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Definition of psychiatric disorder
History. Classification. Prevalence. Comorbidity. Epidemiology.
Definition
                  DSM criteria of abnormal behavior: “ behavior is considered as abnormal if it is
                                                                 A
                  statistically rare, deviates from society's unwritten rules (norms), it is counter-productive
                  to theindividual and affectsindividual'smental well-being”





  Statistically rare behavior       
                                      Statistically rare behavior            
                                                                               Statistically rare behavior

  Deviates from the norm            
                                      Deviates from the norm                 
                                                                               Deviates from the norm

  It's counter-productive           
                                      It's counter productive                
                                                                               It's counter productive

  Affects the mental well-being     
                                      Affects the mental well-being          
                                                                               Affects the mental well-being



              Normal                         Abnormal                                    Normal
Definition
                  DSM criteria of abnormal behavior: “ behavior is considered as abnormal if it is
                                                                 A
                  statistically rare, deviates from society's unwritten rules (norms), it is counter-productive
                  to theindividual and affectsindividual'smental well-being”


 Neuroscience: “   Mental disordersarea diversegroup of brain disordersthat primarily affect
emotion, higher cognition and executivefunction”


               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 isnot expected aspart of normal development or culture”
Diagnostic Systems
         Diagnostic and Statistical Manual of Mental Disorders (DSM)
Publisher: American Psychiatric Association
Last Version: IV-TR
Covers only Mental Disorders


                   International Classification of Diseases (ICD)
Publisher: World Health Organization
Last Version: 10
Covers all medical diagnosis (chapter 5: mental disorders)
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
DSM
Categorical classification system
                                                              
                                                                   Mood disorders
                                                                                              
                                                                                                  Factitious disorders
16 Main Categories:                                                                           
                                                                                                  Impulse-control
                                                              
                                                                   Anxiety disorders

    Disorders usually first diagnosed in infancy,                                                 disorders not
    childhood, or adolescence
                                                              
                                                                   Somatoform disorders           elsewhere classified


    Delirium, dementia, and amnestic and other
                                                              
                                                                   Sleep Disorders            
                                                                                                  Adjustment disorders
    cognitive disorders                                       
                                                                   Dissociative disorders

    Mental disorders due to a general medical                 
                                                                   Sexual and gender identity
    condition not elsewhere classified                             disorder

    Substance-related disorders                               
                                                                   Eating disorders

    Schizophrenia and other psychotic disorders               
                                                                   Personality 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
Diagnostic Systems
DSM
                                                                  Example

    Multi-axial system
     −   Axis I: Clinical, developmental and learning disorders
     −   Axis II: Personality disorders and mental retardation    Axis I: Major Depressive Disorder
     −   Axis III: Medical conditions and physical disorders.     Axis II: None
     −   Axis IV: Psychosocial and environmental factors          Axis III: Cancer
         contributing to the disorder
                                                                  Axis IV: His mother died 2 weeks
     −   Axis V: Global Assessment of Functioning (on a scale        ago
         from 100 to 0)
                                                                  Axis V: 80%
The Timeline...
                                                                                          DSM-V is expected.
                                                                                          Ideally it will include
  International         International Statistical                                        experimental criterion
Classification of           Classification of                                                sets aiming at
Causes of Death         Diseases, Injuries and                                             incorporating new
adopted in Paris.       Causes of Death (v.6).       DSM-II. No          DSM-IV.              genetic and
Little mention of          Contains a whole              major         Conservative          neurobiological
Mental Disorders           section for mental       differences to      Revision of              findings
                               disorders.             the DSM-I          DSM-III



   1893 1918 1948 1952 1968 1980 1994 2000 2011

 Statistical Manual
                          First DSM. Focused
    for the use of                                   DSM-III. Use
                           on diagnosis. Brief                           DSM-IV-TR.
 Institutions for the                                of field-tested
                          descriptions of each                              Text is
      Insane. 22                                       criteria to
                          disorder. Influenced                           revised, but
 categories, mainly                                      achieve
                          from psychoanalytic                           the diagnostic
   referred to the                                   reliability. No
                                 thinking                                 criteria are
 somatic causes of                                    theories of
                                                                               not
behavioral disorders                                    aetiology
Criticism of DSM
Use of categories

 DSM 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-morbidity
Alarge fraction of patients qualifies for multiple diagnoses.
    Possible explanations:
         Shared genetic risk factors
         Errors 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)

  Biological basis of many mental disorders (e.g. schizophrenia, bipolar disorder)

  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)
     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)

 
     Newtechnologies will provide complete
     information about the exact genetic factors
How can Neuroscience help?
Neuroimaging
 
   Anatomical abnormalities
   (e.g. less gray matter in schizophrenics)
   Future diagnostic classifications

  
      Contribution to experimental therapies
      a. Localization of abnormal activations
      b. Direct therapy in these brain regions
      (e.g. Experimental treatment of depression
      with stimulation of cingulate cortex)
How can Neuroscience help?
    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 individuals

 Anatomical differences (brain size ~80%of normal)

 1950: More specific reports
  
    White matter abnormalities (spongy change)
  
    Pallor of myelin staining
  
    Demyelination


 Demyalination is caused after the birth

 More accurate detection of PKU

 Dietary Therapy (lowin phenylalanine)

    
        Today: Animal Models
Prevalence of Mental Disorders in Europe
Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the
                                   Netherlands and Spain


                                 Lifetime Prevalence
                                      Total      Males               Females
  Any 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%
                                       Total             Males        Females
  Major 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
Prevalence of Mental Disorders in Europe
Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the
                                   Netherlands and Spain

                                12-month Prevalence

                                   Declining rates with age
                                  Age Group
                                  18-24            13.7%
                                  25-34            11.2%
                                  35-49            9.6%
                                  50-64            9.8%
                                  >65              5.8%



                                   Higher rates for unmarried/ divorced
                                  Marital Status
                                  Married            8.7%
                                  Previously married 10.9%
                                  Never married      11.8%

                                                      ESEMeD/MHEDEA 2000 Investigators
Prevalence of Mental Disorders in Europe
Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the
                                   Netherlands and Spain

                                12-month Prevalence


                                   Higher rates for higher education levels
                                  Education    Any Mental Disorder    Any Alcohol Disorder
                                  0-4 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%




                                   Higher rates in urban areas
                                    Urbanicity
                                    Rural                 8.6%
                                    Mid-size urban        9.9%
                                    Large Urban           10.5%


                                                      ESEMeD/MHEDEA 2000 Investigators
Prevalence of major psychiatric disorders

Example: Depression

 Depression ranks 5th across women and 7th across men
as a cause of morbidity (World Bank, 1993)

 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
Prevalence of major psychiatric disorders
Example: Depression

 WHO, 1996: 10.4%received a “current depressive episode”
diagnosis

 Co-morbidity: Depression, Anxiety, Alcohol Misuse or
Dependence, Panic Disorder, Obsessive-Compulsive Disorder

 Differences in prevalence across cultures/ countries
  i. Different levels of awareness and recognition
  ii. Popular perceptions about the role of doctor in each country
  iii. Different pathways to health system (i.e. medical care must be
      paid in Nigeria)
  iv. Social stigma
  v. Methodological Issues (lack of appropriate instruments)




                                                                        Bhugra & Mastrogianni, 2004
Prevalence of major psychiatric disorders

Example: Depression – Ethnic Minorities

 USA
  
    No differences between African Americans and
    White Americans (when demographic, sociocultural
    and socio-economic factors are controlled)
  
    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


                                                           Bhugra & Mastrogianni, 2004
Prevalence of major psychiatric disorders

Example: Depression – Diagnosis

 Depression is under-recognized throughout the world. Primary care physicians detect only 50%of the
cases

 UK
  
     Asians: visit their practitioner more frequently, but is less likely to have their psychological difficulties
     identified (complaints about somatic symptoms)
  
     Indian women: 17%recognition

 USA
  
     Physicians are less likely to detect depression among African American and Hispanic patients

 Australia
  
     Asians: lower rate of diagnosis (similar rate of self-reported symptoms)
Prevalence of major psychiatric disorders
Example: Depression – Diagnosis
Summary
Two main categorical systems:

 DSM (mental disorders)

 ICD (diseases and mental disorders)

Need for integration of Neuroscience in the
future versions of these categorical systems

 Diagnosis

 Treatment

 Future Studying

Prevalence & Epidemiology

 450 million people suffer from mental disorders

 Most common: mood disorders

 More women than men

 Development during youth

 Urban Areas > Rural Areas

 Different rates around the world

 Social factors (culture, language, minorities etc)

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Understanding Psychiatric Disorders

  • 1. Definition of psychiatric disorder History. Classification. Prevalence. Comorbidity. Epidemiology.
  • 2. Definition DSM criteria of abnormal behavior: “ behavior is considered as abnormal if it is A statistically rare, deviates from society's unwritten rules (norms), it is counter-productive to theindividual and affectsindividual'smental well-being”  Statistically rare behavior  Statistically rare behavior  Statistically rare behavior  Deviates from the norm  Deviates from the norm  Deviates from the norm  It's counter-productive  It's counter productive  It's counter productive  Affects the mental well-being  Affects the mental well-being  Affects the mental well-being Normal Abnormal Normal
  • 3. Definition DSM criteria of abnormal behavior: “ behavior is considered as abnormal if it is A statistically rare, deviates from society's unwritten rules (norms), it is counter-productive to theindividual and affectsindividual'smental well-being” Neuroscience: “ Mental disordersarea diversegroup of brain disordersthat primarily affect emotion, higher cognition and executivefunction” 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 isnot expected aspart of normal development or culture”
  • 4. Diagnostic Systems Diagnostic and Statistical Manual of Mental Disorders (DSM) Publisher: American Psychiatric Association Last Version: IV-TR Covers only Mental Disorders International Classification of Diseases (ICD) Publisher: World Health Organization Last Version: 10 Covers all medical diagnosis (chapter 5: mental disorders)
  • 5. 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
  • 6. DSM Categorical classification system  Mood disorders  Factitious disorders 16 Main Categories:  Impulse-control  Anxiety disorders  Disorders usually first diagnosed in infancy, disorders not childhood, or adolescence  Somatoform disorders elsewhere classified  Delirium, dementia, and amnestic and other  Sleep Disorders  Adjustment disorders cognitive disorders  Dissociative disorders  Mental disorders due to a general medical  Sexual and gender identity condition not elsewhere classified disorder  Substance-related disorders  Eating disorders  Schizophrenia and other psychotic disorders  Personality 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
  • 7. Diagnostic Systems DSM Example  Multi-axial system − Axis I: Clinical, developmental and learning disorders − Axis II: Personality disorders and mental retardation Axis I: Major Depressive Disorder − Axis III: Medical conditions and physical disorders. Axis II: None − Axis IV: Psychosocial and environmental factors Axis III: Cancer contributing to the disorder Axis IV: His mother died 2 weeks − Axis V: Global Assessment of Functioning (on a scale ago from 100 to 0) Axis V: 80%
  • 8. The Timeline... DSM-V is expected. Ideally it will include International International Statistical experimental criterion Classification of Classification of sets aiming at Causes of Death Diseases, Injuries and incorporating new adopted in Paris. Causes of Death (v.6). DSM-II. No DSM-IV. genetic and Little mention of Contains a whole major Conservative neurobiological Mental Disorders section for mental differences to Revision of findings disorders. the DSM-I DSM-III 1893 1918 1948 1952 1968 1980 1994 2000 2011 Statistical Manual First DSM. Focused for the use of DSM-III. Use on diagnosis. Brief DSM-IV-TR. Institutions for the of field-tested descriptions of each Text is Insane. 22 criteria to disorder. Influenced revised, but categories, mainly achieve from psychoanalytic the diagnostic referred to the reliability. No thinking criteria are somatic causes of theories of not behavioral disorders aetiology
  • 9. Criticism of DSM Use of categories  DSM 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-morbidity Alarge fraction of patients qualifies for multiple diagnoses. Possible explanations: Shared genetic risk factors Errors in splitting symptoms between different disorders
  • 10. 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)  Biological basis of many mental disorders (e.g. schizophrenia, bipolar disorder)  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.
  • 11. How can Neuroscience help? Neurogenetics  Significant influence of genes (twin studies/ adoption studies etc) 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)  Newtechnologies will provide complete information about the exact genetic factors
  • 12. How can Neuroscience help? Neuroimaging  Anatomical abnormalities (e.g. less gray matter in schizophrenics) Future diagnostic classifications  Contribution to experimental therapies a. Localization of abnormal activations b. Direct therapy in these brain regions (e.g. Experimental treatment of depression with stimulation of cingulate cortex)
  • 13. How can Neuroscience help? 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 individuals  Anatomical differences (brain size ~80%of normal)  1950: More specific reports  White matter abnormalities (spongy change)  Pallor of myelin staining  Demyelination  Demyalination is caused after the birth  More accurate detection of PKU  Dietary Therapy (lowin phenylalanine)  Today: Animal Models
  • 14. Prevalence of Mental Disorders in Europe Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the Netherlands and Spain Lifetime Prevalence Total Males Females Any 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% Total Males Females Major 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
  • 15. Prevalence of Mental Disorders in Europe Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the Netherlands and Spain 12-month Prevalence Declining rates with age Age Group 18-24 13.7% 25-34 11.2% 35-49 9.6% 50-64 9.8% >65 5.8% Higher rates for unmarried/ divorced Marital Status Married 8.7% Previously married 10.9% Never married 11.8% ESEMeD/MHEDEA 2000 Investigators
  • 16. Prevalence of Mental Disorders in Europe Prevalence rates of mental disorders in 6 E.U. Countries: Belgium, France, Germany, Italy, the Netherlands and Spain 12-month Prevalence Higher rates for higher education levels Education Any Mental Disorder Any Alcohol Disorder 0-4 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% Higher rates in urban areas Urbanicity Rural 8.6% Mid-size urban 9.9% Large Urban 10.5% ESEMeD/MHEDEA 2000 Investigators
  • 17. Prevalence of major psychiatric disorders Example: Depression  Depression ranks 5th across women and 7th across men as a cause of morbidity (World Bank, 1993)  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
  • 18. Prevalence of major psychiatric disorders Example: Depression  WHO, 1996: 10.4%received a “current depressive episode” diagnosis  Co-morbidity: Depression, Anxiety, Alcohol Misuse or Dependence, Panic Disorder, Obsessive-Compulsive Disorder  Differences in prevalence across cultures/ countries i. Different levels of awareness and recognition ii. Popular perceptions about the role of doctor in each country iii. Different pathways to health system (i.e. medical care must be paid in Nigeria) iv. Social stigma v. Methodological Issues (lack of appropriate instruments) Bhugra & Mastrogianni, 2004
  • 19. Prevalence of major psychiatric disorders Example: Depression – Ethnic Minorities  USA  No differences between African Americans and White Americans (when demographic, sociocultural and socio-economic factors are controlled)  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 Bhugra & Mastrogianni, 2004
  • 20. Prevalence of major psychiatric disorders Example: Depression – Diagnosis  Depression is under-recognized throughout the world. Primary care physicians detect only 50%of the cases  UK  Asians: visit their practitioner more frequently, but is less likely to have their psychological difficulties identified (complaints about somatic symptoms)  Indian women: 17%recognition  USA  Physicians are less likely to detect depression among African American and Hispanic patients  Australia  Asians: lower rate of diagnosis (similar rate of self-reported symptoms)
  • 21. Prevalence of major psychiatric disorders Example: Depression – Diagnosis
  • 22. Summary Two main categorical systems:  DSM (mental disorders)  ICD (diseases and mental disorders) Need for integration of Neuroscience in the future versions of these categorical systems  Diagnosis  Treatment  Future Studying Prevalence & Epidemiology  450 million people suffer from mental disorders  Most common: mood disorders  More women than men  Development during youth  Urban Areas > Rural Areas  Different rates around the world  Social factors (culture, language, minorities etc)