What is Culture-Bound Syndrome?

Introduction

In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognisable disease only within a specific society or culture.

There are no objective biochemical or structural alterations of body organs or functions, and the disease is not recognized in other cultures. The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) which also includes a list of the most common culture-bound conditions (DSM-IV: Appendix I). Counterpart within the framework of ICD-10 (Chapter V) are the culture-specific disorders defined in Annex 2 of the Diagnostic criteria for research.

More broadly, an endemic that can be attributed to certain behaviour patterns within a specific culture by suggestion may be referred to as a potential behavioural epidemic. As in the cases of drug use, or alcohol and smoking abuses, transmission can be determined by communal reinforcement and person-to-person interactions. On etiological grounds, it can be difficult to distinguish the causal contribution of culture upon disease from other environmental factors such as toxicity.

Identification

A culture-specific syndrome is characterised by:

  • Categorisation as a disease in the culture (i.e. not a voluntary behaviour or false claim);
  • Widespread familiarity in the culture;
  • Complete lack of familiarity or misunderstanding of the condition to people in other cultures;
  • No objectively demonstrable biochemical or tissue abnormalities (signs); and
  • The condition is usually recognised and treated by the folk medicine of the culture.

Some culture-specific syndromes involve somatic symptoms (pain or disturbed function of a body part), while others are purely behavioural. Some culture-bound syndromes appear with similar features in several cultures, but with locally specific traits, such as penis panics.

A culture-specific syndrome is not the same as a geographically localised disease with specific, identifiable, causal tissue abnormalities, such as kuru or sleeping sickness, or genetic conditions limited to certain populations. It is possible that a condition originally assumed to be a culture-bound behavioural syndrome is found to have a biological cause; from a medical perspective it would then be redefined into another nosological category.

Medical Perspectives

The American Psychiatric Association states the following:

The term culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be “illnesses,” or at least afflictions, and most have local names. Although presentations conforming to the major DSM-IV categories can be found throughout the world, the particular symptoms, course, and social response are very often influenced by local cultural factors. In contrast, culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations.

The term culture-bound syndrome is controversial since it reflects the different opinions of anthropologists and psychiatrists. Anthropologists have a tendency to emphasize the relativistic and culture-specific dimensions of the syndromes, while physicians tend to emphasize the universal and neuropsychological dimensions. Guarnaccia & Rogler (1999) have argued in favour of investigating culture-bound syndromes on their own terms, and believe that the syndromes have enough cultural integrity to be treated as independent objects of research.

Guarnaccia and Rogler demonstrate the issues that occur when diagnosing cultural bound disorders using the DSM-IV. One of the key problems that arise is the “subsumption of culture bound syndromes into psychiatric categories”, which ultimately creates a medical hegemony and places the western perspective above that of other cultural and epistemological explanations of disease. The urgency for further investigation or reconsideration of the DSM-IV’s authoritative power is emphasized, as the DSM becomes an international document for research and medical systems abroad. Guarnaccia and Rogler provide two research questions that must be considered, “firstly, how much do we know about the culture-bound syndromes for us to be able to fit them into standard classification; and secondly, whether such a standard and exhaustive classification in fact exists”.

It is suggested that the problematic nature of the DSM becomes evident when we view it as definitively conclusive. Questions are raised to whether culture-bound syndromes can be treated as discrete entities, or whether their symptoms are generalised and perceived as an amalgamation of previously diagnosed illnesses. If this is the case, then the DSM may be what Bruno Latour would defined as “particular universalism”. In that the Western medical system views itself to have a privileged insight into the true intelligence of nature, in contrast to the model provided by other cultural perspectives.

Some studies suggest that culture-bound syndromes represent an acceptable way within a specific culture (and cultural context) among certain vulnerable individuals (i.e. an ataque de nervios at a funeral in Puerto Rico) to express distress in the wake of a traumatic experience. A similar manifestation of distress when displaced into a North American medical culture may lead to a very different, even adverse outcome for a given individual and his or her family. The history and etymology of some syndromes such as Brain-Fog Syndrome, have also been reattributed to 19th century Victorian Britain rather than West Africa.

In 2013, the DSM 5, dropped the term culture-bound syndrome, preferring the new name “Cultural Concepts of Distress”.

Cultural Collusion Between Medical Perspectives

Within the traditional Hmong culture, epilepsy (qaug dab peg) directly translates to “the spirit catches you and you fall down” which is said to be an evil spirit called a dab that captures your soul and makes you ill. In this culture, individuals with seizures are seen to be blessed with a gift; an access point into the spiritual realm which no one else has been given. In westernised society, epilepsy is considered a serious long-term brain condition, that can have a major impairment on an individual’s life. The way the illness is dealt with in Hmong culture is vastly different due to the high-status epilepsy has amongst the culture, compared to individuals who have the condition in westernised societies. Individuals with epilepsy within the Hmong culture are a source of pride for their family.

Another culture bound illness is neurasthenia which is a vaguely described medical ailment in Chinese culture that presents as lassitude, weariness, headaches, and irritability and is mostly linked to emotional disturbance. A report done in 1942 showed that 87% of patients diagnosed by Chinese psychiatrists as having neurasthenia could be reclassified as having major depression according to the DSM-3 criteria. Another study conducted in Hong Kong showed that most patients selectively presented their symptoms according to what they perceived as appropriate and tended to only focus on somatic suffering, rather than the emotional problems they were facing.

Globalisation

Globalisation is a process whereby information, cultures, jobs, goods, and services are spread across national borders. This has had a powerful impact on the 21st century in many ways including through enriching cultural awareness across the globe. Greater level of cultural integration is occurring due to rapid industrialisation and globalisation, with cultures absorbing more influences from each other. As cultural awareness begins to increase between countries, there is a consideration into whether cultural bound syndromes will slowly lose their geographically bound nature and become commonly known syndromes that will then become internationally recognised. Anthropologist and psychiatrist Roland Littlewood makes the observation that these diseases are likely to vanish in an increasingly homogenous global culture in the face of globalisation (and industrialisation). Depression for example, was once only accepted in western societies, however it is now recognised as a mental disorder in all parts of the world. In contrast to Eastern civilisations such as Taiwan, depression is still much more common in Western cultures like the United States. This could indicate that globalisation may have an impact on allowing disorders to be spread across borders, however these disorders may remain predominant in certain cultures.

DSM-IV-TR List

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as culture-bound syndromes.

NameGeographical Localisation/Population(s)
Running AmokBrunei, Singapore, Malaysia, Indonesia, Philippines, Timor-Leste
Ataque de NerviosHispanophone, as well as in the Philippines where it is known as “nervous breakdown”
Bilis, CóleraLatinos
Bouffée DéliranteFrance and French-speaking countries
Brain Fag SyndromeWest African students
Dhat SyndromeIndia
Falling-Out, Blacking OutSouthern United States and Caribbean
Ghost SicknessNative American (Navajo, Muscogee/Creek)
HwabyeongKorean
KoroChinese, Malaysian and Indonesian populations in Southeast Asia; Assam; occasionally in the West
LatahMalaysia and Indonesia, as well as the Philippines (as mali-mali, particularly among Tagalogs)
LocuraLatinos in the United States and Latin America
Mal de PeleaPuerto Rico
NerviosLatin America, Latinos in the United States, Philippines
Evil EyeMediterranean; Hispanic populations and Ethiopia
PibloktoArctic and subarctic Inuit populations
Zou huo ru mo
(Qigong Psychotic Reaction)
Han Chinese
RootworkSouthern United States, Caribbean nations
Sangue DormidoPortuguese populations in Cape Verde
Shenjing ShuairuoHan Chinese
Shenkui, shen-kʼueiHan Chinese
ShinbyeongKorean
SpellAfrican American, White populations in the southern United States and Ethiopia
SustoLatinos in the United States; Mexico, Central America and South America
Taijin KyofushoJapanese
ZārEthiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies

DSM-5 List

The fifth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as cultural concepts of distress, a closely related concept.

NameGeographical Localisation/Population(s)
Ataque de NerviosHispanophone, as well as in the Philippines
Dhat SyndromeIndia
Khyâl CapCambodian
Ghost SicknessNative American
KufungisisaZimbabwe
Maladi MounHaiti
NerviosLatin America, Latinos in the US
Shenjing ShuairuoHan Chinese
SustoLatinos in the US, Mexico, Central America and South America
Taijin KyofushoJapanese

ICD-10 List

NameGeographical Localisation/Population(s)
AmokSoutheast Asian Austronesians
Dhat Syndrome (Dhātu), Shen-kʼuei, JiryanIndia and Taiwan
Koro, Suk Yeong, Jinjin BemarSoutheast Asia, India, and China
LatahMalaysia and Indonesia
Nervios, Nerfiza, Nerves, NevraEgypt; Greece; northern Europe; Mexico, Central and South America
Pa-leng (Frigophobia)Taiwan and Southeast Asia
Pibloktoq (Arctic Hysteria)Inuit living within the Arctic Circle
Susto, EspantoMexico, Central and South America
Taijin Kyofusho, Shinkeishitsu (Anthropophobia)Japan
Ufufuyane, SakaKenya, Southern Africa (among Bantu, Zulu, and affiliated groups)
UqamairineqInuit living within the Arctic Circle
Fear of WindigoIndigenous people of Northeast America

Other Examples

Though “the ethnocentric bias of Euro-American psychiatrists has led to the idea that culture-bound syndromes are confined to non-Western cultures”, a prominent example of a Western culture-bound syndrome is anorexia nervosa.

Within the contiguous US, the consumption of kaolin, a type of clay, has been proposed as a culture-bound syndrome observed in African Americans in the rural south, particularly in areas in which the mining of kaolin is common.

In South Africa, among the Xhosa people, the syndrome of amafufunyana is commonly used to describe those believed to be possessed by demons or other malevolent spirits. Traditional healers in the culture usually perform exorcisms in order to drive off these spirits. Upon investigating the phenomenon, researchers found that many of the people claimed to be affected by the syndrome exhibited the traits and characteristics of schizophrenia.

Some researchers have suggested that both premenstrual syndrome (PMS) and the more severe premenstrual dysphoric disorder (PMDD), which have currently unknown physical mechanisms, are Western culture-bound syndromes. However, this is controversial.

Tarantism is an expression of mass psychogenic illness documented in Southern Italy since the 11th century.

Morgellons is a rare self-diagnosed skin condition reported primarily in white populations in the US. It has been described by a journalist as “a socially transmitted disease over the Internet”.

Vegetative-vascular dystonia can be considered an example of somatic condition formally recognised by local medical communities in former Soviet Union countries, but not in Western classification systems. Its umbrella term nature as neurological condition also results in diagnosing neurotic patients as neurological ones, in effect substituting possible psychiatric stigma with culture-bound syndrome disguised as a neurological condition.

Refugee children in Sweden have been known to fall into coma-like states on learning their families will be deported. The condition, known in Swedish as uppgivenhetssyndrom, or resignation syndrome, is believed to only exist among the refugee population in Sweden, where it has been prevalent since the early part of the 21st century. In a 130-page report on the condition commissioned by the government and published in 2006, a team of psychologists, political scientists, and sociologists hypothesized that it was a culture-bound syndrome.

A startle disorder similar to latah, called imu (sometimes spelled imu:), is found among Ainu people, both Sakhalin Ainu and Hokkaido Ainu.

A condition similar to piblokto, called menerik (sometimes meryachenie), is found among Yakuts, Yukaghirs, and Evenks living in Siberia.

The trance-like violent behaviour of the Viking age berserkers – behaviour that disappeared with the arrival of Christianity – has been described as a culture-bound syndrome.

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What is a Spectrum Disorder?

Introduction

A spectrum disorder is a mental disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits.

The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be “not a unitary disorder but rather a syndrome composed of subgroups”. The spectrum may represent a range of severity, comprising relatively “severe” mental disorders through to relatively “mild and nonclinical deficits”.

In some cases, a spectrum approach joins together conditions that were previously considered separately. A notable example of this trend is the autism spectrum, where conditions on this spectrum may now all be referred to as autism spectrum disorders. A spectrum approach may also expand the type or the severity of issues which are included, which may lessen the gap with other diagnoses or with what is considered “normal”. Proponents of this approach argue that it is in line with evidence of gradations in the type or severity of symptoms in the general population.

Origin

The term spectrum was originally used in physics to indicate an apparent qualitative distinction arising from a quantitative continuum (i.e. a series of distinct colours experienced when a beam of white light is dispersed by a prism according to wavelength). Isaac Newton first used the word spectrum (Latin for “appearance” or “apparition”) in print in 1671, in describing his experiments in optics.

The term was first used by analogy in psychiatry with a slightly different connotation, to identify a group of conditions that is qualitatively distinct in appearance but believed to be related from an underlying pathogenic point of view. It has been noted that for clinicians trained after the publication of DSM-III (1980), the spectrum concept in psychiatry may be relatively new, but that it has a long and distinguished history that dates back to Emil Kraepelin and beyond. A dimensional concept was proposed by Ernst Kretschmer in 1921 for schizophrenia (schizothymic – schizoid – schizophrenic) and for affective disorders (cyclothymic temperament – cycloid ‘psychopathy’ – manic-depressive disorder), as well as by Eugen Bleuler in 1922. The term “spectrum” was first used in psychiatry in 1968 in regard to a postulated schizophrenia spectrum, at that time meaning a linking together of what were then called “schizoid personalities”, in people diagnosed with schizophrenia and their genetic relatives (refer to Seymour S. Kety).

For different investigators, the hypothetical common disease-causing link has been of a different nature.

A spectrum approach generally overlays or extends a categorical approach, which today is most associated with the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases (ICD). In these diagnostic guides, disorders are considered present if there is a certain combination and number of symptoms. Gradations of present versus absent are not allowed, although there may be subtypes of severity within a category. The categories are also polythetic, because a constellation of symptoms is laid out and different patterns of them can qualify for the same diagnosis. These categories are aids important for our practical purposes such as providing specific labels to facilitate payments for mental health professionals. They have been described as clearly worded, with observable criteria, and therefore an advance over some previous models for research purposes.

A spectrum approach sometimes starts with the nuclear, classic DSM diagnostic criteria for a disorder (or may join together several disorders), and then include an additional broad range of issues such as temperaments or traits, lifestyle, behavioural patterns, and personality characteristics.

In addition, the term ‘spectrum’ may be used interchangeably with continuum, although the latter goes further in suggesting a direct straight line with no significant discontinuities. Under some continuum models, there are no set types or categories at all, only different dimensions along which everyone varies (hence a dimensional approach).

An example can be found in personality or temperament models. For example, a model that was derived from linguistic expressions of individual differences is subdivided into the Big Five personality traits, where everyone can be assigned a score along each of the five dimensions. This is by contrast to models of ‘personality types’ or temperament, where some have a certain type and some do not. Similarly, in the classification of mental disorders, a dimensional approach, which is being considered for the DSM-V, would involve everyone having a score on personality trait measures. A categorical approach would only look for the presence or absence of certain clusters of symptoms, perhaps with some cut-off points for severity for some symptoms only, and as a result diagnose some people with personality disorders.

A spectrum approach, by comparison, suggests that although there is a common underlying link, which could be continuous, particular sets of individuals present with particular patterns of symptoms (i.e. syndrome or subtype), reminiscent of the visible spectrum of distinct colours after refraction of light by a prism.

It has been argued that within the data used to develop the DSM system there is a large literature leading to the conclusion that a spectrum classification provides a better perspective on phenomenology (appearance and experience) of psychopathology (mental difficulties) than a categorical classification system. However, the term has a varied history, meaning one thing when referring to a schizophrenia spectrum and another when referring to bipolar or obsessive-compulsive disorder spectrum, for example.

Types of Spectrum

The widely used DSM and ICD manuals are generally limited to categorical diagnoses. However, some categories include a range of subtypes which vary from the main diagnosis in clinical presentation or typical severity. Some categories could be considered subsyndromal (not meeting criteria for the full diagnosis) subtypes. In addition, many of the categories include a ‘not otherwise specified’ subtype, where enough symptoms are present but not in the main recognized pattern; in some categories this is the most common diagnosis.

Spectrum concepts used in research or clinical practice include the following.

Anxiety, Stress, and Dissociation

Several types of spectrum are in use in these areas, some of which are being considered in the DSM-5.

NameOutline
Generalised Anxiety SpectrumThis spectrum has been defined by duration of symptoms: a type lasting over six months (a DSM-IV criterion), over one month (DSM-III), or lasting two weeks or less (though may recur), and also isolated anxiety symptoms not meeting criteria for any type.
Social Anxiety SpectrumThis has been defined to span shyness to social anxiety disorder, including typical and atypical presentations, isolated signs and symptoms, and elements of avoidant personality disorder.
Panic-Agoraphobia SpectrumDue to the heterogeneity (diversity) found in individual clinical presentations of panic disorder and agoraphobia, attempts have been made to identify symptom clusters in addition to those included in the DSM diagnoses, including through the development of a dimensional questionnaire measure.
Post-Traumatic Stress Spectrum (or Trauma and Loss Spectrum)Work in this area has sought to go beyond the DSM category and consider in more detail a spectrum of severity of symptoms (rather than just presence or absence for diagnostic purposes), as well as a spectrum in terms of the nature of the stressor (e.g. the traumatic incident) and a spectrum of how people respond to trauma. This identifies a significant amount of symptoms and impairment below threshold for DSM diagnosis but nevertheless important, and potentially also present in other disorders a person might be diagnosed with.
Depersonalisation-Derealisation SpectrumAlthough the DSM identifies only a chronic and severe form of depersonalisation disorder, and the ICD a ‘depersonalisation-derealisation syndrome’, a spectrum of severity has long been identified, including short-lasting episodes commonly experienced in the general population and often associated with other disorders.

Obsessions and Compulsions

An obsessive-compulsive spectrum: This can include a wide range of disorders from Tourette syndrome to the hypochondrias, as well as forms of eating disorder, itself a spectrum of related conditions.

General Developmental Disorders

An autistic spectrum: In its simplest form this joins together autism and Asperger syndrome, and can additionally include other pervasive developmental disorders (PDD). These include PDD ‘not otherwise specified’ (including ‘atypical autism’), as well as Rett syndrome and childhood disintegrative disorder (CDD). The first three of these disorders are commonly called the autism spectrum disorders; the last two disorders are much rarer, and are sometimes placed in the autism spectrum and sometimes not. The merging of these disorders is based on findings that the symptom profiles are similar, such that individuals are better differentiated by clinical specifiers (i.e. dimensions of severity, such as extent of social communication difficulties or how fixed or restricted behaviours or interests are) and associated features (e.g. known genetic disorders, epilepsy, intellectual disabilities). The term specific developmental disorders is reserved for categorising particular specific learning disabilities and developmental disorders affecting coordination.

Psychosis

Refer to Psychosis.

The schizophrenia spectrum or psychotic spectrum: There are numerous psychotic spectrum disorders already in the DSM, many involving reality distortion. These include:

There are also traits identified in first degree relatives of those diagnosed with schizophrenia associated with the spectrum. Other spectrum approaches include more specific individual phenomena which may also occur in non-clinical forms in the general population, such as some paranoid beliefs or hearing voices. Some researchers have also proposed that avoidant personality disorder and related social anxiety traits should be considered part of a schizophrenia spectrum. Psychosis accompanied by mood disorder may be included as a schizophrenia spectrum disorder, or may be classed separately as below.

Schizoaffective Disorders

A schizoaffective spectrum: This spectrum refers to features of both psychosis (hallucinations, delusions, thought disorder etc.) and mood disorder (see below). The DSM has, on the one hand, a category of schizoaffective disorder (which may be more affective (mood) or more schizophrenic), and on the other hand psychotic bipolar disorder and psychotic depression categories. A spectrum approach joins these together and may additionally include specific clinical variables and outcomes, which initial research suggested may not be particularly well captured by the different diagnostic categories except at the extremes.

Schizophrenia-Like Personality Disorders

Schizoid personality disorder, schizotypal personality disorder and paranoid personality disorder can be considered ‘schizophrenia-like personality disorders’ because of their links to the schizophrenia spectrum.

Mood

A mood disorder (affective) spectrum or bipolar spectrum or depressive spectrum. These approaches have expanded out in different directions. On the one hand, work on major depressive disorder has identified a spectrum of subcategories and sub-threshold symptoms that are prevalent, recurrent and associated with treatment needs. People are found to move between the subtypes and the main diagnostic type over time, suggesting a spectrum. This spectrum can include already recognised categories of minor depressive disorder, ‘melancholic depression‘ and various kinds of atypical depression.

In another direction, numerous links and overlaps have been found between major depressive disorder and bipolar syndromes, including mixed states (simultaneous depression and mania or hypomania). Hypomanic (‘below manic’) and more rarely manic signs and symptoms have been found in a significant number of cases of major depressive disorder, suggesting not a categorical distinction but a dimension of frequency that is higher in bipolar II and higher again in bipolar I. In addition, numerous subtypes of bipolar have been proposed beyond the types already in the DSM (which includes a milder form called cyclothymia). These extra subgroups have been defined in terms of more detailed gradations of mood severity, or the rapidity of cycling, or the extent or nature of psychotic symptoms. Furthermore, due to shared characteristics between some types of bipolar disorder and borderline personality disorder, some researchers have suggested they may both lie on a spectrum of affective disorders, although others see more links to post-trauma syndromes.

Substance Use

A spectrum of drug use, drug abuse and substance dependence: One spectrum of this type, adopted by the Health Officers Council of British Columbia in 2005, does not employ loaded terms and distinctions such as “use” vs. “abuse”, but explicitly recognises a spectrum ranging from potentially beneficial to chronic dependence. The model includes the role not just of the individual but of society, culture and availability of substances. In concert with the identified spectrum of drug use, a spectrum of policy approaches was identified which depended partly on whether the drug in question was available in a legal, for-profit commercial economy, or at the other of the spectrum only in a criminal/prohibition, black-market economy. In addition, a standardised questionnaire has been developed in psychiatry based on a spectrum concept of substance use.

Paraphilias and Obsessions

The interpretative key of ‘spectrum,’ developed from the concept of ‘related disorders,’ has been considered also in paraphilias.

Paraphilic behaviour is triggered by thoughts or urges that are psychopathologically close to obsessive impulsive area. Hollander (1996) includes in the obsessive-compulsive spectrum, neurological obsessive disorders, body-perception-related disorders and impulsivity-compulsivity disorders. In this continuum from impulsivity to compulsivity it is particularly hard to find a clear borderline between the two entities.

On this point of view, paraphilias represent such as sexual behaviours due to a high impulsivity-compulsivity drive. It is difficult to distinguish impulsivity from compulsivity: sometimes paraphilic behaviours are prone to achieve pleasure (desire or fantasy), in some other cases these attitudes are merely expressions of anxiety, and the behavioural perversion is an attempt to reduce anxiety. In the last case, the pleasure gained is short in time and is followed by a new increase in anxiety levels, such as it can be seen in an obsessive patient after he performs his compulsion.

Eibl-Eibelsfeldt (1984) underlines a female sexual arousal condition during flight and fear reactions. Some women, with masochistic traits, can reach orgasm in such conditions.

Broad Spectrum Approach

Various higher-level types of spectrum have also been proposed, that subsume conditions into fewer but broader overarching groups.

One psychological model based on factor analysis, originating from developmental studies but also applied to adults, posits that many disorders fall on either an “internalising” spectrum (characterised by negative affectivity; subdivides into a “distress” subspectrum and a “fear” subspectrum) or an “externalising” spectrum (characterised by negative affectivity plus disinhibition). These spectra are hypothetically linked to underlying variation in some of the big five personality traits. Another theoretical model proposes that the dimensions of fear and anger, defined in a broad sense, underlie a broad spectrum of mood, behavioural and personality disorders. In this model, different combinations of excessive or deficient fear and anger correspond to different neuropsychological temperament types hypothesized to underlie the spectrum of disorders.

Similar approaches refer to the overall ‘architecture’ or ‘meta-structure’, particularly in relation to the development of the DSM or ICD systems. Five proposed meta-structure groupings were recently proposed in this way, based on views and evidence relating to risk factors and clinical presentation. The clusters of disorder that emerged were described as:

  • Neurocognitive (identified mainly by neural substrate abnormalities);
  • Neurodevelopmental (identified mainly by early and continuing cognitive deficits);
  • Psychosis (identified mainly by clinical features and biomarkers for information processing deficits);
  • Emotional (identified mainly by being preceded by a temperament of negative emotionality); and
  • Externalising (identified mainly be being preceded by disinhibition).

However, the analysis was not necessarily able to validate one arrangement over others. From a psychological point of view, it has been suggested that the underlying phenomena are too complex, inter-related and continuous – with too poorly understood a biological or environmental basis – to expect that everything can be mapped into a set of categories for all purposes. In this context the overall system of classification is to some extent arbitrary, and could be thought of as a user interface which may need to satisfy different purposes.

What is the Schedule for Affective Disorders and Schizophrenia?

Introduction

The Schedule for Affective Disorders and Schizophrenia (SADS) is a collection of psychiatric diagnostic criteria and symptom rating scales originally published in 1978.

It is organised as a semi-structured diagnostic interview. The structured aspect is that every interview asks screening questions about the same set of disorders regardless of the presenting problem; and positive screens get explored with a consistent set of symptoms. These features increase the sensitivity of the interview and the inter-rater reliability (or reproducibility) of the resulting diagnoses. The SADS also allows more flexibility than fully structured interviews: Interviewers can use their own words and rephrase questions, and some clinical judgment is used to score responses.

There are three versions of the schedule:

  • The regular SADS;
  • The lifetime version (SADS-L); and
  • A version for measuring the change in symptomology (SADS-C).

Although largely replaced by more structured interviews that follow diagnostic criteria such as DSM-IV and DSM-5, and specific mood rating scales, versions of the SADS are still used in some research papers today.

Diagnoses Covered

The diagnoses covered by the interview include schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, anxiety disorders and a limited number of other fairly common diagnoses.

Relationship with the Research Diagnostic Criteria

The SADS was developed by the same group of researchers as the Research Diagnostic Criteria (RDC). While the RDC is a list of diagnostic criteria for psychiatric disorders, the SADS interview allows diagnoses based on RDC criteria to be made, and also rates subject’s symptoms and level of functioning.

K-SADS

The K-SADS (or Kiddie-SADS) is a version of the SADS adapted for school-aged children of 6–18 years. There are various different versions of the K-SADS, each varying slightly in terms of disorders and specific symptoms covered, as well as the scale range used. All of the variations are still semi-structured interviews, giving the interviewer more flexibility about how to phrase and probe items, while still covering a consistent set of disorders.

The K-SADS-E (Epidemiological version) was developed for epidemiological research. It focused on current issues and episodes only. Most of the items used a four point rating scale.

The K-SADS-PL (Present and Lifetime version) is administered by interviewing the parent(s), the child, and integrating them into a summary rating that includes parent report, child report, and clinical observations during the interview. The interview covers both present issues (i.e., the reason the family is seeking an evaluation) as well as past episodes of the disorders. Most items use a three point rating scale for severity (not present, subthreshold, and threshold – which combines both moderate and severe presentations). It has been used with preschool as well as school-aged children. A 2009 working draft removed all reference to the DSM-III-R criteria (which were replaced with the publication of the DSM-IV in 1994) and made some other modifications. A DSM-5 version is being prepared and validated.

The WASH-U K-SADS (Washington University version) added items to the depression and mania modules and used a six point severity rating for severity.

Are Treatments for Common Mental Disorders also Effective for Functional Symptoms & Disorder?

Research Paper Title

Are treatments for common mental disorders also effective for functional symptoms and disorder?

Background

To consider whether the many types of treatments for mental disorders – both those specifically targeting illness mechanisms and nonspecific elements – are also effective in treating functional symptoms and syndromes. The paper discusses the need for well-organised care that emphasizes early treatment and recognition of more complex problems in primary and secondary medical care.

Methods

Evidence from a wide range of research and clinical experience is used to identify and illustrate general themes.

Results

Despite a limited evidence base, it is clear that both specific and nonspecific interventions that are effective with mental disorders are also effective in treating functional complaints. They are also helpful in the management of maladaptive reactions to physical disorders. Delivery is most effective as stepped care.

Conclusions

There is a particular need for more evidence on the effectiveness of the nonspecific elements of treatment and of their most appropriate delivery by non-specialists in general medical settings.

Experience with a variety of treatment methods will enhance our understanding of psychological and other etiological variables and thereby influence the development of improved definitions in Diagnostic and Statistical Manual of Mental Disorders-5(th) Edition.

It is argued that a main focus of review of somatoform disorder should be the resolution of conceptual problems.

Reference

Mayou, R. (2020) Are treatments for common mental disorders also effective for functional symptoms and disorder? Psychosomatic Medicine. 69(9), pp.876-880. doi: 10.1097/PSY.0b013e31815b00a6.

Psychiatrists have Started the Process of Mapping Genetic Architecture of Mental Disorders

Research Paper Title

Psychiatrists begin to map genetic architecture of mental disorders.

Background

Mental illness affects one in six US adults, but scientists’ sense of the underlying biology of most psychiatric disorders remains nebulous.

That is frustrating for physicians treating the diseases, who must make diagnoses based on symptoms that may only appear sporadically.

Now, a large-scale analysis of postmortem brains is revealing distinctive molecular traces in people with mental illness.

An international team of researchers reports that five major psychiatric disorders have often overlapping patterns of gene activity, which furthermore vary in disease-specific – and sometimes counterintuitive – ways.

The findings, they say, might someday lead to diagnostic tests, and one has already inspired a clinical trial of a new way to treat overactive brain cells in autism.

Reference

Dengler, R. (2020) Psychiatrists begin to map genetic architecture of mental disorders. Neuroscience. 359(6376), pp.619. DOI: 10.1126/science.359.6376.619

Linking Brain Imagery, Brain Tumours, and Cognitive & Mental Disorders in Adults

Research Paper Title

Brain tumours, cognitive and mental disorders in adults.

Background

Cognitive and mental disorders are observed in 15-20% of brain tumours, and can be the first symptoms.

The severity of cognitive deficits varies from attention and reasoning disorders to major syndromes such as delirium, amnesic syndrome or dementia.

Mental disorders range from apathy, irritability to major depressive or psychotic symptoms.

Cognitive and mental disorders are related to many factors including the localisation and nature of the tumour, peritumoral and remote changes, and personal susceptibility.

The diagnosis of brain tumour is presently made by brain imagery, but the difficulty remains to determine when imagery is to be used in cognitive or mental disorders.

Reference

Derouesne, C. (2020) Brain tumors, cognitive and mental disorders in adults. Geriatrie et Psychologie Neuropsychiatrie du Vieillissement. 13(2), pp.187-194. doi: 10.1684/pnv.2015.0533.

Conditional Cash Transfers & Mental Health

Research Paper Title

The worse the better? Quantile treatment effects of a conditional cash transfer programme on mental health.

Background

Poor mental health is a pressing global health problem, with high prevalence among poor populations from low-income countries.

Existing studies of conditional cash transfer (CCT) effects on mental health have found positive effects.

However, there is a gap in the literature on population-wide effects of cash transfers on mental health and if and how these vary by the severity of mental illness.

Methods

The researchers use the Malawian Longitudinal Study of Family and Health containing 790 adult participants in the Malawi Incentive Programme, a year-long randomized controlled trial.

They estimate average and distributional quantile treatment effects and we examine how these effects vary by gender, HIV status and usage of the cash transfer.

Results

They find that the cash transfer improves mental health on average by 0.1 of a standard deviation.

The effect varies strongly along the mental health distribution, with a positive effect for individuals with worst mental health of about four times the size of the average effect.

These improvements in mental health are associated with increases in consumption expenditures and expenditures related to economic productivity.

Conclusions

Their results show that CCTs can improve adult mental health for the poor living in low-income countries, particularly those with the worst mental health.

Reference

Ohrnberger, J., Fichera, E., Sutton, M. & Anselmi, L. (2020) The worse the better? Quantile treatment effects of a conditional cash transfer programme on mental health. Health Policy and Planning. doi: 10.1093/heapol/czaa079. Online ahead of print.

What are the Challenges of Mental Healthcare during COVID-19?

Research Paper Title

Current and Future Challenges in the Delivery of Mental Healthcare during COVID-19.

Background

The USA is in the midst of the COVID-19 pandemic.

The researchers assess the impact of COVID-19 on psychiatric symptoms in healthcare workers, those with psychiatric comorbidities, and the general population.

They highlight the challenges ahead and discuss the increased relevance of telepsychiatry.

Methods

The researchers analysed all available literature available as of 25 March 2020, on PubMed, Ovid Medline, and PsychInfo.

They utilised the MeSH term “covid AND (psychiatry OR mental health)” and included all articles.

Duplicates were removed resulting in 32 articles, of which 19 are cited. Four additional references are included to examine suicide data. During the review process, an additional 7 articles were identified which are also included.

Results

Frontline healthcare workers are currently experiencing increased psychiatric symptoms and this is more severe in females and nurses. Non-frontline healthcare workers, as well as the general population, are experiencing vicarious traumatisation.

People with psychiatric comorbidities, and the general population, face increased psychiatric symptom burden. Migrant workers, the elderly, children, and the homeless may be disproportionately impacted. Suicide rates may be impacted.

Conclusions

The COVID-19 pandemic has resulted in a severe disruption to the delivery of mental healthcare.

Psychiatric facilities are facing unprecedented disruptions in care provision as they struggle to manage an infected population with comorbid psychiatric symptoms.

Telepsychiatry is a flawed but reasonable solution to increase the availability of mental healthcare during COVID-19.

Reference

Gautam, M., Thakrar, A., Akinyemi, E. & Mahr, G. (2020) Current and Future Challenges in the Delivery of Mental Healthcare during COVID-19. SN Comprehensive Clinical Medicine. 1-6. doi: 10.1007/s42399-020-00348-3. Online ahead of print.

Identifying Qualitatively Distinct PTSD Symptom Typologies

Research Paper Title

Identifying PTSD Symptom Typologies: A Latent Class Analysis.

Background

Posttraumatic stress disorder (PTSD) is characterised by re-experiencing, avoidance, negative alterations in cognition and mood, and arousal symptoms per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

While numerous symptom combinations are possible to meet diagnostic criteria, simplification of this heterogeneity of symptom presentations may have clinical utility.

Methods

In a nationally representative sample of American adults with lifetime DSM-5 PTSD diagnoses from the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (n = 2,365), the researchers used Latent Class Analysis (LCA) to identify qualitatively distinct PTSD symptom typologies.

Subsequently, they used linear and logistic regressions to identify demographic, trauma-related, and psychiatric characteristics associated with membership in each class.

Results

In contrast to prior LCAs with DSM-IV-TR diagnostic criteria, fit indices for the present analyses of DSM-5 PTSD revealed a four-class solution to the data:

  1. Dysphoric (23.8%);
  2. Threat-Reactivity (26.1%);
  3. High Symptom (33.7%); and
  4. Low Symptom (16.3%).

Exploratory analyses revealed distinctions between classes in socioeconomic impairment, trauma exposure, comorbid diagnoses, and demographic characteristics.

Conclusions

Although the study is limited by its cross-sectional design (preventing analysis of temporal associations or causal pathways between covariates and latent classes), findings may support efforts to develop personalised medicine approaches to PTSD diagnosis and treatment.

Reference

Campbell, S.B., Trachik, B., Goldberg, S. & Simpson, T.L. (2020) Identifying PTSD Symptom Typologies: A Latent Class Analysis. Psychiatry Research. 285:112779. doi: 10.1016/j.psychres.2020.112779. Epub 2020 Jan 23.

Can Adverse Childhood Experiences have an Affect on Mental Health Outcomes through Disrupted Sleep?

Research Paper Title

Sleep disturbance mediates the association of adverse childhood experiences with mental health symptoms and functional impairment in US soldiers.

Background

Adverse childhood experiences (ACEs) can have long-term impacts on a person’s mental health, which extend into adulthood.

There is a high prevalence of ACEs among service members.

Further, service members also report frequently experiencing disrupted sleep.

Methods

The researchers hypothesised that disrupted sleep may serve a mechanistic function connecting ACEs to functional impairment and poorer mental health.

Results

In a cross-sectional sample (n = 759), the researchers found evidence for an indirect effect of ACEs on mental health outcomes through disrupted sleep.

In a different sample using two time-points (n = 410), they found evidence for an indirect effect of ACEs on changes in mental health outcomes and functional impairment during a reset period, through changes in disrupted sleep during the same period.

Conclusions

Implications, limitations and future research directions are discussed.

Reference

Conway, M.A., Cabrera, O.A., Clarke-Walper, K., Dretsch, M.N., Holzinger, J.B., Riviere, L.A. & Quartana, P.J. (2020) Sleep disturbance mediates the association of adverse childhood experiences with mental health symptoms and functional impairment in US soldiers. Journal of Sleep Research. e13026. doi: 10.1111/jsr.13026. [Epub ahead of print].