4. Tradicionalna
Krepelijanska dihotomija
Shizophrenia
Dementia praecox
Bipolarni poremećaj
MD insanity
“... it is becoming increasingly obvious that we cannot satisfactorily distinguish
these two diseases .... We shall have to get accustomed to the notion that our much used
clinical checklist does not permit us to differentiate reliably manic-depressive insanity
from schizophrenia in all circumstances” Kraepelin, 1920 (pp. 26, 28).
5.
6. DSM & ICD “Biblije”DSM & ICD “Biblije”
PSIHOTIČNO - njegovo korišćenje ne podrazumeva pretpostavke o mehanizmima nastanka, već prosto ukazuje
na prisustvo halucinacija, iluzija ili ograničenog broja nekih abnormalnosti u ponašanju, kao što su preterana
uzbudjenost i preterana aktivnost, markirana psihomotorna retardacija i katatono ponašanje.
7. “Zašto kažemo psihoza, a mislimo na shizofreniju”
The new name for schizophrenia?
Evropa, Amerika
Dysfunctional Perception Syndrome
A salience dysregulation syndrome
Japan
Mind-split-disease (Seishin Bunretsu Byo)
Integration-dysregulation syndrome (Tōgō-shitchō-shō)
8. • rana psihoza (McGorry, 2006)
“Zašto kažemo psihoza, a mislimo na shizofreniju”
9. * The work group is recommending that this be
included in DSM-5 but is still examining the
evidence as to whether inclusion is merited in the
main manual or in an Appendix for Further
Research. As such, the work group strongly
encourages feedback regarding this disorder.
10. Hallucinations Delusions Disorganization Abnormal
Psychomotor
Behavior
Restricted
Emotional
Expression
Avolition Impaired
Cognition
Depression Mania
0 Not Present Not Present Not Present Not Present Not Present Not Present Not Present Not Present Not Present
1 Equivocal (severity or
duration not
sufficient to be
considered
psychosis)
Equivocal
(severity or
duration not
sufficient to be
considered
psychosis)
Equivocal (severity or
duration not sufficient
to be considered
disorganization)
Equivocal (severity
or duration not
sufficient to be
considered
abnormal
psychomotor
behavior)
Equivocal decrease
in facial
expressivity,
prosody, or
gestures
Equivocal
decrease in
self-initiated
behavior
Equivocal (cognitive
function not clearly
outside the range
expected for age or
SES, i.e., within 1 SD
of mean)
Equivocal (some
depressed mood, but
insufficient
symptoms, duration
or severity to meet
diagnostic criteria)
Equivocal (some
inflated or irritable
mood, but insufficient
symptoms, duration,
or severity to meet
diagnostic criteria)
2 Present, but mild
(little pressure to act
upon voices, not very
bothered by voices)
Present, but mild
(delusions are
not bizarre, or
little pressure to
act upon
delusional
beliefs, not very
bothered by
beliefs)
Present, but mild
(some difficulty
following speech
and/or occasional
bizarre behavior)
Present, but mild
(occasional
abnormal motor
behavior)
Present, but mild
decrease in facial
expressivity,
prosody, or
gestures
Present, but
mild in self-
initiated
behavior
Present, but mild
(some reduction in
cognitive function
below expected for
age and SES, b/w 1
and 2 SD from mean)
Present, but mild
(meets criteria for
Major Depression,
with minimum
number of
symptoms, duration,
and severity)
Present, but mild
(meets criteria for
Mania with minimum
number of symptoms,
duration, and
severity)
3 Present and
moderate (some
pressure to respond
to voices, or is
somewhat bothered
by voices)
Present and
moderate (some
pressure to act
upon beliefs, or is
somewhat
bothered by
beliefs)
Present and moderate
(speech often difficult
to follow and/or
frequent bizarre
behavior)
Present and
moderate (frequent
abnormal motor
behavior)
Present and
moderate decrease
in facial
expressivity,
prosody, or
gestures
Present and
moderate in
self-initiated
behavior
Present and
moderate (clear
reduction in
cognitive function
below expected for
age and SES, b/w 2
and 3 SD from mean)
Present and
moderate (meets
criteria for Major
Depression with
somewhat more
than the minimum
number of
symptoms, duration,
and/or severity
Present and
moderate (meets
criteria for Mania
with somewhat more
than the minimum
number of symptoms
duration, and/or
severity)
4 Present and severe
(severe pressure to
respond to voices, or
is very bothered by
voices)
Present and
severe (severe
pressure to act
upon beliefs, or is
very bothered by
beliefs)
Present and severe
(speech almost
impossible to follow
and/or behavior
almost always bizarre)
Present and severe
(abnormal motor
behavior almost
constant)
Present and severe
decrease in facial
expressivity,
prosody, or
gestures
Present and
severe in
self-initiated
behavior
Present and severe
(severe reduction in
cognitive function
below expected for
age and SES, > 3SD
from mean)
Present and severe
(meets criteria for
Major Depression
with many more
than the minimum
number of
symptoms and/or
severity)
Present and severe
(meets criteria for
Mania with many
more than the
minimum umber of
symptoms and/or
severity)
11.
12. • osporavana od samog starta
– fenomenolozi Birnbaum (1928) je predvideo kraj Krepelinove
nozologije (“Krepelinovi klinički entiteti su samo tipologija
psihijatrijskih sindroma”)
– savremene neurobiološke studije (šta se proučava psihotičnost ili
shizofrenija vs. bipoalrni afektivni poremećaj)
• opstaje do danas
– konceptualno jednostavna i omogućuje jednostavnu i jasnu
dijagnostiku slozenih kliničkih slika
13. Krepelinove pretpostavke o kategorijalnoj prirodi psihijatrijskih poremećaja
obuhvaćene su u DSM-III a njegove pristalice sebe nazivaju “neoKrepelijancima”
u svojoj knjizi, The broken brain (1990), neokrepelijanksa Nancy
Andreasen predvidja da ce u buducnosti biti dovoljan
psihijatrijski intervju od 15 minuta da bi se postavila dijagnoza
mentalnog poremećaja
14. • Prednosti (Mellsop i sar. 2007)
– odluka (dijagnoza, lečenje)
– dijagnostička pouzdanost
– olakšava komunikaciju
• Nedostaci (Bannister, 1968)
– “Kineski meni” dva od pet
15. Karl Menninger
“If the patient has, let us say, five symptoms, one
can look up each of these symptoms and find which
disease is so characterized under all five
headings. Then, voilà! The diagnosis!”
1893 - 1990
American psychiatrist and a member of the famous
Menninger family of psychiatrists who founded the
Menninger Foundation and the Menninger Clinic in Topeka,
Kansas.
16. • mnogi somatski poremećaji predstavljaju ekstremni kraj kontinuuma (npr. gojaznost,
hipertenzija, dijabetes, anemija)
• kategorijalna podela je poželjna u momentu kada treba započeti lečenje
ZDRAVLJE BOLEST
dijastolni pritisak 85 mmHg
Psihotični poremećaji su ekstrem dimenzije koje nam nameću kategorijalnu
distinkciju u trenutku kada treba započeti lečenje
17. • odražava kontinuum psihotičnosti u populaciji
• obuhvata veći broj podataka
• smanjuje incidencu komorbiditeta
• veća validnost
18. Nema jasne granice izmedju “zdravlja” i “bolesti”
Populacione studije pokazuju da se psihotični simptomi mnogo češće doživljavaju
nego što to pokazuju podaci kliničkih studija.
Životna prevalenca prema DSM-kriterijumima:
•halucinacije: 11.1% (Tein, 1991); 7.9% (van Os et al., 2000); 13.2% (Poulton et al.,
2000)
•sumanute ideje: 12.0% (van Os et al., 2000); 12.6% paranoja (Poulton et al., 2000)
There are many happy, functioning psychotic people in the population!
19. Know Your Own Psychosis Levels
• Do you ever feel that others are
against you?
• Do you believe that others are influencing your mind?
• Do you believe that other people talk
about you?
• Can you communicate with animals?
Do you ever feel that your manager/professor is against you?
Do you believe that drug companies are influencing your
mind?
If you have a pet, can you tell what it
is thinking?
Do members of your clinical/research team gossip about
you?
20. • hibridni kategorijalno-dimenzionalni model
– prednost: bolje razumevanje kliničkih karakteristika bez
izostavljanja tradicionalne Krepelinove dihotomije
24. • Šta su rane pihoze:
– dimenzija vs. kategorija
– težina – kvantitet vs. kvalitet poremećaja
• Prevencija
– kojeg poremećaja
– kojim sredstvima
– do sada ne postoje konzistentni podaci da rane intervencije redukuju prevenciju razvoja
psihotičnog poremećaja
25. • Ukoliko se prihvati koncept rane psihoze sta se leči:
– simptom, sindrom
– dimenzija vs. kategorija
– psihotičnost sch., afektivnog, sumanutog poremećaja...primarnu-sekundarnu
psihotičnost
– da li ćemo imati istim leko lečiti svaku ranu psihozu iako mogu da imaju razlicitu genezu
– farmakološka indukcija psihotičnih ispoljavanja ili promena toka
• Rana psihoza:
– Nova indikacija za farmakoterapiju?
Hinweis der Redaktion
uz koncept unitarne psihoze
A debate exists as to whether the term schizophrenia, which refers to a state of so-called split mind, should be retained in DSM-V and ICD-11.12–15 Japan was the first
country to abandon the term schizophrenia, and modified the name of the illness from Seishin Bunretsu Byo (mind-split disease) into Togo Shitcho Sho (integration-dysregulation syndrome). The change of name had an instant response. Most psychiatrists started using it in the first year, bringing about an improved communication of diagnosis to patients and better
perception of the disorder.16 Thus, the term schizophrenia will continue to evolve; however, the underlying mechanisms and the effect on the person will not change.
KOME CEMO SE CARSTVU PRIKLONITI, kategorialjnom, dimenzinalnom ili nekom trecem gde je tu vreme gde je tu anamneza - individualna
First, it facilitates the decision-making process regarding individuals who present clinically with psychosis [36]. For example, categorical diagnoses are helpful when a clinician is required to make a decision about treatment, especially hospitalization and antipsychotic drug therapy. Trull and Durrett [37] provided a simplified illustration of this decision making process: the presence of a diagnosis necessitates treatment, while the lack of a diagnosis negates the need for treatment. Thus, the current diagnostic system has provided clinicians with a frame of reference for treating patients who present with psychotic experiences.
Kraemer HC, Noda A, O’Hara R: Categorical versus dimensional approaches to diagnosis: methodological challenges. J Psychiatr Res 2004, 38:17–25.
Second, a categorical approach to diagnosis has demonstrated advantages for researchers. For example, researchers interested in determining the effectiveness of particular psychotropic drugs or psychosocial interventions on schizophrenia outcomes fi nd categorical diagnoses useful for determining inclusion and exclusion criteria and ensuring consistency across sites, as discussed subsequently. Even if multiple subtypes are studied, patients are still typically grouped according to diagnosis, and treatments are thus determined to be effective or ineffective according to these diagnostic groups. Kraemer and coworkers [36] discussed how categorical diagnoses also benefit researchers ethically and in terms of cost-effectiveness; for example, a high-risk treatment should only be provided to individuals who meet criteria for a particular disorder, and costly treatments typically cannot be provided to most individuals, especially those who do not cross diagnostic thresholds. Even when dimensional approaches are used, researchers are typically forced to impose cut-offs, which are often arbitrary or empirically derived (eg, the highest quartile of a distribution of scores) and may have no more validity than traditional diagnostic categories.
Third, the categorical diagnostic system has allowed for the improvement in diagnostic reliability (ie, agreement, consistency, and stability) among clinicians and researchers. Early scientifi c literature has been criticized for its lack of reliability with respect to diagnoses; Kendell and Jablensky [38] in particular noted the lack of consensus on disorders such as schizophrenia before the 1970s, making it very diffi cult to compare research fi ndings. A formal diagnostic system provides a framework for determining the presence or absence of a disorder. This has allowed not only for increased reliability among researchers and clinicians but also a better basis for comparison across studies (ie, most researchers use the same formal diagnostic systems for diagnosing patient samples). As Craddock and Owen [39] noted, the Kraepelinian dichotomy “formed the basis of the operational diagnostic criteria that brought a degree of rigor and reproducibility to psychiatric research.” Trull and Durrett [37] acknowledged the wealth of information that is transmitted by the use of a categorical diagnosis such as schizophrenia.
Fourth, related to the discussion above, the current diagnostic system has improved communication among clinicians, researchers, and the lay community. Mellsop and associates [40] discussed how the current diagnostic system is designed to facilitate the communication of information on epidemiology, clinical descriptions, pathogenesis, treatment options, and prognosis and outcome among treatment providers, patients, families, and the public. The availability of categorical diagnoses has provided a method for understanding a particular syndrome and has enabled communication of that understanding.
Kendell R, Jablensky A: Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003, 160:4–12.
Craddock N, Owen MJ: The beginning of the end for the Kraepelinian dichotomy. Br J Psychiatry 2005, 186:364–366.
Mellsop GW, Menkes DB, El-Badri SM: Classification in psychiatry: does it deliver in schizophrenia and depression? Int J Ment Health Syst 2007, 1:7.
The first would be the ability of the diagnostic system to reflect the true continuum of psychosis in the population, which, as reviewed above, ranges from self-reported infrequent psychotic symptoms in the general population, to schizotypal traits, to SPD, and fi nally to full-blown psychosis resulting in a DSM-IV-TR–defined primary psychotic disorder. A dimensional approach would allow diagnostic systems to capture the high degree of heterogeneity and variation that supports the notion that psychosis is primarily dimensional in nature. Recent commentary from Widiger and Samuel [43] noted that the categories of mental disorders rarely capture most individuals; the remarkable popularity of “not-otherwise-specified” diagnoses provides support for this argument.
A second advantage relates to the basic tenet of measurement that categorizing continuous-level data results in a loss of information. Imposing categories on a dimensional construct such as psychosis likely results in the loss of important information, especially with respect to the within-category heterogeneity described previously. For example, early work by Robins and Guze [44] showed that there is a subtype of schizophrenia that is characterized by a shorter time to recovery and better prognosis than what researchers had come to expect. Findings such as this show that grouping individuals into an arbitrary category under the term schizophrenia results in a loss of important information regarding differential outcomes among individuals in the category. Continuous-level data also add utility for research and scientifi c endeavors, especially with respect to statistical procedures such as hypothesis testing. Kraemer and coworkers [36] provided a detailed comparison of categorical versus dimensional approaches to statistical analysis in research. Their illustration demonstrates how researchers are afforded greater statistical power when using a dimensional approach to diagnosis and how much more information is available when investigating continuous/dimensional variables rather than dichotomous/categorical variables.
Third, the extensive comorbidity among the DSM-IV-TR mental disorders points to a high degree of overlap among these disorders. Krueger and associates [45] noted that most individuals who meet criteria for one DSM-IV-TR disorder also meet criteria for one or more other disorders. Furthermore, many disorders exhibit features that overlap with traits of other disorders. For example, research has shown that individuals with SPD are likely to also display features of autistic disorder [46], and a whole host of studies exists concerning the symptom overlap between schizophrenia and bipolar disorder, such that individuals with schizophrenia frequently display signifi cant mood symptoms, and some individuals with bipolar disorder also display full-blown psychotic symptoms. In fact, this research led to the development of the schizoaffective disorder diagnosis. Thus, there exists a continued reifi cation of classes of mental illnesses despite evidence against a discrete nature. Recent research has shown that comorbidity and symptom overlap are likely due to shared susceptibilities.
A fourth advantage of a dimensional approach is that empirical research comparing the validity of a dimensional versus that of a categorical diagnosis of psychotic disorders has overwhelmingly shown favor for the former with respect to predictive power for clinical symptoms, treatment response, and outcomes. For example, Peralta and colleagues [47] examined the external validity of categorical and dimensional approaches to classifying psychotic disorders. Their findings showed that dimensions were more stable across different time frames of illness and they explained a greater percentage of variance in clinical variables compared with categorical approaches. Rosenman and associates [48] studied individuals with a psychotic illness and compared the utility of dimensional measures to categorical diagnoses, finding that a dimensional approach explained more variance in dysfunctional behavior, social adaptation, global functioning, and demand for services. Other studies have revealed similar results. Van Os and coworkers [49] found that dimensional measures of psychotic symptoms provided more clinical information that is necessary for making appropriate treatment recommendations. Another study showed that dimensional models of diagnosis outperformed their categorical counterparts with respect to predicting nine different outcome dimensions [50].
Widiger TA, Samuel DB: Diagnostic categories or dimensions? A question for the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition. J Abnorm Psychol 2005, 114:494–504.
Krueger RF, Watson D, Barlow DH: Toward a dimensionally based taxonomy of psychopathology. J Abnorm Psychol 2005, 114:491–493.
Peralta V, Cuesta MJ, Giraldo C, et al.: Classifying psychotic disorders: issues regarding categorical vs. dimensional approaches and time frame to assess symptoms. Eur Arch Psychiatry Clin Neurosci 2002, 252:12–18.
Rosenman S, Korten A, Medway J, Evans M: Dimensional vs. categorical diagnoses in psychosis. Acta Psychiatr Scand 2003, 107:378–384.
van Os J, Gilvarry C, Bale R, et al.: A comparison of the utility of dimensional and categorical representations of
psychosis. Psychol Med 1999, 29:595–606.
van Os J, Fahy T, Jones P, et al.: Psychopathological syndromes in the functional psychoses: associations with
course and outcome. Psychol Med 1996, 26:203–208.
It is clear that the categories of psychosis as used currently in DSM-IV are not valid in a strictly scientific sense. Their replacement by a developmental and dimensional approach as outlined above has much to recommend it for DSM-V. However, the current system does have some utility in terms of the information about etiology, course of illness, outcome, and treatment response that the different diagnoses convey.77
Abandoning it would be a very dramatic shift, and although we believe it would be an advance, some information of benefit to patients and clinicians would be lost. We consider that at present the best option is to implement a hybrid of a categorical-dimensional approach in DSM-V. This would introduce the benefit of increased explanatory power of clinical characteristics, without completely dismissing the traditional paradigm of the Kraepelinian dichotomy. Similarly, including a rating of developmental impairment would aid understanding of the longitudinal course of illness evolution, rather than considering a diagnosis as a cross-sectional perspective based only on the current clinical picture.
Anything more radical is likely to be premature, with the expectation of further advances in genetic, neurobiological, environmental, and psychosocial research in the coming decade. In parallel with research in individual disciplines, what is needed is a concerted multicenter effort to look back at existing epidemiologically based first-onset psychosis cohorts to investigate how external summary variables, including measures of cognition, social variables, and need for care, as well as symptom dimensions, familial liability scores, and basic structural magnetic resonance imaging data may sharpen the discriminative potential of the DSM classification of psychotic disorders. This should include cohort data from both developing as well as developed countries. From our exploration of cultural issues, we suggest that standardized qualitative and quantitative methods need to be developed that can be employed in a wide range of different communities to conduct culturally sensitive assessments of psychotic symptoms. Only then will it be possible for the nosologist to attempt to identify universal ‘‘gold standard’’ criteria (preferably with unique biological and psychosocial markers) for a discrete set of psychotic diagnoses.
Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry. 2003; 160:4–12.
Young people at risk for later manifestation of a psychotic disorder can be identified. It has been established in follow-back studies that early signs and symptoms of schizophrenia, for example, are present years before diagnosis is established [e.g., Haffner's longitudinal study] and can be predicted even in infants [Walker's home movies study]. However, it is the work of multiple groups of investigators in several countries over the past 15 years that has produced evidence for the effectiveness of detecting at risk individuals. The validity of criteria for identifying individuals as at risk has been published [see Scott et al, below]. An approach to this issue in the DSM-V framework has been published [Heckers, see below and Carpenter, see below]. And also widely debated [see Schizophrenia Research Forum for presentations and commentary by many participants].
Critical issues to consider include sensitivity, specificity, positive predictive power and negative predicitive power; the evidence for effective intervention, and issues related to stigma and potential harm of excessive treatment.
The potential benefit of establishing a category involves the evidence that psychotic illness is most effectively treated early in the course raising the potential that early intervention may have long lasting benefit that is not achievable with later therapeutic intervention. Also, as clarified in a recent IOM report, prevention science requires application. It seems reasonable to anticipate that mental disorders will gradually develop interventions for primary and secondary prevention associated with a number of disorders.
For these reasons, a risk syndrome for psychosis is being considered for either the appendix or possibly the list of disorders. Immediate issues relate to the unanswered question as to whether ordinary users of DSM-V in ordinary settings will be able to reliably and validly identify cases based on criteria developed and validated by expert investigators. Any movement forward with this proposal will depend on affirmative answers to this issue in field trials. A second problem relates to the absence of an evidence-based intervention which has demonstrated benefit in reducing conversion to psychosis. Finally, more information regarding the potential negative effect on false positive identification is needed.
In the final analysis, these factors will be weighed to assess the benefit/harm considerations of moving forward with this proposal.
