Prevalence of subthreshold forms of psychiatric disorders in persons making suicide attempts in Hungary.

BACKGROUND: Suicide and suicide attempts have been associated to psychiatric illnesses; however, little is known about the role in suicide risk of those symptoms that do not meet the full criteria for a DSM-IV disorder. The aim of this study was to examine the prevalence of subthreshold psychiatric disorders among suicide attempters in Hungary. METHODS: Using a modified structured interview (Mini International Neuropsychiatric Interview) determining 16 Axis I psychiatric diagnoses and their subthreshold forms defined by the DSM-IV and a semistructured interview collecting background information, the authors examined 140 consecutive suicide attempters, aged 18-65 years. RESULTS: Eighty-three-point-six percent of the attempters had one or more current threshold diagnoses on Axis I and in addition more than three-quarters (78.6%) of the subjects had at least one subthreshold diagnosis. Six-point-four percent of the subjects (N = 9) had neither subthreshold nor threshold diagnoses at the time of their suicide attempts. Ten percent of the subjects (N = 14), not meeting the full criteria for any DSM-IV diagnoses, had at least one subthreshold diagnosis. In 68.6% of the subjects (N = 96), both subthreshold and threshold disorders were diagnosed at the time of their suicide attempts. The number of subthreshold and threshold diagnoses were positively and significantly related (chi2 = 5.12, df = 1, P < 0.05). Sixty-three-point-six percent of the individuals received two or more current threshold diagnoses on Axis I and 44.3% of the individuals (N = 62) had two or more subthreshold diagnoses at the time of their suicide attempts. LIMITATIONS: The subthreshold definitions in this study included only those forms of the disorders which required the same duration as the criteria DSM-IV disorder with fewer symptoms. Conclusions - Suicide attempts showed a very high prevalence of subthreshold disorders besides psychiatric disorders meeting the full criteria required according to the DSM-IV. Subthreshold forms of mental disorders need to be taken into account in suicide prevention.     

Does "subthreshold" posttraumatic stress disorder have any clinical relevance?

The present report examined the extent to which subthreshold posttraumatic stress disorder (PTSD) (without lifetime PTSD) and full PTSD are associated with impairment or distress, controlling for comorbidity (i.e., major depression and panic disorder) in a sample of treatment-seeking psychiatric patients. Patients were administered diagnostic interviews and assessed for psychosocial impairment and whether or not they desired treatment for their PTSD symptoms. No significant differences were found between patients with full PTSD (N = 156) and those with subthreshold PTSD (N = 56) in degree of impairment (i.e., social and work functioning, as well as number of suicide attempts). In contrast, those with full PTSD had significantly more psychiatric hospitalizations and worse global functioning and were more likely to want treatment for their PTSD symptoms compared to those with subthreshold PTSD, albeit the majority of patients with subthreshold PTSD wanted treatment for their PTSD symptoms. These findings, like past research, suggest that subthreshold PTSD is associated with levels of social and work morbidity comparable to full PTSD. However, the report also underscores the difficulties in identifying a set of clinical criteria that clearly delineates between full PTSD and subthreshold PTSD.     

Psychiatric diagnosis and quality of life: the additional burden of psychiatric comorbidity

Objectives

To compare quality of life (QoL) in mental health outpatients to non-clinical norms, and examine the associations between QoL and principal diagnosis, number of comorbid Axis I diagnoses, and type of comorbidity.

Methods

Consecutively referred and assessed patients (n = 2024) formed the study sample pool. Of these, 1486 individuals who had completed a QoL instrument at intake and had a principal diagnosis amenable to comparison by group analysis were included in the study. Principal diagnoses were unipolar mood disorder (n = 687), eating disorder (n = 226), bipolar disorder (n = 165), social anxiety disorder (n = 165), generalized anxiety disorder (n = 125), and panic disorder (n = 118). QoL for psychiatric groups was compared to non-clinical norms using a valid and reliable measure.

Results

QoL was significantly impaired in all psychiatric groups compared to nonclinical norms. There was a significant interaction between principal diagnosis and number of comorbid Axis I disorders, controlling for age, sex, marital status, employment, and years of school. The addition of one comorbidity significantly attenuated QoL in social anxiety disorder, panic disorder, and bipolar disorder. For all other conditions, a significant loss in QoL occurred with two or more comorbidities. Axis I depressive and anxiety comorbidity significantly attenuated QoL across all diagnostic groups.

Conclusions

QoL is significantly impaired in psychiatric outpatients and diagnostic groups vary in the extent to which they experience additional QoL burden with increasing comorbidities.     

Sexual dysfunction and dual psychiatric diagnoses

Controversy continues to exist about whether a sexual dysfunction is a discrete problem or it is symptomatic of more elaborate psychiatric disorder. To date no study of this question has been reported on patients evaluated using DSM-III criteria. To meet such a need, 592 patients with various sex-related complaints and their partners were evaluated at the Sexual Behaviors Consultation Unit of the Johns Hopkins Hospital over a 2-year period. Two hundred and eighty-eight patients (males = 223; females = 65) fulfilled DSM-III criteria for psychosexual dysfunction. Of these 30.5% (N = 68) of the males and 30.8% (N = 20) of the females were assigned concurrent Axis I/II diagnoses. Patients who had dual diagnoses reported more (P = .026) problems with alcohol. Despite equivalent psychosocial stressors on Axis IV they were rated less (P less than .01) adjusted on Axis V. Dual diagnostic profiles were described for each of the psychosexual dysfunctions. Results support the hypothesis that while the majority of patients with sexual dysfunction have a discrete disorder, there is another group whose sexual dysfunction is but one of several conditions which deserve treatment.     

Differences in emotional experience and emotion regulation as a function of age and psychiatric condition

In this study, self-reported experiences of negative affectivity and emotional regulation in a sample of older and younger adults with and without psychiatric co-morbidity were evaluated. Study participants were divided into four separate groups (younger nonpsychiatric = YN; younger psychiatric = YP; older non-psychiatric = ON; and older psychiatric = OP). Findings indicated that, as hypothesized, individuals in the OP and YP groups reported more negative affect intensity and reactivity and more maladaptive emotion regulation than individuals in the ON and YN groups. Contrary to hypotheses, when collapsed across psychiatric conditions, older adults did not report significantly less negative affect intensity and reactivity than younger adults. A significant age by psychiatric group interaction effect on negative affect intensity occurred such that individuals in YN and ON groups reported similar levels of negative affect intensity and individuals in the YP group reported more negative affect intensity than individuals in the OP group. The finding that older adults with Axis I and Axis II diagnoses differ in their symptom reports from younger adults with similar diagnoses suggests there may be important assessment and intervention issues related to the interaction of aging and psychopathology. Clinical implications and directions for future studies are discussed.     

Psychosocial and clinical correlates of ADHD in a community sample of school-age children.

OBJECTIVE: To identify the psychosocial and clinical correlates of attention-deficit hyperactivity disorder (ADHD) in a community sample of children and to examine the validity of a subclinical form of ADHD. METHOD: The sample of 449 children (mean age 9.2 years, SD 1.78; 53.6% boys) participated in the second stage of a community survey. Of these, 359 (80%) screened positive at stage 1. On the basis of a structured diagnostic interview with a parent, children were classified into 1 of 3 mutually exclusive groups: ADHD (n = 89), subthreshold ADHD (n = 100), and non-ADHD (n = 260). RESULTS: As measured by the Children's Global Assessment Scale, the ADHD group was more impaired than the subthreshold group, which was more impaired than the non-ADHD group (p < .05 for each test). Children in the ADHD group were more likely to be male, to have mothers with a history of psychiatric treatment, to have fathers with a history of excessive alcohol use, and to live in low-income families with higher levels of family dysfunction (p < .05 for all variables). A model containing male gender, family dysfunction, and low income was most predictive of ADHD status (p < .01). ADHD was also associated with psychiatric comorbidity, especially disruptive behavior disorders. CONCLUSIONS: These results support a dimensional approach to ADHD. More severe forms of ADHD are associated with psychosocial adversity and psychiatric comorbidity.     

A comparison of schizophrenic patients with or without coexisting substance use disorder

Increasing numbers of research investigations have documented psychosocial, demographic, and treatment course differences between schizophrenic patients with and without additional substance use disorder. However, many of these studies have failed to control for additional psychiatric diagnoses. This study sought to elucidate differences between schizophrenic patients with versus without coexisting substance use disorder, while controlling for the possible confounding impact of additional Axis I or Axis II diagnoses. We explored the records of 308 psychiatric inpatients who were either solely diagnosed with schizophrenia or solely diagnosed with coexisting schizophrenia and substance use disorder. We compared these two groups on a variety of psychosocial, demographic, and clinical variables shown in prior research to differentiate these two types of patients. Findings revealed that substance use interacts with schizophrenia to increase psychiatric admissions and decrease lengths of stay upon admission. Findings also revealed that patients with coexisting substance use and schizophrenia have unique psychosocial and demographic presentations that reflect more challenging life circumstances. Differences were not revealed between groups in terms of legal and criminal involvement. Based on pure diagnostic groupings, findings indicate that an additional substance use disorder is associated with psychosocial, demographic, and treatment course differences among individuals with a schizophrenia diagnosis. When screening, developing treatment, and planning aftercare, it is crucial to not view individuals with schizophrenia diagnoses as a monolithic group, but rather to consider the presence of a substance abuse diagnosis; such consideration will increase the likelihood of appropriate treatment and successful outcomes.     

Quality of life in patients with chronic idiopathic urticaria: the impact of Axis I and Axis II psychiatric disorders

OBJECTIVE: Chronic idiopathic urticaria (CIU) associated with lower quality of life (QoL) levels. Psychiatric disturbances are frequently present in patients with CIU. This study examined the impact of Axis I and Axis II psychiatric disorders on the QoL of patients with CIU. METHOD: The study sample consisted of 100 subjects including CIU patients with only Axis I psychiatric diagnoses (n=25), CIU patients with only Axis II diagnoses (n=25), CIU patients with both Axis I and Axis II diagnoses (n=25), CIU patients without any Axis I and Axis II diagnosis (n=25), and healthy control subjects with respect to urticaria and psychiatric disorders (n=25). The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID-1) and the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders (SCID-II) was used to determine Axis I and Axis II psychiatric disorders, respectively. QoL levels were assessed by means of the World Health Organization QoL Assessment-Brief (WHOWOL-BREF). RESULTS: There were significant differences among the groups with respect to all WHOQOL-BREF subscale scores. The QoL levels were similar among CIU patients with only Axis I psychiatric diagnoses, CIU patients with only Axis II diagnoses and CIU patients with both Axis I and Axis II diagnoses, and between CIU patients without any Axis I and Axis II diagnosis, and healthy control subjects. When compared with those of CIU patients without any Axis I and Axis II diagnosis, CIU patients without concurrent psychiatric diagnoses had significantly lower scores in most domains of the QoL scale. CONCLUSIONS: Axis I and Axis II psychiatric disorders seem to be considerable factors influencing the QoL in CIU patients.     

Quality of life in children with psychiatric disorders: self-, parent, and clinician report

OBJECTIVE: To study the relationship between child psychiatric disorders and quality of life (QoL). METHOD: In a sample of 310 children (ages 6-18 years) referred for psychiatric problems, children, parents, and clinicians reported on psychopathology and subjective and objective QoL indicators. RESULTS: Six diagnostic categories were distinguished: attention-deficit and disruptive behavior disorders, anxiety disorders, pervasive developmental disorders, mood disorders, other disorders, and no diagnosis. In overall QoL, no differences were found between the diagnostic categories, except in clinician's ratings, who rated children with pervasive developmental disorder as having a poorer QoL than children with other diagnoses. In each diagnostic category specific QoL subdomains were affected: for children with attention-deficit and disruptive behavior disorder, school functioning and social functioning; for children with anxiety disorder, emotional functioning; for children with pervasive developmental disorder, social functioning; and for children with mood disorder, emotional functioning. CONCLUSIONS: Across multiple raters, the distinguished child psychiatric disorders had a different impact on QoL. Knowledge about domains of QoL that are affected in specific child psychiatric disorders can help clinicians to focus on particular QoL domains during the diagnostic process and to define adequate treatment goals.     

The adjustment disorders: the conundrums of the diagnoses

This article discusses the conundrums and the dilemmas of the conceptual framework of the diagnoses of the adjustment disorders (ADs). The psychiatric diagnoses that arise between normal behavior and the major psychiatric morbidities constitute the problematic subthreshold disorders. These subthreshold entities are also juxtaposed between problem-level diagnoses and more clearly defined major disorders. They present important taxonomic and diagnostic dilemmas in that they are often poorly defined, overlap with other diagnostic groupings, and have indefinite symptomatology. ADs were designed as a "wild card" to allow the coding of a psychiatric "diagnosis" for work done by psychiatrists and other mental health care specialists when the patient's symptoms do not reach the criterion of a major mental disorder. It is therefore not surprising that issues of reliability and validity prevail. The issues of diagnostic rigor and clinical utility seem at odds for the AD. Clinicians need a wild card, and field studies need to use reliable and valid concepts of AD and assessments instruments to determine more exact specification of the parameters of the diagnosis. Finally, appropriate and timely treatment is essential for patients with AD so that their symptoms do not worsen; their important relationships are not further impaired; or their capacity to work, study, or be active in their essential interpersonal pursuits is not compromised.     

Axis I and Axis II diagnoses in women with PCOS

Objective

The objective was to determine the current prevalence of Axis I and Axis II psychiatric diagnoses in patients with polycystic ovary syndrome (PCOS).

Method

The study sample included 73 patients with PCOS and 73 control subjects. Psychiatric disorders were determined by structured clinical interviews.

Results

The rate of any Axis I psychiatric disorder (28.8% vs. 15.1%), social phobia (13.7% vs. 2.7%), generalized anxiety disorder (11.0% vs. 1.4%), any Axis II psychiatric disorder (23.3% vs. 9.6%) and avoidant personality disorder (12.3% vs. 1.4%) was significantly more common in the patient group compared to the control group.Of women with PCOS, 21 (28.8%) had at least one Axis I and 17 (23.3%) had at least one Axis II diagnosis. The most common Axis I disorder was social phobia (13.7%) and the most common Axis II disorder was avoidant personality disorder (12.3%) in women with PCOS. Social phobia, generalized anxiety disorder, and avoidant personality disorder were significantly more common in the patient group compared to the control group.

Conclusion

Our results suggest that a considerable proportion of women with PCOS also present with anxiety and personality disorders.     

Psychiatric diagnosis in clinical practice: is comorbidity being missed?

The recognition of comorbidity has important clinical significance. Comorbidity predicts a poorer outcome for patients with depressive and anxiety disorders, and the presence of multiple psychiatric disorders is associated with greater psychosocial impairment. In routine clinical settings, an unstructured interview is typically used to assess patients. However, unstructured interviews may result in missed diagnoses, with potential negative clinical consequences. The goal of the present study was to examine whether diagnostic comorbidity is less frequently identified during a routine clinical evaluation versus a semistructured diagnostic interview. Axis I diagnoses derived from structured and unstructured clinical interviews were compared in two groups of psychiatric outpatients in the same practice setting. Five hundred individuals presenting for an intake appointment to a general adult psychiatric practice underwent a routine unstructured clinical interview. Subsequent to completion of the first study, the method of conducting diagnostic evaluations was changed and 500 individuals were interviewed with the Structural Clinical Interview for DSM-IV Axis I Disorders (SCID). The two groups had similar demographic characteristics and scored similarly on symptom questionnaires. Individuals interviewed with the SCID were assigned significantly more axis I diagnoses than individuals assessed with an unstructured interview. More than one third of the patients interviewed with the SCID were diagnosed with three or more disorders, in contrast to fewer than 10% of the patients assessed with an unstructured interview. Fifteen disorders were more frequently diagnosed in the SCID sample, and these differences occurred across mood, anxiety, eating, somatoform, and impulse-control disorder categories. The results suggest that in routine clinical practice, clinicians underrecognize diagnostic comorbidity. Anxiety, somatoform, and not otherwise specified (NOS) disorders were the most frequently underdetected disorders. The implications of underdiagnosis for the treatment outcome are discussed.     

Suicidality, aggression, and other treatment considerations among pregnant, substance-dependent women with posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) and other Axis I comorbidity among women with substance use disorders (SUDs) appear similarly prevalent and are associated with comparable negative clinical profiles and treatment outcomes. The relative contribution of comorbid PTSD vs other Axis I psychiatric disorders to clinical characteristics is largely unexamined, however, despite theory and empirical data indicating that PTSD and SUDs may have a unique relationship that confers specific risk for clinical severity and poor treatment outcome. In a sample of pregnant, opioid- and/or cocaine-dependent women entering substance abuse treatment, women with PTSD (SUD-PTSD; n = 23) were compared to those with other Axis I comorbidity (SUD-PSY; n = 45) and those without Axis I comorbidity (SUD-only; n = 37). Data were collected via face-to-face interviews and urinalysis drug assays. Although the study groups had similar substance use severity, the SUD-PTSD group was more likely to report suicidality, aggression, and psychosocial impairment than both the SUD-PSY and SUD-only groups. Findings indicate treatment considerations for substance-dependent women with PTSD are broader and more severe than those with other Axis I conditions or substance dependence alone.     

Diagnosis and treatment of psychiatric disorders in children with a schizophrenic parent

Many children of a schizophrenic parent may inherit a portion of the genetic risk factors for schizophrenia. The frequency of DSM-IV psychopathology in children of a schizophrenic parent and the frequency and type of mental health treatment accessed by these youths is not well understood. Twenty-eight adults with schizophrenia were identified and 43 of their 6--15 year old children recruited. Clinical diagnoses, based on a structured DSM-IV interview; severity of impairment, based on the Child Global Assessment Scale; and treatment histories were obtained. Seventy-four per cent of children-with-a-schizophrenic-parent met diagnostic criteria for a current Axis I psychiatric disorder. The most common diagnostic categories included attention deficit/hyperactivity disorder (40%), any anxiety disorder (23%), and any depressive disorder (12%). Psychosis was present in 9% of this childhood sample. Of those children with a psychiatric diagnosis, 47% demonstrated current moderate or severe impairment. Approximately half of the children had received mental health evaluations and 26% had experienced at least one psychiatric medication trial. Children-with-a-schizophrenic-parent have frequent, often impairing, psychiatric problems. Despite this high prevalence, mental health evaluation and treatment is of similar frequency and type to other at-risk populations. The effectiveness and appropriateness of standard treatments remain unstudied in children-with-a-schizophrenic-parent.     

Follow-up of psychiatric comorbidity in the general hospital

Although appropriate follow-up is an important task in the consultation setting, little attention has been directed to its frequency, or the risk profile for minimal or maximal follow-up. Eight hundred twenty-three patients from 1983 to 1986 were examined at the Mount Sinai Hospital using a computerized psychiatric consultation database that recorded demographic information, reason for referral, DSM-III 5 Axes diagnosis, recommendations and number of follow-up interviews. Forty-two percent of the consultations had three or less (minimum) follow-up visits. The minimum follow-up group were significantly less often referred for depression or diagnosed as depression (p = .01), had fewer psychosocial stressors (Axis III) (p = .03), and recommendations for psychosocial treatment by the psychiatric consultant (p = .0001), but had significantly more personality disorders (Axis II) (p = .04). Sixty-two percent of the consultation patients were correctly classified into the follow-up groups by the variables: 1) marital status; 2) living situation; 3) problem assessed as chronic illness or pain; 4) absence of an Axis I diagnosis or diagnostic uncertainty; and 5) number of recommendations by the consultant.     

The reliability of child psychiatric diagnosis. A comparison among Danish child psychiatrists of traditional diagnoses and a multiaxial diagnostic system

The study was conducted to compare an experimental multiaxial diagnostic system (MAS) with traditional multicategorical diagnoses in child psychiatric work. Sixteen written case histories were circulated to 21 child psychiatrists, who made diagnoses independently of one another, using two different diagnostic systems. Diagnostic reliability was measured as percentage of interrater agreement. The highest diagnostic reliability was obtained in psychotic disorders, the lowest in personality disorders. The MAS implied improved diagnostic reliability of mental retardation, somatic disorders and developmental disorders. Adjustment reaction (reactio maladaptiva) was the diagnosis most commonly used, but with varying reliability in both systems. The reliability of the socio-economic and psychosocial axes were generally high.     

Facial emotion recognition impairment predicts social and emotional problems in children with (subthreshold) ADHD

Children with attention-deficit/hyperactivity disorder (ADHD) symptoms often experience social and emotional problems. Impaired facial emotion recognition has been suggested as a possible underlying mechanism, although impairments may depend on the type and intensity of emotions. We investigated facial emotion recognition in children with (subthreshold) ADHD and controls using a novel task with children’s faces of emotional expressions varying in type and intensity. We further investigated associations between emotion recognition accuracy and social and emotional problems in the ADHD group. 83 children displaying ADHD symptoms and 30 controls (6–12 years) completed the Morphed Facial Emotion Recognition Task (MFERT). The MFERT assesses emotion recognition accuracy on four emotions using five expression intensity levels. Teachers and parents rated social and emotional problems on the Strengths and Difficulties Questionnaire. Repeated measures analysis of variance revealed that the ADHD group showed poorer emotion recognition accuracy compared to controls across emotions (small effect). The significant group by expression intensity interaction (small effect) showed that the increase in accuracy with increasing expression intensity was smaller in the ADHD group compared to controls. Multiple regression analyses within the ADHD group showed that emotion recognition accuracy was inversely related to social and emotional problems, but not prosocial behavior. Not only children with an ADHD diagnosis, but also children with subthreshold ADHD experience impairments in facial emotion recognition. This impairment is predictive for social and emotional problems, which may suggest that emotion recognition may contribute to the development of social and emotional problems in these children.

     

Psychosocial adversity in an adolescent psychiatry inpatient cohort: WHO ICD-10 findings from a multicentre prospective study

Sixteen Axis 5 ICD-10 codes were applied to a prospective multicentre study of 276 adolescent psychiatric inpatients. Frequency distributions were obtained for the whole cohort and separately for each of the seven main ICD-9 psychiatric diagnoses. Certain abnormal psychosocial situations were associated with particular diagnoses, and many significant correlations were found between Axis 5 codes. Factor analysis with varimax rotation produced four factors accounting for 46% of the total variance.     

The relationship of suicidality and psychiatric diagnosis in hospitalized pre-adolescent children

Two structured interview measures of suicidal behavior were administered to 43 child psychiatric inpatients between the ages of 7 and 11 and their parents. DSM-III-R diagnoses were assigned to the children, with twenty-six Axis I and Axis II diagnostic categories represented. Generally, the interview measures of suicidal behavior were found to be unrelated to psychiatric diagnosis. The results suggest that to better understand pre-adolescent suicidal behaviors, it may be more useful to examine associations between these behaviors and the biopsychosocial dimensions that underlie the diagnostic categories.This study was funded in part by a Biomedical Research Support Grant from the Medical College of Ohio.     

History of the introduction of lithium into medicine and psychiatry. Birth of modern psychopharmacology 1949

Angst J, Gamma A, Clarke D, Ajdacic‐Gross V, Rössler W, Regier D. Subjective distress predicts treatment seeking for depression, bipolar, anxiety, panic, neurasthenia and insomnia severity spectra. Objective: To examine correlates of mental health treatment seeking such as gender, diagnosis, impairment, distress and mastery. Method: Longitudinal epidemiological data from the Zurich Study of common psychiatric syndromes, including unipolar and bipolar depression, panic, anxiety, neurasthenia and insomnia, were utilized. In longitudinal Generalized Estimating Equations, treatment seeking was regressed on measures of subjective distress and impairment, childhood family problems, mastery and number of comorbid diagnoses. Results: Approximately half of all treated participants across all six syndromes suffered from subthreshold disorders. Meeting full or subthreshold diagnostic criteria was associated with treatment seeking for insomnia. Being female was associated with treatment seeking for depression. The only variable highly and consistently associated with treatment seeking, across all syndromes, was subjective distress. Treated participants reported high levels of distress, work and social impairment in both diagnostic and subthreshold groups. Conclusion: Subjective distress may be a better indicator of treatment seeking than symptom count.