Psychiatric developments最新文献

This paper reviews recent research that used the Diagnostic Interview Schedule (DIS) to characterize medically unexplained symptoms and their clustering in clinical and community populations. While the type of symptom(s) differed little across samples, the distribution of a less restrictive construct of somatization ('abridged' somatization) showed interesting differences across the various groups. The authors propose that in view of its relatively high prevalence, abundant psychiatric comorbidity and the simple and unintrusive nature of the assessment, use of the abridged construct may have practical value particularly when exploring psychopathology among medical and community populations.

Positron emission tomography permits the study of human brain function. With a positron labelled tracer and a model for quantitation, regional brain metabolism and neuroreceptor characteristics can be determined with PET. Schizophrenia is the most extensively studied psychiatric disorder. Most studies have demonstrated decreased metabolic rates in wide areas of the brain. It is proposed that the metabolic changes observed in the brains of schizophrenic patients are due to a fundamental change in neuronal function. Fewer studies have been performed in other psychiatric disorders. Bipolar depressed patients probably have a decreased brain metabolism. Obsessive compulsive and panic disorders (if sensitive to lactate) have an increased brain metabolism. This is probably also the case for female anorectic patients. Alcohol dependent subjects with a long duration of abuse may have a decreased brain metabolism. Neuroreceptor studies with PET have in one study of psychotropic drug naive schizophrenic patients demonstrated an increase of D2-dopamine receptors. In another study no difference between controls and patients was found. Treatment of schizophrenic patients with conventional doses of neuroleptic drugs results in a D2 receptor occupancy of 65 to 85 per cent, suggesting that there is no need for high dose treatment in schizophrenic patients. The studies reviewed clearly demonstrate that PET is a valuable tool in psychiatric research.

The Parental Bonding Instrument (PBI) was designed as a refined self-report measure of fundamental parental dimensions of care and protection. The utility of such a self-report measure is dependent on demonstration of robust psychometric characteristics, particularly the extent to which the PBI provides valid ratings of actual and not merely perceived characteristics. This paper reviews initial and more recently published studies assessing the psychometric properties of the PBI, and which suggest satisfactory reliability and validity.

An interviewer rating scale for the measurement of (agora)phobic avoidance, the Phobic Avoidance Rating Scale (PARS), is described and psychometrically evaluated. The criteria of avoidance used are purported to correct weaknesses of the sets of criteria used in self-report instruments. Two samples with inpatients satisfying DSM-III-R criteria for unipolar depressive and/or anxiety disorder were studied. Intercorrelational and factor analyses revealed 3 dimensions among agoraphobic fears: separation fears, social fears and simple phobic fears. Overall, the 3 subscales constructed from these dimensions proved to have good reliability, validity, and sensitivity to change following treatment. The internal consistency of the social subscale seemed to be somewhat low. The PARS should be well suited to assess avoidance among agoraphobic patients on separate dimensions and to distinguish patients with agoraphobia from other psychiatric patients. It seems to be the first interviewer rated agoraphobic scale that is psychometrically investigated and should ideally be used for research purposes in combination with a self-report instrument.

Avoidance behaviour and secondary major depression are both frequent in clinical samples of patients with panic disorder. Their status is unclear: indicators of severity of panic disorder or indicators of separate psychiatric disorders. Among the data of the Cross-National Collaborative Panic Study (n = 1,168) we found that especially avoidance behaviour defines more severe states of panic disorder (earlier age at onset, higher frequency of panic attacks and higher level of psychopathology); co-occurrence of major depression is less clearly associated with more severe panic disorder. The results are compatible with the DSM-III-R concepts of comorbidity of panic disorder and major depression and of subtyping panic disorder by avoidance behaviour.

Phenomenological data are presented for panic attacks and non-panic anxiety in 159 patients. Anxiety episodes of sudden onset tend to have greater severity, more symptoms, and shorter duration and some distinctive cognitive features. This cluster of features emerged from the analysis as characteristic of the panic attack. There were no differences between situational and spontaneous attacks nor are attacks occurring in depressed patients different from those in-patients who suffered from anxiety disorders. The ideas characteristic of normal anxiety are directed towards ordeals in the future. It is the immediacy of the anxious cognitions of imminent death, collapse or becoming insane that are characteristic of panic attacks. A definition of panic attacks is suggested.

Before the advent of antidepressants, no generally accepted and operationalized classification of depression existed. In the late fifties and sixties we developed a multi-axial and operationalized depression taxonomy in order to be able to study systematically the clinical and biochemical action of antidepressants and biological characteristics of depressives responsive to antidepressants. The keypoints of that system and the data on which it was based are discussed, after which it is compared with the depression classification proposed by the DSM III and DSM III-R. Though it is recognized that a system based on consensus opinion can never be overall acceptable to everyone, the conclusion is reached that the DSM depression classification is outright unsatisfactory and contributes to diagnostic confusion rather than to reduce it. It is recommended that an immediate moratorium should be laid on expert-opinion-based alterations in the classification of depressions and that future changes will be based only on research specifically designed to resolve issues pertinent to that classification. In organizing, conducting and funding such a collaborative, goal-directed effort, the National Institute of Mental Health could play a seminal role.

Circadian rhythm dysfunction has recently been suggested to have a causal role in major depressive disorders. Against this background, experiments on circadian rhythms are outlined that yield a state of sustained sleepless activity. Such states can be brought about it seems by manipulation of the external zeitgebers to which rhythms are synchronized rather than by any alteration of the circadian clock. This can be expected to yield a disorganized rhythmic state rather than any discrete phase shifting or desynchronization of rhythms. This state it is suggested should lead to a mild dysphoria, psychomotor activation and a subtle disordering of thought form. It is proposed that these changes lead to the typical clinical picture of mania when distorted cognitively by mechanisms similar to those found in depression. There are a number of implications of this hypothesis. Firstly, mania should commonly be precipitated by similar psychosocial factors to those which precipitate depression. Secondly, similar neuroendocrine findings should be found in both depression and mania. Thirdly, similar agents should be effective in the treatment of mania and depression. Fourthly, cognitive therapy may play a significant part in the management of acute episodes of mania and reduce liability to chronicity.

Recognized since the Middle Ages, and clearly described for more than 100 years, obsessive-compulsive disorder (OCD) continues to intrigue and challenge mental health professionals. Recent evidence has implicated dysfunctional serotonergic neurotransmission in OCD. This review summarizes the evidence favoring a serotonergic hypothesis for OCD followed by a more detailed discussion of the implications the hypothesis holds for treatment.