmacologic agents has greatly reduced but not eliminated the use of physical restraint. The question of who is restrained on the modern milieu ward and why must be asked in this dynamic context.     

Toward DSM-V: an item response theory analysis of the diagnostic process for DSM-IV alcohol abuse and dependence in adolescents

ObjectiveItem response theory analyses were used to examine alcohol abuse and dependence symptoms and diagnoses in adolescents. Previous research suggests that the DSM-IV alcohol use disorder (AUD) symptoms in adolescents may be characterized by a single dimension. The present study extends prior research with a larger and more comprehensive sample and an examination of an alternative diagnostic algorithm for AUDs.MethodApproximately 5,587 adolescents between the ages of 12 and 18 years from adjudicated, clinical, and community samples were administered structured clinical interviews. Analyses were conducted to examine the severity of alcohol abuse and dependence symptoms and the severity of alcohol use problems (AUDs) within the diagnostic categories created by the DSM-IV.ResultsAlthough the DSM-IV diagnostic categories differ in severity of AUDs, there is substantial overlap and inconsistency in AUD severity of persons across these categories. Item Response Theory-based AUD severity estimates suggest that many persons diagnosed with abuse have AUD severity greater than persons with dependence. Similarly, many persons who endorse some symptoms but do not quality for a diagnosis (i.e., diagnostic orphans) have more severe AUDs that persons with an abuse diagnosis. Additionally, two dependence items, “tolerance” and “larger/longer,” show differences in severity between samples.ConclusionsThe distinction between DSM-IV abuse and dependence based on severity can be improved using an alternative diagnostic algorithm that considers all of the alcohol abuse and dependence symptoms conjointly.     

When should “chronic migraine” patients be considered “refractory” to pharmacological prophylaxis?

Patients with chronic headache forms evolving from a previous episodic migraine (‘chronic migraine’) are often difficult to treat. In this paper we focus attention on aspects we believe important for producing a definition of “refractory” in relation to this headache form. We propose a “chronic migraine” patient should be considered “refractory” to pharmacological prophylaxis when adequate trials of preventive therapies at adequate doses have failed to reduce headache frequency and improve headache-related disability and, in patients with medication overuse, reduce the consumption of symptomatic drugs. However before a definition of “refractory” chronic migraine can become established, generally accepted diagnostic criteria and treatment guidelines for this condition need to be developed.