Comorbidity

New Insights Into Diagnosis, Comorbidities, and Treatment Approaches

Allen Frances, MD, identifies a number of concerns about the draft DSM5 revisions.1 Not mentioned in his commentary, but of significant concern, is a proposal that might subsume tic disorders under a new category called “Anxiety and Obsessive-Compulsive Disorders.”

It is generally held that the offspring of parents with bipolar disorder (BD) are at risk for BD. The degree of risk is an important question for both clinicians and parents. A recent study of bipolar offspring by Birmaher and colleagues1 sheds light on this issue.

The young adult years (18 to 29) are a critical time of transition, and they present unique challenges in regard to mental health issues and development. Until recently, most research has focused either on children and adolescents or adults. Grant and Potenza’s Young Adult Mental Health is a comprehensive text for clinicians and researchers who work with persons in the transitional period of young adulthood.

Obesity has emerged as a significant threat to public health throughout the developed world. The World Health Organization defines overweight as a body mass index of 25.0 to 29.9 kg/m2 and obesity as a BMI of 30.0 kg/m2 or greater.1 Nearly two-thirds of Americans are overweight or obese according to these criteria.2 Numerous health problems, including diabetes, cardiovascular disease, arthritis, and cancer, are associated with obesity. In addition, overweight and obese persons are more likely than their normal-weight peers to have a variety of psychiatric disorders.

Pediatric bipolar disorder (PBD) is a serious psychiatric illness that impairs children’s emotional, cognitive, and social development. PBD causes severe mood instability that manifests in chronic irritability, episodes of rage, tearfulness, distractibility, grandiosity or inflated self-esteem, hypersexual behavior, a decreased need for sleep, and behavioral activation coupled with poor judgment. While research in this area has accelerated during the past 15 years, there are still significant gaps in knowledge concerning the prevalence, etiology, phenomenology, assessment, and treatment for PBD.

Smoking cessation services should be integrated into substance use disorder treatment programs, according to David Kalman, MD, Department of Psychiatry, University of Massachusetts, and colleagues, in their recent review of tobacco dependency among patients who sought treatment for alcoholism.1

Patients who exaggerate, feign, or induce physical illness are a great challenge to their physicians. Trained to trust their patients’ self-reports, even competent and conscientious physicians can fall victim to these deceptions.

While violence is often portrayed in the media as related to persons with mental illnesses, there are limited research data to support this idea. This article reviews laws and obligations for mental health professionals.

The editors of Psychiatric Times interview Vladimir Maletic, MD, PA, clinical professor of neuropsychiatry and behavioral science at the University of South Carolina School of Medicine, Columbia; founding member of the Integrative Neurobiology Educational Alliance; and member of the U.S. Psychiatric and Mental Health Congress 2009 advisory board.

The prevalence of depression in children and adolescents ranges from 2% to 8% in the general population, which indicates that depression in this population is a major public health concern.1-3 This is especially apparent when rates of depression are compared with other serious medical conditions in childhood, such as diabetes, which has a prevalence of 0.18%.4 The burden of depressive illness-including significant functional impairment in interpersonal relationships, school, and work-on the developing child has been well documented. Affected youths are frequently involved in the juvenile justice system.5-8 Furthermore, adolescents with depression are at increased risk for substance abuse, recurrent depression in adulthood, and attempted or completed suicide.3,9-15

In 2007, cancer was diagnosed in 10,400 children and adolescents under the age of 15 years.1 While cancer remains the second leading cause of death in children, increasing numbers of children with cancer are surviving into adulthood.2 Over the past 30 years, 5-year survival rates for children with cancer have significantly improved, from 59% in 1975 to 1977 to 80% in 1996 to 2004.3 Pediatric cancer, increasingly considered a chronic rather than an acute condition, is an intense emotional and physical experience for patients and their families.4

Anxiety disorders are one of the most common psychiatric disorders in children and adolescents, but they often go undetected or untreated. Identification and effective treatment of childhood anxiety disorders can decrease the negative impact of these disorders on academic and social functioning in youth and their persistence into adulthood.

Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.1 The soldier’s heartache of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).2 The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.3

Restless legs syndrome (RLS) is a neurosensory disorder first described by Sir Thomas Willis in 1672. As early as the 19th century, Theodor Wittmaack observed the comorbidity of RLS with depression and anxiety. He termed this condition “anxietas tibiarum” and believed it to be a form of hysteria.

In our last installment, we discussed a familiar finding from the National Comorbidity Survey Replication (NCS-R): the peak age of onset for any mental health disorder is about 14 years. In an attempt to explain these data, we are exploring some of the known developmental changes in the teenaged brain at the level of gene, cell, and behavior.

Physicians generally display better health and have lower rates of all-cause mortality than the general population. However, their education, nutrition, and lifestyle do not offer similar protection from substance abuse and dependence.

The editorial board and staff of Psychiatric Times wish to announce, with much regret, the retirement of Max Fink, MD, from our journal’s editorial board. Dr Fink-who is emeritus professor of psychiatry and neurology at the State University of New York at Stony Brook-has been a valued member of our board since 2002, and a regular contributor to the journal for many years before that.

Surveys show that approximately 60% of the general population has gambled within the past 12 months.1 The majority of people who gamble do so socially and do not incur lasting adverse consequences or harm. Beyond this, approximately 1% to 2% of the population currently meets criteria for pathological gambling.2 This prevalence is similar to that of schizophrenia and bipolar disorder, yet pathological gambling often goes unrecognized by most health care providers.

What the New Mind-Body Science Tells Us About the Pathophysiology of Major Depression-Focus on Treatment

Historically, borderline patients were considered “help-rejecting complainers.” Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms.

The articles in this Special Report reflect the growing recognition of the importance of the problem of treatment-resistant psychiatric disorders.

This statistic is as familiar as it is startling. According to the National Comorbidity Survey-Replication (NCS-R), the peak age of onset for any disease involving mental health is 14 years. True for bipolar disorder. True for anxiety. True for schizophrenia and substance abuse and eating disorders. The data suggest that most mental health challenges emerge during adolescence. If true, this brings to mind an important developmental question:

Rages are part of a syndrome of severe mood dysregulation, which is defined by markedly increased and frequent reactivity to negative emotional stimuli.

Currently the Veterans Administration (VA) is the world’s largest recipient of per patient funding for PTSD. The VA treats 200,000 veterans with this diagnosis annually at a cost of $4 billion. But research calls into question the very existence of the “PTSD” syndrome, and its diagnostic formulation remains invalid. We do not minimize the suffering of those who experience trauma or the need for comfort and restitution. We seek only to reexamine research evidence, to clarify the impact of culture on diagnosis, to reevaluate the consequences of trauma, and to ensure optimal allocation of resources.