Tag: DSM: Diagnostic & Statistical Manual

What is the Structured Clinical Interview for DSM?

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Introduction

The Structured Clinical Interview for DSM (SCID) is a semi-structured interview guide for making diagnoses according to the diagnostic criteria published in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The development of SCID has followed the evolution of the DSM and multiple versions are available for a single edition covering different categories of mental disorders. The first SCID (for DSM-III-R) was released in 1989, SCID-IV (for DSM-IV) was published in 1994 and the current version, SCID-5 (for DSM-5), is available since 2013.

It is administered by a clinician or trained mental health professional who is familiar with the DSM classification and diagnostic criteria. The interview subjects may be either psychiatric or general medical patients or individuals who do not identify themselves as patients, such as participants in a community survey of mental illness or family members of psychiatric patients. SCID users should have had sufficient clinical experience to be able to perform diagnostic evaluation, however, non-clinicians who have comprehensive diagnostic experience with a particular study population may be trained to administer the SCID. Generally additional training is required for individuals with less clinical experience.

DSM-III Editions of SCID

The SCID for the DSM-III-R helped determine Axis I (SCID-I) and Axis II disorders (SCID-II). Separate versions were used to assess psychiatric patients (SCID-P) and to study non-patient populations (SCID-NP). Another form of the SCID-P, SCID-P W/PSY SCREEN, was developed for patients in which psychotic disorders were expected to be rare and only included screening questions for these disorders but not the complex module. Special versions were also created for studying panic disorder, assessing PTSD and combat experience in Vietnam veterans and studying the social and psychiatric consequences of HIV infection.

The reliability and validity of the SCID for DSM-III-R has been reported in several published studies. With regard to reliability, the range in reliability is enormous, depending on the type of the sample and research methodology (i.e. joint vs. test-retest, multi-site vs. single site with raters who have worked together, etc.).

SCID-D

The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) is used to diagnose dissociative disorders, especially in research settings. It was originally designed for the DSM-III-R but early access to DSM-IV criteria for dissociative disorders allowed them to be incorporated into the SCID-D.

For subjects with non-dissociative disorders administration takes between 30 minutes and 1.5 hours. Subjects with dissociative disorders usually require between 40 minutes to 2.5 hours. These subjects should be given enough time to describe their experiences fully.

The SCID-D has been translated into Dutch and Turkish and is used in the Netherlands and Turkey.

DSM-IV Editions of SCID

SCID for DSM-IV also follows the multi-axial system, SCID-I for Axis I disorders (major mental disorders) and SCID-II for Axis II disorders (personality disorders).

There are several variants of SCID-I addressed to different audiences. Similarly to the previous edition SCID-I is available for examining psychiatric patients (SCID-I/P) and studying non-patients (SCID-I/NP) and patient populations where psychotic disorders are not expected (SCID-I/P W/ PSY SCREEN). Specific version for clinicians (SCID-CV) and clinical trials (SCID-CT) were also developed. The SCID-II for DSM-IV comes in a single edition.

A variant of the tool (KID-SCID) was developed at York University for generating childhood DSM-IV diagnoses for clinical research studies. In 2015 a study evaluated the psychometric properties of the KID-SCID in a Dutch sample of children and adolescents which later led to the creation of SCID-5-Junior for the DSM-5 (see below).

An Axis I SCID assessment with a psychiatric patient usually takes between 1 and 2 hours, depending on the complexity of the subject’s psychiatric history and their ability to clearly describe episodes of current and past symptoms. A SCID with a non-psychiatric patient takes 1⁄2 hour to 1+1⁄2 hours. A SCID-II personality assessment takes about 1⁄2 to 1 hour.

There are at least 700 published studies in which the SCID was the diagnostic instrument used. Major parts of the SCID have been translated into other languages, including Danish, French, German, Greek, Hebrew, Italian, Portuguese, Spanish, Swedish, Turkish, and Zulu.

DSM-5 Editions of SCID

SCID-5-RV (Research Version) is the most comprehensive version of the SCID-5. It contains more disorders and includes all of the relevant subtypes and severity and course specifiers. An important feature is its customisability, allowing the instrument to be tailored to meet the requirements of a particular study. SCID-5-CV (Clinician Version) is a reformatted version of the SCID-5-RV for use by clinicians. It covers the most common diagnoses seen in clinical settings. Despite the “clinician” designation, it can be used in research as long as the disorders of interest are among those included in this version. SCID-5-CT (Clinical Trials version) is an adaptation of the SCID-5-RV that has been optimised for use in clinical trials.

SCID-5-PD (Personality Disorders version) is used to evaluate the 10 personality disorders. Its name reflects the elimination of the multiaxial system of the SCID-IV. The SCID-5-AMPD (Alternative Model for Personality Disorders) provides dimensional and categorical approaches to personality disorders. Designed for trained clinicians, the modular format allows the researcher or clinician to focus on those aspects of the Alternative Model of most interest.

Various versions of the SCID-5 have been translated to Chinese, Danish, Dutch, German, Greek, Hungarian, Italian, Japanese, Korean, Norwegian, Polish, Portuguese, Romanian, Spanish, Turkish.

As a result of earlier studies conducted on Dutch youth a variant of the tool, SCID-5-Junior, a revision of the KID-SCID, is available in Dutch. There are plans to create a more widely available version for children and adolescents.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Structured_Clinical_Interview_for_DSM >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

On This Day … 15 December [2022]

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Events

People (Births)

  • 1911 – Nicholas P. Dallis, American psychiatrist and illustrator (d. 1991).

People (Deaths)

  • 2010 – Eugene Victor Wolfenstein, American psychoanalyst and theorist (b. 1940).

Nicholas P. Dallis

Nicholas Peter Dallis (15 December 1911 to 06 July 1991), was an American psychiatrist turned comic strip writer, creator of the soap opera-style strips Rex Morgan, M.D., Judge Parker and Apartment 3-G. Separating his comics career from his medical practice, he wrote under pseudonyms, Dal Curtis for Rex Morgan, M.D. and Paul Nichols for Judge Parker.

Born in New York City, Nick Dallis grew up on Long Island. He graduated from Washington & Jefferson College in 1933 and from Temple University’s medical school in 1938 and married a nurse, Sarah Luddy. He decided to specialise in psychiatry, and after World War II, started a practice in Toledo, Ohio. Allen Saunders was chair at the time of the local mental hygiene centre that invited him there, and in his autobiography, he recalled that Dallis approached him, as a well-known comics writer (Steve Roper and Mike Nomad, Mary Worth), about “his desire to write a comic strip, one tracing the history of medicine. I told him that, commendable as his idea was, such a feature would not succeed. Readers want entertainment, not enlightenment. But a story about a handsome young doctor’s involvement with his patients might be a winner.”

Eugene Victor Wolfenstein

Eugene Victor Wolfenstein (09 July 1940 to 15 December 2010) was an American social theorist, practicing psychoanalyst, and a professor of political science at University of California, Los Angeles.

What is Disruptive Mood Dysregulation Disorder?

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Introduction

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterised by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers.

DMDD was added to the DSM-5 as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble those of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder.

DMDD first appeared as a disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013 and is classified as a mood disorder. Treatments include medication to manage mood symptoms as well as individual and family therapy to address emotion-regulation skills. Children with DMDD are at risk for developing depression and anxiety later in life.

Brief History

Beginning in the 1990s, some clinicians began observing children with hyperactivity, irritability, and severe temper outbursts. These symptoms greatly interfered with their lives at home, school, and with friends. Because other diagnoses, like ADHD and ODD, did not capture the severity of children’s irritability and anger, many of these children were diagnosed with bipolar disorder. Longitudinal studies showed that children with chronic irritability and temper outbursts often developed later problems with anxiety and depression, and rarely developed bipolar disorder in adolescence or adulthood. Consequently, the developers of DSM-5 created a new diagnostic label, DMDD, to describe children with persistent irritability and angry outbursts. In 2013, the American Psychiatric Association (APA) added DMDD to the DSM-5 and classified it as a depressive disorder.

Signs and Symptoms

Children with DMDD show severe and recurrent temper outbursts three or more times per week. These outbursts can be verbal or behavioural. Verbal outbursts often are described by observers as “rages”, “fits”, or “tantrums”. Children may scream, yell, and cry for excessively long periods of time, sometimes with little provocation. Physical outbursts may be directed toward people or property. Children may throw objects; hit, slap, or bite others; destroy toys or furniture; or otherwise act in a harmful or destructive manner.

Children with DMDD also display persistently irritable or angry mood that is observable by others. Parents, teachers, and classmates describe these children as habitually angry, touchy, grouchy, or easily “set off”. Unlike the irritability that can be a symptom of other childhood disorders, such as ODD, anxiety disorders, and major depressive disorder (MDD), the irritability displayed by children with DMDD is not episodic or situation-dependent. In DMDD, the irritability or anger is severe and is shown most of the day, nearly every day in multiple settings, lasting for one or more years.

The DSM-5 includes several additional diagnostic criteria which describe the duration, setting, and onset of the disorder: the outbursts must be present for at least 12 months and occur in at least two settings (e.g. home and school), and it must be severe in at least one setting. Symptoms appear before the age of 10, and diagnosis must be made between ages 6 and 18.

Comorbidity

The core features of DMDD – temper outbursts and chronic irritability – are sometimes seen in children and adolescents with other psychiatric conditions. Differentiating DMDD from these other conditions can be difficult. Three disorders that most closely resemble DMDD are ADHD, oppositional defiant disorder (ODD), and bipolar disorder in children.

ADHD

ADHD is a neurodevelopmental disorder characterised by problems with inattention and/or hyperactivity-impulsivity.

ODD

ODD is a disruptive behaviour disorder characterised by oppositional, defiant, and sometimes hostile actions directed towards others.

Bipolar Disorder

One of the main differences between DMDD and bipolar disorder is that the irritability and anger outbursts associated with DMDD are not episodic; symptoms of DMDD are chronic and displayed constantly on an almost daily basis. On the other hand, bipolar disorder is characterised by distinct manic or hypomanic episodes usually lasting a few days, or a few weeks at most, that parents should be able to differentiate from their child’s typical mood and behaviour in between episodes. The DSM precludes a dual diagnosis of DMDD and bipolar disorder. Bipolar disorder alone should be used for youths who show classic symptoms of episodic mania or hypomania.

Prior to adolescence, DMDD is much more common than bipolar disorder. Most children with DMDD see a decrease in symptoms as they enter adulthood, whereas individuals with bipolar disorder typically display symptoms for the first time as teenagers and young adults. Children with DMDD are more at risk for developing MDD or generalised anxiety disorder when they are older rather than bipolar disorder.

Causes

Youth with DMDD have difficulty attending, processing, and responding to negative emotional stimuli and social experiences in their everyday lives. For example, some studies have shown youths with DMDD to have problems interpreting the social cues and emotional expressions of others. These youths may be especially bad at judging others’ negative emotional displays, such as feelings of sadness, fearfulness, and anger. Functional MRI studies suggest that under-activity of the amygdala, the brain area that plays a role in the interpretation and expression of emotions and novel stimuli, is associated with these deficits. Deficits in interpreting social cues may predispose children to instances of anger and aggression in social settings with little provocation. For examples, youths with DMDD may selectively attend to negative social cues (e.g. others scowling, teasing) and minimize all other information about the social events. They may also misinterpret the emotional displays of others, believing others’ benign actions to be hostile or threatening. Consequently, they may be more likely than their peers to act in impulsive and angry ways.

Children with DMDD may also have difficulty regulating negative emotions once they are elicited. To study these problems with emotion regulation, researchers asked children with DMDD to play computer games that are rigged so that children will lose. While playing these games, children with DMDD report more agitation and negative emotional arousal than their typically-developing peers. Furthermore, youths with DMDD showed markedly greater activity in the medial frontal gyrus and anterior cingulate cortex compared to other youths. These brain regions are important because they are involved in evaluating and processing negative emotions, monitoring one’s own emotional state, and selecting an effective response when upset, angry, or frustrated. Altogether, these findings suggest that youths with DMDD are more strongly influenced by negative events than other youths. They may become more upset and select less effective and socially acceptable ways to deal with negative emotions when they arise.

Treatment

Medication

Evidence for treatment is weak, and treatment is determined based on the physician’s response to the symptoms that people with DMDD present. Because the mood stabilizing medication, lithium, is effective in treating adults with bipolar disorder, some physicians have used it to treat DMDD although it has not been shown to be better than placebo in alleviating the signs and symptoms of DMDD.[7] DMDD is treated with a combination of medications that target the child’s symptom presentation. For youths with DMDD alone, antidepressant medication is sometimes used to treat underlying problems with irritability or sadness. For youths with unusually strong temper outbursts, an atypical antipsychotic medication, such as risperidone, may be warranted. Both medications, however, are associated with significant side effects in children. Finally, for children with both DMDD and ADHD, stimulant medication is sometimes used to reduce symptoms of impulsivity.

Psychosocial

Several cognitive-behavioural interventions have been developed to help youths with chronic irritability and temper outbursts. Because many youths with DMDD show problems with ADHD and oppositional-defiant behaviour, experts initially tried to treat these children using contingency management. This type of intervention involves teaching parents to reinforce children’s appropriate behaviour and extinguish (usually through systematic ignoring or time out) inappropriate behaviour. Although contingency management can be helpful for ADHD and ODD symptoms, it does not seem to reduce the most salient features of DMDD, namely, irritability and anger.

Epidemiology

There are not good estimates of the prevalence of DMDD, but primary studies have found a rate of 0.8 to 3.3%. Epidemiological studies show that approximately 3.2% of children in the community have chronic problems with irritability and temper, the essential features of DMDD. These problems are probably more common among clinic-referred youths. Parents report that approximately 30% of children hospitalised for psychiatric problems meet diagnostic criteria for DMDD; 15% meet criteria based on the observations of hospital staff.

This page is based on the copyrighted Wikipedia article <https://en.wikipedia.org/wiki/Disruptive_mood_dysregulation_disorder >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What was the National Survey of Mental Health and Wellbeing?

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Introduction

The 2007 National Survey of Mental Health and Wellbeing (NSMHWB) was designed to provide lifetime prevalence estimates for mental disorders.

Purpose

To gain statistics on key mental health issues including the prevalence of mental disorders, the associated disability, and the use of services.

As such the NSMHWB was a national epidemiological survey of mental disorders that used similar methodology to the NCS. It aimed to answer three main questions:

  1. How many people meet DSM-IV and ICD-10 diagnostic criteria for the major mental disorders?
  2. How disabled are they by their mental disorders? and
  3. How many have seen a health professional for their mental disorder?

Background

Respondents were asked about experiences throughout their lifetime. In this survey, 12-month diagnoses were derived based on lifetime diagnosis and the presence of symptoms of that disorder in the 12 months prior to the survey interview. Assessment of mental disorders presented in this publication are based on the definitions and criteria of the World Health Organisation’s (WHO) International Classification of Diseases, Tenth Revision (ICD-10). Prevalence rates are presented with hierarchy rules applied (i.e. a person will not meet the criteria for particular disorders because the symptoms are believed to be accounted for by the presence of another disorder).

Results

  • Among the 16,015,300 people aged 16-85 years, 45% (or 7,286,600 people) had a lifetime mental disorder (i.e. a mental disorder at some point in their life).
  • More than half (55% or 8,728,700 people) of people had no lifetime mental disorders.
  • Of people who had a lifetime mental disorder:
    • 20% (or 3,197,800 people) had a 12-month mental disorder and had symptoms in the 12 months prior to the survey interview; and
    • 25% (or 4,088,800 people) had experienced a lifetime mental disorder but did not have symptoms in the 12 months prior to the survey interview.

Prevalence of 12-Month Mental Health Disorders

Prevalence of mental disorders is the proportion of people in a given population who met the criteria for diagnosis of a mental disorder at a point in time

  • Among the 3,197,800 people (or 20% of people) who had a 12-month mental disorder and had symptoms in the 12 months prior to interview:
    • 14.4% had a 12-month Anxiety disorder (includes Panic disorder (2.6%); Agoraphobia (2.8%); Social Phobia (4.7%); Generalised Anxiety Disorder (2.7%); Obsessive-Compulsive Disorder (1.9%); and Post-Traumatic Stress Disorder (6.4%))
    • 6.2% had a 12-month Affective disorder (includes Depressive Episode (4.1%) (includes severe, moderate and mild depressive episodes); Dysthymia (1.3%); and Bipolar Affective Disorder (1.8%)), and
    • 5.1% had a 12-month Substance Use Disorder (includes Alcohol Harmful Use (2.9%); Alcohol Dependence (1.4%); and Drug Use Disorders (includes harmful use and dependence) (1.4%)).
  • Note that a person may have had more than one mental disorder.
    • The components when added may therefore not add to the total shown.
    • Includes Severe Depressive Episode, Moderate Depressive Episode, and Mild Depressive Episode.
    • Includes Harmful Use and Dependence.

There were 3.2 million people who had a 12-month mental disorder. In total, 14.4% (2.3 million) of Australians aged 16-85 years had a 12-month Anxiety disorder, 6.2% (995,900) had a 12-month Affective disorder and 5.1% (819,800) had a 12-month Substance Use disorder.

Women experienced higher rates of 12-month mental disorders than men (22% compared with 18%). Women experienced higher rates than men of Anxiety (18% and 11% respectively) and Affective disorders (7.1% and 5.3% respectively). However, men had twice the rate of Substance Use disorders (7.0% compared with 3.3% for women).

The prevalence of 12-month mental disorders varies across age groups, with people in younger age groups experiencing higher rates of disorder. More than a quarter (26%) of people aged 16-24 years and a similar proportion (25%) of people aged 25-34 years had a 12-month mental disorder compared with 5.9% of those aged 75-85 years old.

You can read the full survey results here and a shorter analysis can be found here.

What is the Chinese Classification of Mental Disorders?

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Introduction

The Chinese Classification of Mental Disorders (CCMD; Chinese: 中国精神疾病分类方案与诊断标准), published by the Chinese Society of Psychiatry (CSP), is a clinical guide used in China for the diagnosis of mental disorders.

It is currently on a third version, the CCMD-3, written in Chinese and English. It is intentionally similar in structure and categorisation to the International Classification of Diseases (ICD) and DSM, the two most well-known diagnostic manuals, though it includes some variations on their main diagnoses and around 40 culturally related diagnoses.

Brief History

The first published Chinese psychiatric classificatory scheme appeared in 1979. A revised classification system, the CCMD-1, was made available in 1981 and further modified in 1984 (CCMD-2-R). The CCMD-3 was published in 2001.

Many Chinese psychiatrists believed the CCMD had special advantages over other manuals, such as simplicity, stability, the inclusion of culture-distinctive categories, and the exclusion of certain Western diagnostic categories. The Chinese translation of the ICD-10 was seen as linguistically complicated, containing very long sentences and awkward terms and syntax (Lee, 2001).

Diagnostic Categories

The diagnosis of depression is included in the CCMD, with many similar criteria to the ICD or DSM, with the core having been translated as ‘low spirits’. However, Neurasthenia is a more central diagnosis. Although also found in the ICD, its diagnosis takes a particular form in China, called ‘shenjing shuairuo’, which emphasizes somatic (bodily) complaints as well as fatigue or depressed feelings. Neurasthenia is a less stigmatising diagnosis than depression in China, being conceptually distinct from psychiatric labels, and is said to fit well with a tendency to express emotional issues in somatic terms. The concept of neurasthenia as a nervous system disorder is also said to fit well with the traditional Chinese epistemology of disease causation on the basis of disharmony of vital organs and imbalance of qi.

The diagnosis of schizophrenia is included in the CCMD. It is applied quite readily and broadly in Chinese psychiatry.

Some of the wordings of the diagnosis are different, for example rather than borderline personality disorder as in the DSM, or emotionally unstable personality disorder (borderline type) as in the ICD, the CCMD has impulsive personality disorder.

Diagnoses that are more specific to Chinese or Asian culture, though they may also be outlined in the ICD (or DSM glossary section), includes:

  • Koro or Genital retraction syndrome: excessive fear of the genitals (and also breasts in women) shrinking or drawing back into the body.
  • Zou huo ru mo (走火入魔) or qigong deviation (氣功偏差): perception of uncontrolled flow of qi in the body.
  • Mental disorders due to superstition or witchcraft.
  • Travelling psychosis.

The CCMD-3 lists several “disorders of sexual preference” including ego-dystonic homosexuality, but does not recognise paedophilia.

Koro

Koro or Genital retraction syndrome is a culture-specific syndrome from Southeast Asia in which the patient has an overpowering belief that the genitalia (or nipples in females) are shrinking and will shortly disappear. In China, it is known as shuk yang, shook yong, and suo yang (simplified Chinese: 缩阳; traditional Chinese: 縮陽). This has been associated with cultures placing a heavy emphasis on balance, or on fertility and reproduction.

Zou Huo Ru Mo

Zou huo ru mo (走火入魔) or “qigong deviation” (氣功偏差) is a mental condition characterised by the perception that there is uncontrolled flow of qi in the body. Other complaints include localised pains, headache, insomnia, and uncontrolled spontaneous movements.

Book: A Straight Talking Introduction to Psychiatric Diagnosis

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Book Title:

A Straight Talking Introduction to Psychiatric Diagnosis.

Author(s): Lucy Johnstone.

Year: 2014.

Edition: First (1st).

Publisher: PCCS Books.

Type(s): Paperback and Kindle.

Synopsis:

Do you still need your psychiatric diagnosis? This book will help you to decide. A revolution is underway in mental health. If the authors of the diagnostic manuals are admitting that psychiatric diagnoses are not supported by evidence, then no one should be forced to accept them. If many mental health workers are openly questioning diagnosis and saying we need a different and better system, then service users and carers should be allowed to do so too. This book is about choice. It is about giving people the information to make up their own minds, and exploring alternatives for those who wish to do so.

What is Relational Disorder?

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Introduction

According to Michael First of the Diagnostic and Statistical Manual of Mental Disorders Version 5 (DSM-5) working committee the focus of a relational disorder, in contrast to other DSM-IV disorders, “is on the relationship rather than on any one individual in the relationship”.

Relational disorders involve two or more individuals and a disordered “juncture”, whereas typical Axis I psychopathology describes a disorder at the individual level. An additional criterion for a relational disorder is that the disorder cannot be due solely to a problem in one member of the relationship, but requires pathological interaction from each of the individuals involved in the relationship.

For example, if a parent is withdrawn from one child but not another, the dysfunction could be attributed to a relational disorder. In contrast, if a parent is withdrawn from both children, the dysfunction may be more appropriately attributable to a disorder at the individual level.

First states that “relational disorders share many elements in common with other disorders: there are distinctive features for classification; they can cause clinically significant impairment; there are recognizable clinical courses and patterns of comorbidity; they respond to specific treatments; and they can be prevented with early interventions. Specific tasks in a proposed research agenda: develop assessment modules; determine the clinical utility of relational disorders; determine the role of relational disorders in the aetiology and maintenance of individual disorders; and consider aspects of relational disorders that might be modulated by individual disorders.”

The proposed new diagnosis defines a relational disorder as “persistent and painful patterns of feelings, behaviors, and perceptions” among two or more people in an important personal relationship, such a husband and wife, or a parent and children.

According to psychiatrist Darrel Regier, MD, some psychiatrists and other therapists involved in couples and marital counselling have recommended that the new diagnosis be considered for possible incorporation into the DSM IV.

Brief History

The idea of a psychology of relational disorders is far from new. According to Adam Blatner, MD, some of the early psychoanalysts alluded to it more or less directly, and the history of marital couple therapy began with a few pioneers in 1930s. J.L. Moreno, the inventor of psychodrama and a major pioneer of group psychotherapy and social psychology, noted the idea that relationships could be “sick” even if the people involved were otherwise “healthy,” and even vice versa: Otherwise “sick” people could find themselves in a mutually supportive and “healthy” relationship.

Moreno’s ideas may have influenced some of the pioneers of family therapy, but also there were developments in general science, namely, cybernetic theory, developed in the mid-1940s, and noting the nature of circularity and feedback in complex systems. By the 1950s, the idea that relationships themselves could be problematic became quite apparent. So, diagnostically, in the sense not of naming a disease or disorder, but just helping people think through what was really going on, the idea of relational disorder was nothing new.

Types

The majority of research on relational disorders concerns three relationship systems:

  • Adult children and their parents;
  • Minor children and their parents; and
  • The marital relationship.

There is also an increasing body of research on problems in dyadic gay relationships and on problematic sibling relationships.

Marital

Marital disorders are divided into “Marital Conflict Disorder Without Violence” and “Marital Abuse Disorder (Marital Conflict Disorder With Violence).” Couples with marital disorders sometimes come to clinical attention because the couple recognise long-standing dissatisfaction with their marriage and come to the clinician on their own initiative or are referred by a health care professional. Secondly, there is serious violence in the marriage which is “usually the husband battering the wife”. In these cases the emergency room or a legal authority often is the first to notify the clinician.

Most importantly, marital violence “is a major risk factor for serious injury and even death and women in violent marriages are at much greater risk of being seriously injured or killed” (National Advisory Council on Violence Against Women 2000). The authors of this study add that “There is current considerable controversy over whether male-to-female marital violence is best regarded as a reflection of male psychopathology and control or whether there is an empirical base and clinical utility for conceptualizing these patterns as relational.”

Recommendations for clinicians making a diagnosis of “Marital Relational Disorder” should include the assessment of actual or “potential” male violence as regularly as they assess the potential for suicide in depressed patients. Further, “clinicians should not relax their vigilance after a battered wife leaves her husband, because some data suggest that the period immediately following a marital separation is the period of greatest risk for the women.

Many men will stalk and batter their wives in an effort to get them to return or punish them for leaving. Initial assessments of the potential for violence in a marriage can be supplemented by standardised interviews and questionnaires, which have been reliable and valid aids in exploring marital violence more systematically.

The authors conclude with what they call “very recent information” on the course of violent marriages which suggests that “over time a husband’s battering may abate somewhat, but perhaps because he has successfully intimidated his wife.”

The risk of violence remains strong in a marriage in which it has been a feature in the past. Thus, treatment is essential here; the clinician cannot just wait and watch. The most urgent clinical priority is the protection of the wife because she is the one most frequently at risk, and clinicians must be aware that supporting assertiveness by a battered wife may lead to more beatings or even death.

In some cases, men are abuse victims of their wives; there is not exclusively male-on-female physical violence, although this is more common than female-on-male violence.

Parent-Child Abuse

Research on parent-child abuse bears similarities to that on marital violence, with the defining characteristic of the disorder being physical aggression by a parent toward a child. The disorder is frequently concealed by parent and child, but may come to the attention of the clinician in several ways, from emergency room medical staff to reports from child protection services.

Some features of abusive parent–child relationships that serve as a starting point for classification include:

  • The parent is physically aggressive with a child, often producing physical injury;
  • Parent-child interaction is coercive, and parents are quick to react to provocations with aggressive responses, and children often reciprocate aggression;
  • Parents do not respond effectively to positive or prosocial behaviour in the child;
  • Parents do not engage in discussion about emotions;
  • Parent engages in deficient play behaviour, ignores the child, rarely initiates play, and does little teaching;
  • Children are insecurely attached and, where mothers have a history of physical abuse, show distinctive patterns of disorganised attachment; and
  • Parents relationship shows coercive marital interaction patterns.

Defining the relational aspects of these disorders can have important consequences. For example, in the case of early appearing feeding disorders, attention to relational problems may help delineate different types of clinical problems within an otherwise broad category. In the case of conduct disorder, the relational problems may be so central to the maintenance, if not the aetiology, of the disorder that effective treatment may be impossible without recognising and delineating it.

On This Day … 22 May

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People (Births)

  • 1932 – Robert Spitzer, American psychiatrist and academic (d. 2015).

Robert Spitzer

Robert Leopold Spitzer (22 May 1932 to 25 December 2015) was a psychiatrist and professor of psychiatry at Columbia University in New York City. He was a major force in the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Education

He received his bachelor’s degree in psychology from Cornell University in 1953 and his M.D. from New York University School of Medicine in 1957. He completed his psychiatric residency at New York State Psychiatric Institute in 1961 and graduated from Columbia University Centre for Psychoanalytic Training and Research in 1966.

Spitzer wrote an article on Wilhelm Reich’s theories in 1953 which the American Journal of Psychiatry declined to publish.

Career

Spitzer spent most of his career at Columbia University in New York City as a Professor of Psychiatry until he retired in 2003. He was on the research faculty of the Columbia University Centre for Psychoanalytic Training and Research where he retired after 49 years in December 2010. He has been called one of the most influential psychiatrists of the 20th century. The Lancet’s obituary described him as “Stubborn, sometimes abrasive, and always eager, Spitzer’s work was guided by a strong sense of ethical fairness”. A colleague at Columbia has described him as an “iconoclast” who “looked for injustice”.

Screening and Diagnostic Tools

Spitzer was a major architect of the modern classification of mental disorders. In 1968, he co-developed a computer program, Diagno I, based on a logical decision tree, that could derive a diagnosis from the scores on a Psychiatric Status Schedule which he co-published in 1970 and that the United States Steering Committee for the United States-United Kingdom Diagnostic Project used to check the consistency of its results.

Spitzer was a member on the four-person United States Steering Committee for the United States-United Kingdom Diagnostic Project, which published their results in 1972. They found the most important difference between countries was that the concept of schizophrenia used in New York was much broader than the one used in London, and included patients who would have been termed manic-depressive or bipolar.

He developed psychiatric methods that focused on asking specific interview questions to get at a diagnosis as opposed to the open-ended questioning of psychoanalysis, which was the predominant technique of mental health. He codeveloped the Mood Disorder Questionnaire (MDQ), a screening technique used for diagnosing bipolar disorder. He also co-developed the Patient Health Questionnaire (PRIME-MD) which can be self-administered to find out if one has a mental illness. The portions of PRIME-MD directed at depression (PHQ2 and PHQ9) have since become accepted in primary care medicine for screening and diagnosis of major depression as well as for monitoring response to treatment.

Position on the Diagnostic and Statistical Manual of Mental Disorders

In 1974, Spitzer became the chair of the American Psychiatric Association’s task force of the third edition of the Diagnostic and Statistical Manual of Mental Disorders the so-called, DSM-III which was released in 1980. Spitzer is a major architect of the modern classification of mental disorders which involves classifying mental disorders in discrete categories with specified diagnostic criteria but later criticised what he saw as errors and excesses in the DSM’s later versions, although he maintained his position that the DSM is still better than the alternatives.

In 2003, Spitzer co-authored a position paper with DSM-IV editor Michael First, stating that the “DSM is generally viewed as clinically useful” based on surveys from practicing professionals and feedback from medical students and residents, but that primary care physicians find the DSM too complicated for their use. The authors emphasized that given then-current limitations in understanding psychiatric disorders, a multitude of DSM codes/diagnoses might apply to some patients, but that it would be a “total speculation” to assign a single diagnosis to a patient. The authors rejected calls to adopt the ICD-9 because it lacked diagnostic criteria and would “[set] psychiatry back 30 years,” while the ICD-10, closely resembled the DSM-III-R classification.[14] In 2013, a definitive autobiography of Spitzer, The Making of DSM-III®: A Diagnostic Manual’s Conquest of American Psychiatry, was published by author and historian Hannah S. Decker.

Spitzer was briefly featured in the 2007 BBC TV series The Trap, in which he stated that the DSM, by operationalising the definitions of mental disorders while paying little attention to the context in which the symptoms occur, may have medicalised the normal human experiences of a significant number of people.

In 2008, Spitzer had criticised the revision process of the DSM-5 for lacking transparency. He has also criticised specific proposals, like the proposed introduction of the psychosis risk syndrome for people who have mild symptoms found in psychotic disorders.

On Homosexuality

Spitzer led a successful effort, in 1973, to stop treating homosexuality as a mental illness.

It was partly due to Spitzer’s efforts that homosexuality was “removed” (i.e. renamed as Sexual Orientation Disturbance) in 1974 DSM-II: “By withdrawing it from the manual, homosexuality was legitimized as a normal difference rather than a psychiatric behavior. This early powerful statement by institutional psychiatry that this is normal sped up the confidence of people in the movement.”

In 2001, Spitzer delivered a controversial paper, “Can Some Gay Men and Lesbians Change Their Sexual Orientation?” at the 2001 annual APA meeting; he argued that it is possible that some highly motivated individuals could successfully change their sexual orientation from homosexual to heterosexual.

Awards

Spitzer received the Thomas William Salmon Medal from the New York Academy of Medicine for his contributions to psychiatry.

On This Day … 07 April

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People (Deaths)

  • 1999 – Heinz Lehmann, German-Canadian psychiatrist and academic (b. 1911).

Heinz Lehmann

Heinz Edgar Lehmann, OC FRSC (17 July 17 1911 to 07 April 1999) was a German-born Canadian psychiatrist best known for his use of chlorpromazine for the treatment of schizophrenia in 1950s and “truly the father of modern psychopharmacology.”

Early Life

Born in Berlin, Germany, he was educated at the University of Freiburg, the University of Marburg, the University of Vienna, and the University of Berlin. He emigrated to Canada in 1937.

Hospital Work in Canada

In 1947, he was appointed the clinical director of Montreal’s Douglas Hospital. From 1971 to 1975, he was the chair of the McGill University Department of Psychiatry. He was also a humane lecturer in psychiatry in 1952, and was able to give empathetic lectures on the plight of people suffering from anxiety, depression obsessions, paranoia etc. No one to that time had been able to understand or help schizophrenic patients, who filled mental hospitals around the world, so when chlorpromazine showed some promise he helped to promote it in North America and start the drug revolution. He was ahead of his time in that he supported research in the use of the active ingredient psilocybin to alleviate anxiety.

Le Dain Commission

From 1969 to 1972, he was one of the five members of the Le Dain Commission, a royal commission appointed in Canada to study the non-medical use of drugs. He was an advocate for decriminalisation of marijuana.

DSM Work

In 1973, he was a member of the Nomenclature Committee of the American Psychiatric Association that decided to drop homosexuality from the Diagnostic and Statistical Manual of Mental Disorders, i.e. to depathologise it.

Honours and Awards

In 1970 he was made a Fellow of the Royal Society of Canada and, in 1976, he was made an Officer of the Order of Canada. He was inducted into the Canadian Medical Hall of Fame in 1998.

Heinz Lehmann Award

In 1999, the Canadian College of Neuropsychopharmacology established the Heinz Lehmann Award in his honour, given in recognition of outstanding contributions to research in neuropsychopharmacology in Canada.

On This Day … 15 December

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Events

  • 1973 – The American Psychiatric Association votes 13-0 to remove homosexuality from its official list of psychiatric disorders, the DSM-II.

People (Births)

  • 1911 – Nicholas P. Dallis, American psychiatrist and illustrator (d. 1991).

People (Deaths)

  • 2005 – Heinrich Gross, Austrian physician and psychiatrist (b. 1914).
  • 2010 – Eugene Victor Wolfenstein, American psychoanalyst and theorist (b. 1940).

Nicholas P. Dallis

Nicholas Peter Dallis (15 December 1911 to 06 July 1991), known as Nick Dallis, was an American psychiatrist turned comic strip writer, creator of the soap opera-style strips Rex Morgan MD, Judge Parker and Apartment 3-G. Separating his comics career from his medical practice, he wrote under pseudonyms, Dal Curtis for Rex Morgan MD, and Paul Nichols for Judge Parker.

Born in New York City, Nick Dallis grew up on Long Island. He graduated from Washington & Jefferson College in 1933 and from Temple University’s medical school in 1938 and married a nurse, Sarah Luddy. He decided to specialize in psychiatry, and after World War II, started a practice in Toledo, Ohio. Allen Saunders was chair at the time of the local mental hygiene centre that invited him there, and in his autobiography, he recalled that Dallis approached him, as a well-known comics writer (Steve Roper and Mike Nomad, Mary Worth), about “his desire to write a comic strip, one tracing the history of medicine. I told him that, commendable as his idea was, such a feature would not succeed. Readers want entertainment, not enlightenment. But a story about a handsome young doctor’s involvement with his patients might be a winner.”

Heinrich Gross

Heinrich Gross (14 November 1915 to 15 December 2005) was an Austrian psychiatrist, medical doctor and neurologist, a reputed expert as a leading court-appointed psychiatrist, ill-famed for his proven involvement in the killing of at least nine children with physical, mental and/or emotional/behavioural characteristics considered “unclean” by the Nazi regime, under its Euthanasia Programme. His role in hundreds of other cases of infanticide is unclear. Gross was head of the Spiegelgrund children’s psychiatric clinic for two years during World War II.

A significant element of the controversy surrounding Gross’ activities is that after the children had been murdered, parts of their bodies, particularly their brains, were preserved and retained for future study for decades after the murders. It was only on 28 April 2002 that the preserved remains of these murdered children were finally buried.

Pre-War Career

Heinrich Gross was born in Vienna on 14 November 1915. His parents, Karl and Petronella Gross, were in the wool and knitwear business. His father died before Heinrich was born and his mother placed him in a Catholic boarding school for his early education. He graduated from a public high school in 1934 and received a medical degree in 1939 from the University of Vienna.

In 1932 Gross became a member of the Hitler Youth and joined the Sturmabteilung in 1934. He remained a member throughout the period 1934 to 1938 when these organisations were outlawed in Austria. After Germany annexed Austria in 1938, Gross joined the Nazi Party.

Euthanasia Programme

Euthanasia was commonly practiced long before the infamous Nazi concentration camps. The euthanasia programme was introduced to the German people as an efficient manner to obtain a Master Race for the Nazi people and an economic relief to families. As Nazi popularity grew and the economy still struggling these options were widely accepted by the German people. Am Spiegelgrund was a youth care facility on the grounds of a mental institution. From the years of 1940 to 1945 it was used for mentally handicapped adults or children. During their stay they suffered numerous forms of torture and up to 800 people were murdered there. Gross began in pavilion 15 in November 1940. By 1942 he had killed more children than any other doctor in the hospital. He became the leading psychiatrist and began studying the neurology of mentally handicapped children. With the passing of Aktion T4 the killings increased and Gross began to harvest the brains of his victims for further study. In 1943 Gross was called for military service returning pretty regularly for research until his capture in 1945.

Post-war Career

In the same year of his overturned manslaughter case, Gross was allowed to resume his research at Rose Hill. In 1955, he completed his training as a specialist in nervous and mental diseases and became the head prison doctor or physician in the former Hospital and nursing home Am Steinhof. In 1957 he became the Chief court psychiatrist for men’s mental institutions. There he worked with the justice system in insanity cases and was the main decision maker in all sterilisation cases as well. He got promoted to the management of the “Ludwig Boltzmann Institute for the study of the abnormalities of the nervous system” created specially for him in 1968. Gross worked as a reviewer and for years was considered the most busy court expert in Austria. In 1975 the Republic of Austria awarded him the medal für Wissenschaft und Kunst 1, of which he was stripped of in 2003. In 1975 it was realised that he had been involved in illegal killings during the Nazi occupation of Austria. Gross was stripped of many awards but continued serving as a court expert until he came under investigation in 1997 for nine counts of murder.

Eugene Victor Wolfenstein

Eugene Victor Wolfenstein (09 July 1940 to 15 December 2010) was an American social theorist, practicing psychoanalyst, and a professor of political science at University of California, Los Angeles.

Career

Wolfenstein graduated with his Bachelor of Arts magna cum laude from Columbia College in 1962. He was a member of Phi Beta Kappa.

Wolfenstein received his Master of Arts in political science in 1964 and his PhD in political science in 1965 from Princeton University. Wolfenstein became a professor of political science at UCLA.

He also completed a PhD in psychoanalysis from the Southern California Psychoanalytic Institute in 1984. He was the member of the faculty of the institute from 1988 to 2004. Moreover, he was in private practice from the time he received his degree up to the time of his death.

Wolfenstein worked in the critical theory tradition, with a focus on African American culture and social movements. In his book The Victims of Democracy: Malcolm X and the Black Revolution, he used a theory of the interaction between social classes and psychological groups to analyse white racism and the black liberation struggle. He developed a more general version of this theory in Psychoanalytic-Marxism: Groundwork (1993) and refined it further through engagement with Nietzsche’s philosophy in Inside/Outside Nietzsche: Psychoanalytic Explorations (2000). These later works add a concern with gender identity to the earlier agenda. His research is in the area of African-American narrative. A Gift of the Spirit: Reading THE SOULS OF BLACK FOLK (2007) offered a sustained reconstruction of W.E.B. Du Bois’s canonical text. A further study entitled “Talking Books: Toni Morrison Among the Ancestors” was published right before his death.

He was a professor at UCLA. At the undergraduate level, he taught the lower division Introduction to Political Theory, along with Ancient Political Theory, African-American Freedom Narratives, Malcolm X and Black Liberation, Marxist Political Theory, and an occasional seminar on Platonic Dialectic and Spiritual Liberation. At the graduate level, he focused on major works of Du Bois, Foucault, Freud, Hegel, Marx, and Nietzsche, along with the related critical literatures.

His main interests were History of Political Theory, Psychoanalytic Theory and Practice, Critical Theory, Critical Race Theory and Feminist Theory.