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In Chapter 12, we develop subthemes concerning how our participants narrated treatment as a cost of their illness and how it contributed to well-being. We highlight how insights into the impact of treatment on narrative identity may aid healthcare professionals in providing the best possible support for individuals with mental illness. Generally, few stories seemed to follow a structure where increased well-being followed automatically from symptom remission, pointing to the need for psychiatric care that directly targets well-being. Being diagnosed was narrated with both positive and negative identity implications. Some participants evidenced subthemes revolving around inadequate access to help and negative treatment events, including hospitalizations and side effects of medicine. These subthemes may ground identity conclusions such as “I am harmed by treatment” and “no one cares.” When treatment contributed to well-being, subthemes featured the growing and agentic self: individuals striving to improve in treatment and noting their growth. Further subthemes concerned helpful relationships with staff, grounding identity implications such as “I am understood and supported by staff,” that may shape engagement with treatment and support personal recovery.
Compulsory Community Treatment Orders (CTOs) enable psychiatric medication without the need for consent. Careful scrutiny of outcomes including mortality is required to ensure compulsory treatment is evidence-based and ethical.
To report mortality for patients placed on CTOs and analyse data according to CTO status, mortality cause and diagnosis.
Data for all patients placed under CTOs between 1 January 2009 and 31 December 2018 was provided by the Ministry of Health, New Zealand. Data included diagnostic and demographic information, dates of CTOs, and any dates and causes of death. Deaths were categorised into suicides, accidents and assaults, and medical causes. Mortality data are reported according to CTO status and diagnosis.
A total of 14 726 patients were placed on CTOs over the study period, during which there were 1328 deaths. The mortality rate was 2.97 on and 2.31 off CTOs (rate ratio 1.29, 95% CI 1.14–1.45; P < 0.01). The mortality rate for accidents and assaults was 0.44 on and 0.25 off CTOs (rate ratio 1.73, 95% CI 1.23–2.42; P < 0.01). The mortality rate for medical causes was 2.33 on and 1.90 off CTOs (rate ratio 1.22, 95% CI 1.07–1.40; P < 0.01). The suicide rate was 0.20 on and 0.15 off of CTOs (rate ratio 1.33, 95% CI 0.81–2.12; P = 0.22).
Increased care and medication provided during compulsory treatment does not the modify the course of illness sufficiently to reduce mortality during CTOs. Higher mortality rates during CTO periods compared with non-CTO periods may reflect greater unwellness during CTOs.
The diagnosis of obsessive compulsive disorder (OCD) is characterised by intrusive thoughts leading to compulsions to alleviate anxiety. However, research is lacking on impact post-diagnosis. Some research suggests diagnosis may benefit treatment access, but potentially leads to higher levels of stigma and altered self-identity.
The present study assessed the utility (treatment access and problem identification) and impact (stigma, personal wellbeing or social identity) of receiving a diagnosis of OCD.
Semi-structured interviews with 12 individuals who had received a diagnosis of OCD were conducted between February and April 2020, then transcribed and analysed using theoretical thematic analysis.
Participants reported positive impacts of diagnosis on both ‘utility’ and ‘impact’.
The diagnosis of OCD was helpful for participants in making their symptoms tangible, providing relief and hope for recovery. Non-diagnostic or alternative frameworks should aim to meet this need. Future research may wish to identify how this understanding of disorders vary between different diagnoses, especially in terms of stigma and personal wellbeing.
The aim of the study was to characterize dogs in which fear-motivated aggression was diagnosed, to describe the therapy used, and to evaluate the effectiveness of this therapy using a retrospective descriptive study. During the research period 284 dogs were referred for problem behaviour. Fear-motivated aggression was diagnosed in 73 (26%) dogs: intact males (35), castrated males (15), intact females (11) and castrated females (12). The mean age of the animals was 3.4 years ± 2.2 (SD). Mixed-breed dogs were most frequent, followed by Golden Retrievers, Rottweilers and Bernese Mountain Dogs. The majority of the dogs expressed growling, snapping, biting, ears down, tail down and low posture. The aggression occurred mainly inside the house, towards adults or children, and especially when the dog was approached and/or touched. Diagnosis was based on data about the behavioural expressions of the animals, and about owner-dog interactions, obtained from both the owner and our own observation. Treatment consisted of 1) avoiding eliciting stimuli, 2) optimizing owner-dog communication, 3) adaptation of the owner's punishing threats to the dog's response to punishment, and 4) for a certain period fitting the dog with a choker chain connected to a leash during the day. The behaviour of the dogs improved (55; 75%), remained unchanged (13; 18%), or deteriorated (5; 7%). In conclusion: fear-motivated aggression in dogs is likely to be more frequent than generally is assumed. Growling or biting in a low posture towards both adults and children, especially when the animals were approached or touched inside the house, were the main characteristics on which the diagnosis fear-motivated aggression was based. Therapy, mainly based on optimizing communication between owner and dog, proved significantly effective.
Identifies the important characteristics of clinical assessment. Describes the various tests that psychologists use. Explains the way psychologists organize information in an intake report. Explains the purpose and limitations of diagnosis. Summarizes the way diagnostic manuals have changed over time. Describes the research evaluating the effectiveness of psychotherapy.
This study assessed the prevalence and correlates of depression following the April 2020 flooding in Fort McMurray.
A cross-sectional study design. Questionnaires were self-administered through an anonymous, online survey. Data collected included sociodemographics, flooding-related variables, clinical information, and likely major depressive disorder (MDD) using PHQ-9 scoring. Data were analyzed using descriptive statistics, the chi-square test, and logistic regression at P = < 0.05.
Of the 186 respondents who completed the survey, 85.5% (159) of the respondents were females, 14.5% (27) were males, 52.7% (98) were above 40 years of age, and 94% (175) were employed. The prevalence of mild to severe depression among the respondents was 53.7% (75). Respondents who reported that they are unemployed are 12 times more likely to have a moderate to severe depression (OR = 12.16; 95% CI: 1.08–136.26). Respondents who had previously received a mental health diagnosis of MDD are five times more likely to have moderate to severe depression (OR = 5.306; 95% CI: 1.84–15.27).
This study suggests that flooding could impact the psychosocial and mental health of affected people. There is a need to reassess the existing guidelines on emergency planning for flooding to reduce its impacts on mental health and identify where research can support future evidence-based guidelines.
Low- and middle-income countries contribute to the majority of dementia and mild cognitive impairment cases worldwide, yet cognitive tests for diagnosis are designed for Western cultures. Language and cultural discrepancies mean that translated tests are not always reliable or valid. We propose a model for culturally adapting cognitive tests, one step of which is to assess the quality of any translation and cultural adaptation undertaken. We developed the Manchester Translation Evaluation Checklist (MTEC) to act as a tool for quality assessment and demonstrated its use by assessing a popular cognitive test that had been adapted.
Assess quality of the translation and cultural adaptation of the Urdu Mini-Mental State Examination developed for a Pakistani population.
Two raters completed the MTEC for the Mini-Mental State Examination (MMSE) Urdu and compared feedback. All authors were fluent in English and Urdu and familiar with Pakistani culture.
Raters had 78.5% agreement across the MTEC. The MMSE Urdu was appropriately translated and retained grammar and verb tense, but three questions had spelling errors. Across 20 MMSE questions, 5 required further cultural adaptation because the questions were not understandable in daily use, comfortable to answer, relevant to the language and culture, and relevant to original concepts.
The MTEC highlighted errors in the MMSE Urdu and demonstrated how this tool can be used to improve it. Future studies could employ the MTEC to improve existing translated measures of health assessment, particularly cognitive tests, and act as a quality check when developing new adaptations of tests and before psychometric validation.
Primary progressive aphasias are rare younger-onset dementias. As the label denotes, these dementias are characterised clinically by marked changes in language skills. Evidence over the years has shown that individuals with primary progressive aphasia experience widespread cognitive and behavioural changes that extend beyond language. This evidence, however, seems to be largely ignored or downplayed. This article proposes that linguistic relativity which induces a cognitive bias may be responsible for this omission; it also indicates that a revision of the current diagnostic criteria may need to be revised.
Diagnosis of soil-transmitted helminth (STH) and schistosome infections relies largely on conventional microscopy which has limited sensitivity, requires highly trained personnel and is error-prone. Rapid advances in miniaturization of optical systems, sensors and processors have enhanced research and development of digital and automated microscopes suitable for the detection of these diseases in resource-limited settings. While some studies have reported proof-of-principle results, others have evaluated the performance of working prototypes in field settings. The extensive commercialization of these innovative devices has, however, not yet been achieved. This review provides an overview of recent publications (2010–2022) on innovative field applicable optical devices which can be used for the diagnosis of STH and schistosome infections. Using an adapted technology readiness level (TRL) scale taking into account the WHO target product profile (TPP) for these diseases, the developmental stages of the devices were ranked to determine the readiness for practical applications in field settings. From the reviewed 18 articles, 19 innovative optical devices were identified and ranked. Almost all of the devices (85%) were ranked with a TRL score below 8 indicating that, most of the devices are not ready for commercialization and field use. The potential limitations of these innovative devices were discussed. We believe that the outcome of this review can guide the end-to-end development of automated digital microscopes aligned with the WHO TPP for the diagnosis of STH and schistosome infections in resource-limited settings.
Central and peripheral biomarkers can be used to diagnose, treat, and potentially prevent major psychiatric disorders. But there is uncertainty about the role of these biological signatures in neural pathophysiology, and their clinical significance has yet to be firmly established. Psychomotor, cognitive, affective, and volitional impairment in these disorders results from the interaction between neural, immune, endocrine, and enteric systems, which in turn are influenced by a person’s interaction with the environment. Biomarkers may be a critical component of this process. The identification and interpretation of biomarkers also raise ethical and social questions. This article analyzes and discusses these aspects of biomarkers and how advances in biomarker research could contribute to personalized psychiatry that could prevent or mitigate the effects of these disorders.
This study aimed to provide insight into the congruity of acute cystitis (AC) diagnosis in women, measured both by the Acute Cystitis Symptom Score (ACSS) questionnaire and urine test(s).
The ACSS questionnaire was developed as a self-administering tool for assessing urinary symptoms, quality of life (QoL) and treatment outcomes in healthy, nonpregnant female patients.
This prospective observational cohort study compared AC diagnosis based on the questionnaire with a GP diagnosis based on dipstick/dipslide test(s). ACSS questionnaire form A (typical and differential symptoms, QoL and relevant conditions) was filled in by the patient group, women suspected for AC visiting a GP practice with a urine sample, and the reference group, women visiting a community pharmacy for any medication. Analyses were performed assuming that the GP diagnosis based on urine test(s) was correct. Divergent result(s) of urine test(s) and ACSS questionnaire were analysed for scores of all individual questionnaire domains. Statistical analyses included descriptive statistics and the positive predictive value (PPV) and the negative predictive value (NPV) of the ACSS questionnaire and the urine test(s).
In the patient group, 59 women were included, 38 of whom a GP positively diagnosed for AC. The reference group included 70 women. The PPV of the ACSS questionnaire was 77.3%, and the NPV was 73.3%. Analysis of patient data for divergent results showed that differential symptoms, QoL and relevant conditions explained false-positive and false-negative results. Revised results (most probable diagnosis) based on this analysis showed a PPV and NPV of 88.6% and 73.3% for the ACSS questionnaire and 100% and 76.2% for the urine test(s). For use in primary care, a reduction in false-positive and false-negative results can be achieved by including scores for differential symptoms, QoL and relevant conditions, alongside a total typical symptoms score of 6 or higher.
Paediatric bipolar disorder – bipolar disorder occurring in prepubertal children – is a diagnosis subject to considerable controversy. Whilst historically considered to be very rare, proponents since the 1990s have argued that mania can present differently in children and, as such, is much more common than previously thought. Such proposals raise questions about the validity of proposed phenotypes and potential risks of iatrogenic harm.
I critically examine the construct of paediatric bipolar disorder using Robins and Guze’s (1970, American Journal of Psychiatry126, 983–987) influential criteria for the validity of a psychiatric diagnosis. I review, in turn, evidence relating to its clinical description, delimitation from other conditions, follow-up studies, family studies, laboratory studies, and treatment response.
Across domains, existing research highlights significant challenges establishing the diagnosis. This includes significant heterogeneity in operationalising criteria for children; variable or poor inter-rater reliability; difficulty distinguishing paediatric bipolar disorder from other conditions; large differences in rates of diagnosis between the United States of America and other countries; limited evidence of continuity with adult forms; and a lack of evidence for proposed paediatric phenotypes in children at genetic high-risk of the condition. Laboratory and treatment studies are limited, but also do not provide support for the construct.
Evidence for the more widespread existence of paediatric bipolar disorder and its various proposed phenotypes remains weak. The ongoing popularity of the diagnosis, most evident in America, may reflect social pressures and broader limitations in psychiatric nosology. The uncertainty around the diagnosis highlights the need for careful longitudinal assessment of children potentially affected.
Concerns that American psychiatry was neglecting an important dimension of human experience led to the introduction into DSM-IV of a V Code for a Religious or Spiritual Problem. The 1994 DSM-IV also included the new Outline for a Cultural Formulation, later accompanied by a Cultural Formulation Interview and 12 Supplemental Modules added to help clinicians to gather information for the Outline for Cultural Formulation. Recommendations from the APIRE Workgroup led to revisions in DSM-5, and outlined several areas for future research into the implications of spirituality, religion and culture for diagnosis and treatment. In particular, future research will need to better clarify the relationship between spiritual/religious and psychopathological phenomena, the different manifestations of psychiatric disorders in religious populations, the influences of spirituality/religion on the course and outcome of mental disorders, and the role of spirituality/religion in developmental and personality disorders.
The helminth infection caused by Strongyloides stercoralis is widespread in tropical regions, but rare in European countries. Unfamiliarity with the disease and diagnostic obstacles could contribute to its lethal outcome. Frequent use of corticosteroids during the COVID-19 pandemic could increase its significance. The aim of this retrospective descriptive study was to explore disease patterns and discuss clinical dilemmas in patients with S. stercoralis hyperinfection treated at the University Hospital for Infectious Diseases ‘Dr. Fran Mihaljević’ in Zagreb, Croatia, between 2010 and 2021. Five out of 22 (22.7%) immunosuppressed patients treated due to strongyloidiasis developed hyperinfection. All patients were male, median 64 years; four were immunosuppressed by corticosteroids (although ileum resection could have been the trigger in one) and one by rituximab. The diagnosis was established after a median of 1.5 months of symptom duration, accidentally in all patients, by visualizing the parasite in the gastric/duodenal mucosa in four cases, and bronchial aspirate in one. All patients were cachectic, four out of five had severe hypoalbuminemia and all suffered secondary bacterial/fungal infection. Despite combined antibiotic, antifungal and antihelmintic therapy, three out of five of the patients died, after failing to clear living parasites from stool samples. We can conclude that significant delays in diagnosis and lack of clinical suspicion were observed among our patients with the most severe clinical presentations of strongyloidiasis. Although being beyond diagnostic recommendations for strongyloidiasis, an early upper gastrointestinal endoscopy with mucosal sample analysis could expedite diagnosis in severe, immunosuppressed patients. The persistence of viable parasites in the stool despite antihelmintic therapy should be further investigated.
Important worldwide changes in human aging are developing rapidly. Life expectancy has doubled during the past century. Due to advances in public health, vaccines, and science, people are living longer. The increase in the elderly population is happening in varying degrees all over the world. Although heart disease and cancer rates are falling, Alzheimer’s is increasing because of its strong link to aging and lack of disease-modifying therapies. It is important to consider what can be done about the expansion of aged populations. A forward-looking approach to health care will provide resources to people throughout life to keep them healthy and enhance their four reserve factors. This is ethically and economically preferable to a health care system which only takes care of people when they’re sick and doesn’t strive to prevent illness. Recent advances in diagnosis, metagenomics (studies of gut bacteria), and artificial intelligence will hopefully assist in the growth of preventive measures. Advances in public policy and technology can help people to enhance their four reserve factors and help them to avoid disease and remain fit as they age.
The vast majority of people worldwide are religious, but religions are enormously diverse. Psychiatric research has attended more to the paths that people take in pursuit of the special things that religion represents than it has to religion itself. Religion is generally supportive of good mental health, and facilitates coping with illness and adversity, but religious and spiritual struggles (e.g., anger towards God, demonic attributions, religious conflicts, guilt and doubt) can impair mental well-being. Religious experiences, both positive and negative, can be mistaken for psychopathology and therefore need to be taken into account in diagnosis, but a differential diagnosis between spiritual/religious experience and mental disorder is not always helpful. It is possible both to be having a meaningful religious experience and to be suffering from a diagnosable mental disorder. Good clinical practice requires an ability to talk with patients in a sensitive and respectful way about their religious concerns.
The use of “operational criteria” in DSM-III was proposed as a solution to low reliability among psychiatrist’s diagnosis. It is considered a turning point in the psychiatric classification and diagnostic process, furtherly adopted in ICD. However, the utility of using such criteria in everyday clinical practice is still not clear.
To measure agreement between prototypical and ICD-10 categorical diagnosis.
In IPUB’s outpatient clinics, psychiatry residents work in a real-life clinical scenario, attending patients from Rio de Janeiro/RJ-Brazil. Although regularly trained in ICD criteria, it is not usual to check every criterion in their daily practice. Thus, patients are diagnosed with a prototype-based disorder, not necessarily strictly attached to ICD criteria. We propose a cross-sectional study, where psychiatry residents check their clinical diagnosis according to ICD criteria and compare its agreement with kappa statistics.
Three of thirty residents joined the study, providing diagnosis for 146 patients under their care. Forty-five diagnoses were obtained before and 51 after ICD-10 criterion application. Diagnoses were grouped under 8 groups (Organic, Schizophrenia Spectrum Disorders, Bipolar Affective Disorder, Depression, Anxiety-Related Disorders, Personality Disorders, Neurodevelopmental Disorders), and kappa agreement obtained using ICD-10 diagnosis as the gold standard against prototypical diagnoses. Overall kappa was 0.77 (IC - 0.69 - 0.85), ranging from 0.58 (Personality Disorders) to 0.91 (Schizophrenia Spectrum Disorder). These findings also were reflected as high sensibility, specificity, Positive Predictive, and Negative Predictive values in all groups.
Prototypical diagnostic elaboration, while probably based on previously learned, but not applied operational criteria, was equivalent to diagnostic obtained through ICD-10 categories.
Specific diagnoses have specific implications, and this chapter examines these. Prevalence of specific conditions is difficult to establish, but some broad findings are reviewed. Specific diagnoses are then considered in turn, looking at their conceptual basis and potential misunderstandings, diagnostic criteria and the difficulty of categorising symptoms, and the implications of making, or not making, each. For each diagnosis the authors consider how culturally normal reactions may wrongly be labelled as ‘symptoms’ but equally how problems may be wrongly ascribed to ‘culturally normal’ experience. Some diagnoses may be overlooked, especially if difficulties are ascribed to cultural factors – substance abuse, traumatic brain injury, intellectual disability and neuroatypicality.
Situations where there is no diagnosis, or changing and overlapping diagnoses are reviewed. Fabrication is considered, and the value and hazards of raising the possibility in an assessment.
Schizophrenia is a severe and chronic disorder causing significant disability and functional decline. Schizophrenia is a polygenic disease, with about 100 monogenic sites and 11 sites of chromosomal deletions / duplications involved in its pathogenesis identified. It is a pleiotropic disease, with causative genetic changes leading to multiple symptoms, including bipolar disorder, autism spectrum disorders, ADHD, mental retardation and epilepsy. The chromosomal microarray (CMA) technology detects submicroscopic chromosomal changes, which are involved in neurodevelopmental disorders, and are subject to prenatal diagnosis. Pathological findings in CMA are detected in 10-20% of patients with neurodevelopmental disorders and can contribute significantly to medical follow-up, prognosis assessment, influence treatment choice, and allow prenatal diagnosis. Preliminary studies in schizophrenia identified pathological CMA findings in 10–30% of patients.
CMA testing of schizophrenia patients to detect genetic changes causing the disease.
Recruitment of schizophrenia patients from the Haifa and Western Galilee districts of Clalit, genetic counseling in Carmel Hospital, CMA testing of the consenting patients.
Schizophrenia patients with and without neurodevelopmental disorders underwent CMA analysis, with the findings of significant chromosomal submicroscopic disorders (such as 22q11 microdeletion, among others) in 30% of the patients, providing the explanation for the patients’ symptoms and enabling specific medical follow-up and adjusted pharmacological treatment.
CMA can be used in diagnosing schizophrenia, assessing prognosis, adjusting pharmacological treatment and follow-up and providing genetic counseling including prenatal diagnosis, as in cases neurodevelopmental disorders. The findings support the application of CMA as part of a routine procedures in schizophrenia.