psychiatric disorders: history. classification. prevalence. comorbidity. epidemiology

Definition of psychiatric disorderHistory. Classification. Prevalence. Comorbidity. Epidemiology.

DefinitionDSM criteria of abnormal behavior: “A behavior is considered as abnormal if it is statistically rare, deviates from society's unwritten rules (norms), it is counter-productive to the individual and affects individual's mental well-being”

Statistically rare behaviorDeviates from the normIt's counter-productiveAffects the mental well-being

Normal

Statistically rare behaviorDeviates from the normIt's counter productiveAffects the mental well-being

Abnormal

Statistically rare behaviorDeviates from the normIt's counter productiveAffects the mental well-being

Normal

Definition

Neuroscience: “Mental disorders are a diverse group of brain disorders that primarily affect emotion, higher cognition and executive function”

Philosopher: “There is no such thing as mental illness in any culture, and that there could not be, because the very notion of mental illness is based on a fundamental mistake or set of mistakes.”

Wikipedia: “Mental disorder or mental illness are terms used to refer to a psychological or physiological pattern that occurs in an individual and is usually associated with distress or disability that is not expected as part of normal development or culture”

DSM criteria of abnormal behavior: “A behavior is considered as abnormal if it is statistically rare, deviates from society's unwritten rules (norms), it is counter-productive to the individual and affects individual's mental well-being”

Diagnostic Systems

Diagnostic and Statistical Manual of Mental Disorders (DSM)

D

Publisher: American Psychiatric Association

Last Version: IV-TR

Covers only Mental Disorders

International Classification of Diseases (ICD)

I

Publisher: World Health Organization

Last Version: 10

Covers all medical diagnosis (chapter 5: mental disorders)

C

ICD-10[International Statistical Classification of Diseases and Related Health Problems]

International Classification System. Coding of all kind of diseases and mental disorders.

22 Categories

Examples:

Certain infectious and parasitic diseases

Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

Endocrine, nutritional and metabolic diseases

Mental and behavioural disorders

Diseases of the nervous system

Diseases of the eye and adnexa

Diseases of the ear and mastoid process

DSMCategorical classification system

16 Main Categories: Disorders usually first diagnosed in infancy,

childhood, or adolescence

Delirium, dementia, and amnestic and other cognitive disorders

Mental disorders due to a general medical condition not elsewhere classified

Substance-related disorders

Schizophrenia and other psychotic disorders

Example: Major Depressive Episode. 5 or more of these symptoms / 2 weeks:

• Depressed mood most of the day• Markedly diminished interest or pleasure in all• Significant weight loss when not dieting or weight gain • Insomnia or hypersomnia nearly every day • Psychomotor agitation or retardation nearly every day • Fatigue or loss of energy nearly every day • Feelings of worthlessness or excessive or inappropriate guilt nearly every day • Diminished ability to think or concentrate, or indecisiveness, nearly every day • Recurrent thoughts of death

Mood disorders

Anxiety disorders

Somatoform disorders

Sleep Disorders

Dissociative disorders

Sexual and gender identity disorder

Eating disorders

Personality disorders

Factitious disorders

Impulse-control disorders not elsewhere classified

Adjustment disorders

Diagnostic Systems

DSM

Multi-axial system

− Axis I: Clinical, developmental and learning disorders

− Axis II: Personality disorders and mental retardation

− Axis III: Medical conditions and physical disorders.

− Axis IV: Psychosocial and environmental factors contributing to the disorder

− Axis V: Global Assessment of Functioning (on a scale from 100 to 0)

f

Example

Axis I: Major Depressive Disorder

Axis II: None

Axis III: Cancer

Axis IV: His mother died 2 weeks ago

Axis V: 80%

The Timeline...

1893 1918 1948 1952 1968 1980 1994 2000 2011

International Classification of Causes of Deathadopted in Paris. Little mention of Mental Disorders

International Statistical Classification of

Diseases, Injuries and Causes of Death (v.6).

Contains a whole section for mental

disorders.

Statistical Manual for the use of

Institutions for the Insane. 22

categories, mainly referred to the

somatic causes of behavioral disorders

First DSM. Focused on diagnosis. Brief

descriptions of each disorder. Influenced from psychoanalytic

thinking

DSM-II. No major

differences to the DSM-I

DSM-III. Use of field-tested

criteria to achieve

reliability. No theories of aetiology

DSM-IV. Conservative Revision of

DSM-III

DSM-IV-TR. Text is

revised, but the diagnostic

criteria are not

DSM-V is expected. Ideally it will include

experimental criterion sets aiming at

incorporating new genetic and

neurobiological findings

Criticism of DSM

Use of categoriesDSM uses categories, but drugs do not respect the boundaries of the disorders.Many disorders are better conceptualized as dimensional traits.

Normal Abnormal/ Mental Disorder

Different levels of symptoms. More or less severe cases.“Not Otherwise Specified” category is used very often!

Co-morbidityA large fraction of patients qualifies for multiple diagnoses.

Possible explanations:Shared genetic risk factorsErrors in splitting symptoms between different disorders

Mental Disorders and Neuroscience

Need for integration of Neuroscience into DSM-V Arbitrary boundaries between mental and neurological disorders. Overlapping practice patterns between neurology and psychiatry. Use of neurological techniques in order to treat mental disorders (e.g. deep brain stimulation) Both treat higher brain functions (e.g. autism, Alzheimer's disease, ADHD)

B

Biological basis of many mental disorders (e.g. schizophrenia, bipolar disorder)

B

Need to build a new dimensional diagnostic system. Ultimate goal: a diagnostic classification system for mental disorders based not only on symptomatology but also on aetiology and pathophysiology of the disorders.

How can Neuroscience help?

Neurogenetics Significant influence of genes (twin

studies/ adoption studies etc)

s

Many studies tried to identify the role of genetic factors in development of disorders.

Interaction between multiple genetic factors that cause a common symptom in different mental disorders (e.g. gene catechol-O-methyltransferase => metabolism of neurotransmitters like dopamine=> schizophrenia-like symptoms)

d

New technologies will provide complete information about the exact genetic factors


Neuroimaging Anatomical abnormalities

(e.g. less gray matter in schizophrenics)Future diagnostic classifications

Contribution to experimental therapiesa. Localization of abnormal activationsb. Direct therapy in these brain regions(e.g. Experimental treatment of depression with stimulation of cingulate cortex)

w


Example: Phenylketonuria [1 in 15,000 births]autosomal recessive genetic disorder deficiency in the PAH enzyme→

Discovery of phenylketones in urine of some mentally retarded individualsAnatomical differences (brain size ~80% of normal)

A

1950: More specific reports White matter abnormalities (spongy change)

W

Pallor of myelin staining Demyelination

Demyalination is caused after the birthMore accurate detection of PKUDietary Therapy (low in phenylalanine)

D

Today: Animal Models

Prevalence of Mental Disorders in EuropePrevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the

Netherlands and Spain

Total Males FemalesAny Mental Disorder 25,00% 21.8% 28.1%Any Mood Disorder 14,00% 9.5% 18.2%Any Anxiety Disorder 13.6% 9.5% 17.5%Any Alcohol Disorder 5.2% 9.3% 1.4%

Lifetime Prevalence

Total Males FemalesMajor Depression 12.8% 8.9% 16.5%Dysthymia 4.1% 2.6% 5.6%GAD 2.8% 2.0% 3.6%Social Phobia 2.4% 1.9% 2.9%Specific Phobia 7.7% 4.9% 10.3%PTSD 1.9% 0.9% 2.9%Agoraphobia 0.9% 0.6% 1.1%Panic Disorder 2.1% 1.6% 2.5%Alcohol Abuse 4.1% 7.4% 1.0%Alcohol Dependence 1.1% 1.8% 0.4%

ESEMeD/MHEDEA 2000 Investigators



Declining rates with ageAge Group18-24 13.7%25-34 11.2%35-49 9.6%50-64 9.8%>65 5.8%

Higher rates for unmarried/ divorced

Marital StatusMarried 8.7%Previously married 10.9%Never married 11.8%

12-month Prevalence




Higher rates for higher education levels

Higher rates in urban areas

Education Any Mental Disorder Any Alcohol Disorder0-4 Years 8.9% 0.2%5-8 Years 7.0% 0.5%9-12 Years 9.1% 0.9%>13 Years 9.0% 1.2%

12-month Prevalence


UrbanicityRural 8.6%Mid-size urban 9.9%Large Urban 10.5%

Prevalence of major psychiatric disorders

Example: DepressionDepression ranks 5th across women and 7th across men as a cause of morbidity (World Bank, 1993)

a

WHO: in 2020 depression will be the second most important cause of disability.The cultural background is likely to determine whether depression will be experienced and expressed in psychological and emotional terms or in physical terms.

Bhugra & Mastrogianni, 2004


Example: DepressionWHO, 1996: 10.4% received a “current depressive episode” diagnosisCo-morbidity: Depression, Anxiety, Alcohol Misuse or Dependence, Panic Disorder, Obsessive-Compulsive DisorderDifferences in prevalence across cultures/ countries

i. Different levels of awareness and recognitionii. Popular perceptions about the role of doctor in each countryiii. Different pathways to health system (i.e. medical care must be

paid in Nigeria)iv. Social stigmav. Methodological Issues (lack of appropriate instruments)

v



Example: Depression – Ethnic MinoritiesUSA

No differences between African Americans and White Americans (when demographic, sociocultural and socio-economic factors are controlled)

a

Puerto Ricans: higher depression rates Asian Americans: lower prevalence of depression

UK In general, higher prevalence rates of depression on

minority groups African-Caribbean women: higher prevalence of

depression Punjabis: more depressive ideas



Example: Depression – DiagnosisDepression is under-recognized throughout the world. Primary care physicians detect only 50% of the casesUK

Asians: visit their practitioner more frequently, but is less likely to have their psychological difficulties identified (complaints about somatic symptoms)

i

Indian women: 17% recognitionUSA

Physicians are less likely to detect depression among African American and Hispanic patientsAustralia

Asians: lower rate of diagnosis (similar rate of self-reported symptoms)

A


Example: Depression – Diagnosis

SummaryTwo main categorical systems:DSM (mental disorders)ICD (diseases and mental disorders)

Need for integration of Neuroscience in the future versions of these categorical systemsDiagnosisTreatmentFuture Studying

Prevalence & Epidemiology450 million people suffer from mental disordersMost common: mood disordersMore women than menDevelopment during youthUrban Areas > Rural AreasDifferent rates around the worldSocial factors (culture, language, minorities etc)

psychiatric disorders: history. classification. prevalence. comorbidity. epidemiology

Health & Medicine

metabolic diseases mental

mental disorderscicd

behavioural disorders

notion of mental illness

parasitic diseases diseases

certain disorders

adnexa diseases

kind of diseases