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Chapter 1 - Diagnosis without Borders

A Pluripotential Approach to Preventive Intervention in Emerging Mental Disorders

from Section 1 - Conceptual and Strategic Issues

Published online by Cambridge University Press:  08 August 2019

Patrick D. McGorry
University of Melbourne
Ian B. Hickie
University of Sydney
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A fundamental aim of diagnosis is to guide treatment planning and predict illness course. Yet for too long psychiatric diagnosis, grounded on traditional silo-based approaches, has lacked clinical utility. This chapter explores the purpose of diagnosis and classification as well as the inability to validate diagnosis in psychiatry. It is proposed that new testable models are needed to improve the utility of diagnosis and support more personalised and sequential treatment selection. A number of new approaches have been put forward, including hierarchical and network-based methods, however at present, these offer limited value in guiding treatment selection. Clinical staging offers a viable solution. Clinical staging in psychiatry recognises that mental disorders are not static and discretely defined entities, but rather they are syndromes that overlap and develop in stages. The model ensures that interventions are proportional to both need and the risk of progressing to later stages and more established syndromes, which are likely to be comorbid, persistent, recurrent and disabling. Ultimately, it advocates a transdiagnostic approach to intervention, with a pre-emptive focus, that is based on risk-benefit considerations and patient needs. Clinical staging also provides a framework in which underlying biological mechanisms can be linked to each stage, to build a personalised and pre-emptive psychiatry.

Clinical Staging in Psychiatry
Making Diagnosis Work for Research and Treatment
, pp. 1 - 11
Publisher: Cambridge University Press
Print publication year: 2019

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Ahuja, A., & McGorry, P. (2012, 23 March). Diagnostic disorder and how to help its recovery. Australian Financial Review.
Angell, M. (2011, 14 July). The illusions of psychiatry. New York Review of Books.CrossRef
Borsboom, D. (2017). A network theory of mental disorders. World Psychiatry, 16(1), 513.CrossRefGoogle ScholarPubMed
Boseley, S. (2012, 9 February). Psychologists fear US manual will widen mental illness diagnosis: mental disorders listed in publication that should not exist, warn UK experts. Guardian.
Carey, B. (2012, 19 January). New definition of autism will exclude many, study suggests. New York Times.
Carpenter, W. T., & van Os, J. (2011). Should attenuated psychosis syndrome be a DSM-5 diagnosis? American Journal of Psychiatry, 168(5), 460463.CrossRefGoogle ScholarPubMed
Caspi, A., Houts, R. M., Belsky, D. W., Goldman-Mellor, S. J., Harrington, H., Israel, S., … Poulton, R. (2014). The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clinical Psychological Science, 2(2), 119137.CrossRefGoogle Scholar
Collins, F. S., & Varmus, H. (2015). A new initiative on precision medicine. New England Journal of Medicine, 372(9), 793795.CrossRefGoogle ScholarPubMed
Cuijpers, P. (2003). Examining the effects of prevention programs on the incidence of new cases of mental disorders: the lack of statistical power. American Journal of Psychiatry, 160(8), 13851391.CrossRefGoogle ScholarPubMed
Cuthbert, B. N., & Insel, T. R. (2010). Toward new approaches to psychotic disorders: the NIMH Research Domain Criteria project. Schizophrenia Bulletin, 36(6), 10611062.CrossRefGoogle ScholarPubMed
Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J. P., … Zaslavsky, A. M. (2004). Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA, 291(21), 25812590.Google Scholar
Dominguez, M. D., Wichers, M., Lieb, R., Wittchen, H. U., & van Os, J. (2011). Evidence that onset of clinical psychosis is an outcome of progressively more persistent subclinical psychotic experiences: an 8-year cohort study. Schizophrenia Bulletin, 37(1), 8493.CrossRefGoogle Scholar
Eaton, W. W., Badawi, M., & Melton, B. (1995). Prodromes and precursors: epidemiologic data for primary prevention of disorders with slow onset. American Journal of Psychiatry, 152(7), 967972.Google ScholarPubMed
Frances, A. (2010, 14 August). Good grief. New York Times.
Frances, A. (2013). Saving normal: an insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: William Morrow.Google Scholar
Fusar-Poli, P., & Yung, A. R. (2012). Should attenuated psychosis syndrome be included in DSM-5? Lancet, 379(9816), 591592.CrossRefGoogle ScholarPubMed
Greenberg, G. (2013). The book of woe: the DSM and the unmaking of psychiatry. New York: Blue Rider Press.Google Scholar
Jablensky, A. (2012). Prototypes, syndromes and dimensions of psychopathology: an open agenda for research. World Psychiatry, 11(1), 2223.CrossRefGoogle ScholarPubMed
Jablensky, A. (2016). Psychiatric classifications: validity and utility. World Psychiatry, 15(1), 2631.CrossRefGoogle ScholarPubMed
Judd, L. L., Schettler, P. J., & Akiskal, H. S. (2002). The prevalence, clinical relevance, and public health significance of subthreshold depressions. Psychiatric Clinics of North America, 25(4), 685698.CrossRefGoogle ScholarPubMed
Kaymaz, N., Drukker, M., Lieb, R., Wittchen, H. U., Werbeloff, N., Weiser, M., … van Os, J. (2012). Do subthreshold psychotic experiences predict clinical outcomes in unselected non-help-seeking population-based samples? A systematic review and meta-analysis, enriched with new results. Psychological Medicine, 42(11), 22392253.CrossRefGoogle ScholarPubMed
Kendell, R. E. (1975a). The role of diagnosis in psychiatry. Oxford: Blackwell.Google Scholar
Kendell, R. E. (1975b). The concept of disease and its implications for psychiatry. British Journal of Psychiatry, 127, 305315.CrossRefGoogle ScholarPubMed
Kendell, R. E., & Jablensky, A. (2003). Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry, 160(1), 412.CrossRefGoogle ScholarPubMed
Kendler, K. S. (2016). The nature of psychiatric disorders. World Psychiatry, 15(1), 512.CrossRefGoogle ScholarPubMed
Kendler, K. S., Zachar, P., & Craver, C. (2011). What kinds of things are psychiatric disorders? Psychological Medicine, 41(6), 11431150.CrossRefGoogle ScholarPubMed
Kotov, R., Krueger, R. F., & Watson, D. (2018). A paradigm shift in psychiatric classification: the Hierarchical Taxonomy Of Psychopathology (HiTOP). World Psychiatry, 17(1), 2425.CrossRefGoogle Scholar
Linscott, R. J., & van Os, J. (2013). An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders. Psychological Medicine, 43(6), 11331149.CrossRefGoogle ScholarPubMed
McGorry, P. D. (2013). The next stage for diagnosis: validity through utility. World Psychiatry, 12(3), 213215.CrossRefGoogle ScholarPubMed
McGorry, P. D., Hartmann, J. A., Spooner, R., & Nelson, B. (2018). Beyond the ‘at risk mental state’ concept: transitioning to transdiagnostic psychiatry. World Psychiatry, 17(2), 133142.CrossRefGoogle Scholar
McGorry, P. D., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H. J. (2006). Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safe and more effective interventions. Australian and New Zealand Journal of Psychiatry, 40(8), 616622.CrossRefGoogle Scholar
McGorry, P. D., Nelson, B., Goldstone, S., & Yung, A. R. (2010). Clinical staging: a heuristic and practical strategy for new research and better health and social outcomes for psychotic and related mood disorders. Canadian Journal of Psychiatry, 55(8), 486497.CrossRefGoogle ScholarPubMed
McGorry, P. D., Purcell, R., Goldstone, S., & Amminger, G. P. (2011). Age of onset and timing of treatment for mental and substance use disorders: implications for preventive intervention strategies and models of care. Current Opinion in Psychiatry, 24(4), 301306.CrossRefGoogle ScholarPubMed
McGorry, P. D., Purcell, R., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H. J. (2007). Clinical staging: a heuristic model for psychiatry and youth mental health. Medical Journal of Australia, 187(7 Suppl.), S40S42.Google ScholarPubMed
Moffitt, P. (2016). My way (2nd ed.). Newcastle, NSW: Principal Print.Google Scholar
National Research Council. (2011). Toward precision medicine: building a knowledge network for biomedical research and a new taxonomy of disease. Washington, DC: National Academies Press.
Paus, T., Keshavan, M., & Giedd, J. N. (2008). Why do many psychiatric disorders emerge during adolescence? Nature Reviews Neuroscience, 9(12), 947957.CrossRefGoogle ScholarPubMed
Reininghaus, U., Böhnke, J. R., Chavez-Baldini, U., Gibbons, R., Ivleva, E., Clementz, B. A., … Tamminga, C. A. (2018). Transdiagnostic dimensions of psychosis in the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP). World Psychiatry, 18(1), 6776.CrossRefGoogle Scholar
Reininghaus, U., Böhnke, J. R., Hosang, G., Farmer, A., Burns, T., McGuffin, P., & Bentall, R. P. (2016). Evaluation of the validity and utility of a transdiagnostic psychosis dimension encompassing schizophrenia and bipolar disorder. British Journal of Psychiatry, 209(2), 107113.CrossRefGoogle ScholarPubMed
Reininghaus, U., Priebe, S., & Bentall, R. P. (2013). Testing the psychopathology of psychosis: evidence for a general psychosis dimension. Schizophrenia Bulletin, 39(4), 884895.CrossRefGoogle ScholarPubMed
Rutledge, R., & Osler, T. (1998). The ICD-9-based illness severity score: a new model that outperforms both DRG and APR-DRG as predictors of survival and resource utilization. Journal of Trauma, 45(4), 791799.CrossRefGoogle ScholarPubMed
Stephan, K. E., Bach, D. R., Fletcher, P. C., Flint, J., Frank, M. J., Friston, K. J., … Breakspear, M. (2016a). Charting the landscape of priority problems in psychiatry, part 1: classification and diagnosis. Lancet Psychiatry, 3(1), 7783.CrossRefGoogle ScholarPubMed
Stephan, K. E., Binder, E. B., Breakspear, M., Dayan, P., Johnstone, E. C., Meyer-Lindenberg, A., … Friston, K. J. (2016b). Charting the landscape of priority problems in psychiatry, part 2: pathogenesis and aetiology. Lancet Psychiatry, 3(1), 8490.CrossRefGoogle ScholarPubMed
Trusheim, M. R., Berndt, E. R., & Douglas, F. L. (2007). Stratified medicine: strategic and economic implications of combining drugs and clinical biomarkers. Nature Reviews Drug Discovery, 6(4), 287293.CrossRefGoogle ScholarPubMed
van Os, J., & Linscott, R. J. (2012). Introduction: the extended psychosis phenotype – relationship with schizophrenia and with ultrahigh risk status for psychosis. Schizophrenia Bulletin, 38(2), 227230.CrossRefGoogle Scholar
Wang, P. S., Demler, O., & Kessler, R. C. (2002). Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health, 92(1), 9298.CrossRefGoogle ScholarPubMed
Woods, S. W., Walsh, B. C., Saksa, J. R., & McGlashan, T. H. (2010). The case for including Attenuated Psychotic Symptoms Syndrome in DSM-5 as a psychosis risk syndrome. Schizophrenia Research, 123(2–3), 199207.CrossRefGoogle ScholarPubMed
Yung, A. R., & McGorry, P. D. (1996). The initial prodrome in psychosis: descriptive and qualitative aspects. Australian and New Zealand Journal of Psychiatry, 30(5), 587599.CrossRefGoogle ScholarPubMed
Yung, A. R., Phillips, L. J., McGorry, P. D., McFarlane, C. A., Francey, S., Harrigan, S., … Jackson, H. J. (1998). Prediction of psychosis: a step towards indicated prevention of schizophrenia. British Journal of Psychiatry, 172(33), 1420.CrossRefGoogle ScholarPubMed
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