Archives 1992-2013

2012, volume 21, issue 3

World Psychiatry Forum

Prototype diagnosis of psychiatric syndromes

Drew Westin
Postępy Psychiatrii i Neurologii 2012; 21(3): 155–174

The method of diagnosing patients used since the early 1980s in psychiatry, which involves evaluating each of several hundred symptoms for their presence or absence and then applying idiosyncratic rules for combining them for each of several hundred disorders, has led to great advances in research over the last 30 years. However, its problems have become increasingly apparent, particularly for clinical practice. An alternative approach, designed to maximize clinical utility, is prototype matching. Instead of counting symptoms of a disorder and determining whether they cross an arbitrary cutoff, the task of the diagnostician is to gauge the extent to which a patient’s clinical presentation matches a paragraph-length description of the disorder using a simple 5-point scale, from 1 (“little or no match”) to 5 (“very good match”). The result is both a dimensional diagnosis that captures the extent to which the patient “has” the disorder and a categorical diagnosis, with ratings of 4 and 5 corresponding to presence of the disorder and a rating of 3 indicating “subthreshold” or “clinically significant features”. The disorders and criteria woven into the prototypes can be identified empirically, so that the prototypes are both scientifically grounded and clinically useful. Prototype diagnosis has a number of advantages: it better captures the way humans naturally classify novel and complex stimuli; is clinically helpful, reliable, and easy to use in everyday practice; facilitates both dimensional and categorical diagnosis and dramatically reduces the number of categories required for classification; allows for clinically richer, empirically derived, and culturally relevant classification; reduces the gap between research criteria and clinical knowledge, by allowing clinicians in training to learn a small set of standardized prototypes and to develop richer mental representations of the disorders over time through clinical experience; and can help resolve the thorny issue of the relation between psychiatric diagnosis and functional impairment.

Original article

Caregiver burden in mental illness

Magdalena Ciałkowska-Kuźmińska, Andrzej Kiejna
Postępy Psychiatrii i Neurologii 2012; 21(3): 175–181

Objectives. To analyze: (1) the caregiver burden in carers of currently hospitalized patients with mental illness, and (2) health-related consequences of their caregiver burden.
Method. Participants in the study, 60 key carers indicated by inpatients of mental hospitals in Wroclaw (the capital of Lower Silesia, Poland), completed two tools: the Involvement Evaluation Questionnaire (IEQ) to assess their caregiver burden, and the 12-item General Health Questionnaire (GHQ-12) to assess their health deterioration.
Results. As many as 57% of the caregivers experienced the burden of caregiving in the domain of worrying, while somewhat less, i.e. 38% of caregivers in the aspect of urging. A genuine deterioration in health status as measured by the GHQ-12 was found in 67% of the caregivers. Caregiver burden experienced in the area of interpersonal tension explains as much as 44% of the total variance in the data set (sten scores in the sample studied).
Conclusions. Key carers of psychiatric inpatients do experience the burden of caregiving. Their general health is a significant indicator of the caregiver burden they experience in all aspects. Therefore, in the process of therapy provided to psychiatric inpatients interventions aimed at caregivers should be also included, such as their experienced burden and general health assessment, as well as psychoeducation concerning individual stressors and coping.

Original article

Anxiety levels in women in the perioperative period

Magdalena Lewicka, Marta Makara-Studzińska, Magdalena Sulima, Grzegorz Bakalczuk, Katarzyna Kanadys, Henryk Wiktor
Postępy Psychiatrii i Neurologii 2012; 21(3): 183–189

Objectives. The assessment of anxiety level in women receiving surgery in the gynecology department is an important component of the medical and nursing diagnoses. It may allow us to better understand the patients' needs in the perioperative period. The aim of the study was to measure the severity of perioperative anxiety in women treated in the gynecology department.
Methods. Participants in the study were 232 women receiving surgery to treat various gynecologic conditions. The sample inclusion criterion was absence of any mental disorders diagnosed earlier. The Spielberger State-Trait Anxiety Inventory (STAI) was used.
Results. The state anxiety level was significantly lower (p < 0.05) both before and after surgery in the age group under 40 years than in the groups aged 41‒50 and over 50 years. The state anxiety level in the perioperative period was significantly higher (p < 0.05) in women with either primary or vocational education than among women with secondary or university education.
Conclusions. An early assessment of anxiety level in female patients treated surgically for gynecologic conditions allows to identify those who require psychoeducational interventions. Implementation of such procedures may help to optimize the nursing care process and to increase patient satisfaction with the treatment received, leading to a higher rating of the facility providing medical services in the perioperative period.

Original article

Clinical predictors of response to cholinesterase inhibitors: results of an observational program concerning the use of cholinesterase inhibitors in the treatment of dementias

Tomasz Sobów
Postępy Psychiatrii i Neurologii 2012; 21(3): 191–198

Objectives. To evaluate the effectiveness of cholinesterase inhibitors (ChEI) in the treatment of dementias in routine clinical practice and to identify clinical predictors of treatment outcome in terms of cognition and neuropsychiatric symptoms.
Method. The total of 3080 patients treated by 220 medical specialists in routine clinical practice participated in the open, observational, non-interventional clinical trial. The data recorded on uniform observation sheets were prospectively collected during 6 months. Treatment outcomes of 900 randomly selected patients were analyzed.
Results. A clinically meaningful response (defined as an increase in the MMSE scores by at least 3 points or a change in dementia severity as measured by the FAST scores) was observed in 12% of patients, while in 73‒82% of the sample (depending on the measure used) no change was found in the clinical status. The prevalence of a majority of behavioral symptoms was reduced during the trial, so was the use of some psychotropic drugs. The best treatment outcomes (measured by the ratios of arbitrarily defined improvement or deterioration) were noticed in the vascular dementia group, while the poorest response was attained in patients diagnosed with dementia with parkinsonism. Multiple logistic regression analysis showed that positive predictors of clinical response to treatment included, besides dementia type, also lower baseline MMSE scores (i.e. higher dementia severity), longer duration of cognitive impairments, and the presence of depression/tearfulness and anxiety, while the presence of apathy at baseline was a significant predictor of poor prognosis. Neither the type of ChEI administered (rivastigmine or donepezil) nor the patient's age had a significant effect on the treatment outcome and drug tolerance.
Conclusions. Cholinesterase inhibitors are moderately effective in the treatment of dementias, in terms of both cognitive dysfunction and behavioral symptoms. Comorbid vascular pathology not only should not be considered a contraindication to ChEI therapy, but even proved to be a predictor of positive clinical response. No clinically relevant variation in the treatment response depending on the type of ChEI used (rivastigmine or donepezil) was noted in the study.

Review article

The significance of residual symptoms in the course of treatment for depression

Marcin Bugaj, Andrzej Jakubczyk, Marcin Wojnar
Postępy Psychiatrii i Neurologii 2012; 21(3): 199–206

Objectives. To discuss the definition of residual symptoms and their significance in the course and treatment of depression.
Review. Remission is a target state to be achieved and maintained as a result of therapeutic procedures provided to patients diagnosed with depression or other mental disorders. However, despite continuous advancements in diagnostics and therapeutics, this target is not always achieved and long-term treatment outcomes are still unsatisfactory. Residual symptoms accompanying complete or partial remission are important factors affecting the course of illness. The most common manifestations include typical depression symptoms of mild severity, such as depressed mood, sleep problems, tiredness, or somatic symptoms (pain mostly) that are often perceived as unrelated to depression. Many studies have shown earlier relapse of the disease in patients with residual symptoms.
Conclusion. Residual symptoms should be taken into account in the diagnosis, and properly implemented treatment should be aimed at their minimization. This should be a standard practice in the management of such a common and life-impairing condition as depressive disorder.

Review article

Tools for evaluation of mental health services

Magdalena Ciałkowska-Kuźmińska, Andrzej Kiejna
Postępy Psychiatrii i Neurologii 2012; 21(3): 207–215

Background. In this paper The International Classification of Mental Health Care (ICMHC), The European Services Mapping Schedule (ESMS), World Health Organization – Assessment Instrument for Mental Health Systems (WHO-AIMS) and The Quality Indicator for Rehabilitative Care (QuIRC) were presented as tools useful in the analysis of mental health services in Poland.
Review. Information about the mental health system is essential for mental health care planning at the local and national levels. Unfortunately, no systematic analyses concerning the structure and provision of mental health services are conducted in Poland. Therefore, it is difficult to evaluate the process of mental health care provision. The likely cause of this situation – besides systemic and political issues – is the limited knowledge about evaluation tools, while appropriate use of such tools allows to analyze not only the direction of changes introduced in the field of mental health care, but also adequacy and/or quality of mental health services.
Conclusions. Application of the presented tools might help to monitor progress in the implementation of mental health policy reforms in Poland, the more so that continuous evaluation of mental health services would prevent deterioration of their quality.

Review article

Comparative studies of persons with various mental disorders and their healthy siblings

Marta Makara-Studzińska, Rafał Łoś
Postępy Psychiatrii i Neurologii 2012; 21(3): 213–218

Objectives. Using the available databases such as PubMed, Embase and the Polish Medical Bibliography, a thorough review was made of recently published English- and Polish-language studies and reports presenting comparisons between individuals with schizophrenia, mood disorders or neurotic disorders and their healthy siblings. The following key words were used in the bibliographic database search: mental disorders, healthy siblings, schizophrenia, depression and anxiety disorders.
Review. Recent research findings provide more and more evidence of both structural and functional abnormalities in healthy siblings of persons suffering from mental disorders. Identification and description of these abnormalities may contribute to our better understanding of the mechanisms underpinning the effect of genetic and environmental factors on the onset of mental disorders.
Conclusions. The literature on schizophrenia research, especially that concerning neurocognitive dysfunctions, is definitely the most abundant [1‒9]. The majority of publications pertaining to persons with mental illness and their healthy siblings are focused on pathogenesis of mental disorders and the role of familial and environmental factors in their origin. The issue of the role of siblings in the lives of people with mental disorders is less oft en dealt with.