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    <recommendedItem id="20100101_19_468"
                     title="DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses"
                     score="0.013"
                     href="http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/18399?impressionId=1265782021373"
                     
      &lt;p&gt;Substantial changes are in the offing for the &quot;psychiatrist&apos;s bible,&quot; the Diagnostic and Statistical Manual of Mental Disorders, according to a draft of the forthcoming fifth edition.&lt;/p&gt;
&lt;p&gt;The American Psychiatric Association (APA) has posted the draft of DSM-V on a special Web site, &lt;a href=&quot;http://www.psych.org/dsmv.aspx&quot; mce_href=&quot;http://www.psych.org/dsmv.aspx&quot; target=&quot;_blank&quot;&gt;www.dsm5.org&lt;/a&gt;, to obtain comments from its members, other members of the mental health community, and the public.&lt;/p&gt;
&lt;p&gt;At a telephone press briefing before the draft&apos;s release, members of the APA team leading the DSM revision highlighted several substantial innovations they are proposing: &lt;ul&gt; &lt;li&gt;Recategorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term &quot;mental retardation&quot; with &quot;intellectual disability&quot;&lt;/li&gt; &lt;li&gt;Eliminating &quot;substance abuse&quot; and &quot;substance dependence&quot; as disorders, to be replaced with a single &quot;addiction and related disorders&quot; category&lt;/li&gt; &lt;li&gt;Creating a &quot;behavioral addictions&quot; category that will include addictions to gambling but not to the Internet or sex&lt;/li&gt; &lt;li&gt;Offering a new assessment tool for suicide risk&lt;/li&gt; &lt;li&gt;Including a category of &quot;risk syndromes&quot; for psychosis and cognitive impairment, intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do&lt;/li&gt; &lt;li&gt;Adding a new disorder in children, &quot;temper dysregulation with dysphoria,&quot; for persistent negative mood with bursts of rage&lt;/li&gt; &lt;li&gt;Revising criteria for some eating disorders, including creation of a separate &quot;binge eating disorder&quot; distinct from bulimia&lt;/li&gt; &lt;li&gt;Using &quot;dimensional assessments&quot; to account for severity of symptoms, especially those that appear in multiple diagnostic categories&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The APA will accept comments through April 20. The work groups managing the revision will consider them and make further changes as needed to the draft, said David Kupfer, MD, of the University of Pittsburgh, chairman of the DSM-V task force.&lt;/p&gt;
&lt;p&gt;The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, &lt;a href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/17482&quot; mce_href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/17482&quot; target=&quot;_blank&quot;&gt;a year later than originally planned&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;New Categories for Dyslexia, Autism&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia  --  reflecting disabilities of reading and mathematics, respectively  --  into a new category of learning disabilities.&lt;/p&gt;
&lt;p&gt;Autism, Asperger&apos;s syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new &quot;autism and related disorders&quot; category.&lt;/p&gt;
&lt;p&gt;The head of the APA&apos;s work group on substance-related disorders, Charles O&apos;Brien, MD, PhD, of the University of Pennsylvania, told reporters on the press call that substance dependence and abuse had no basis in the research on addictions.&lt;/p&gt;
&lt;p&gt;&quot;We unanimously agreed that . . . there really isn&apos;t evidence for an intermediate stage [short of addiction] that is now known as abuse,&quot; he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.&lt;/p&gt;
&lt;p&gt;He added that the term &quot;dependence&quot; was problematic as a psychiatric diagnosis because some types of physical dependence are &quot;completely normal&quot; for some medications, such as opioid painkillers.&lt;/p&gt;
&lt;p&gt;In fact, under the draft, DSM-V will include &quot;discontinuation syndromes&quot; to allow physicians to properly assess symptoms of withdrawal from psychoactive substances, including caffeine, O&apos;Brien said.&lt;/p&gt;
&lt;p&gt;He also said his work group had considered including sex and Internet addictions as disorders, but decided there was insufficient evidence to allow development of reliable diagnostic criteria for them.&lt;/p&gt;
&lt;p&gt;Consequently, gambling addiction is slated to be the only disorder formally listed in the behavioral addictions category.&lt;/p&gt;
&lt;p&gt;But O&apos;Brien added that, under current plans, sex and Internet addictions would be included in an appendix to DSM-V, intended to encourage additional research that could lead to their inclusion in future editions.&lt;/p&gt;
&lt;p&gt;Carole Lieberman, MD, a Beverly Hills, Calif., psychiatrist who appears frequently on television, regretted the omission of Internet addiction.&lt;/p&gt;
&lt;p&gt;Contacted for comment by &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News, Lieberman said in an e-mail that behavioral addictions are a worthy category. &quot;But why would it not include &apos;Internet addiction,&apos;&quot; she wrote. &quot;Could it be that the psychiatrists involved do not want to acknowledge that their own Internet usage could meet the criteria for addiction?&quot;&lt;/p&gt;
&lt;p&gt;Lieberman added that compulsive shopping was another form of behavioral addiction that deserves recognition.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Dimensional and Risk Assessments&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;APA leaders also emphasized the two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults.&lt;/p&gt;
&lt;p&gt;David Shaffer, MD, of Columbia University, told reporters on the press call that suicide nearly always occurs in the context of some psychiatric disorder, but not always depression.&lt;/p&gt;
&lt;p&gt;The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness.&lt;/p&gt;
&lt;p&gt;In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.&lt;/p&gt;
&lt;p&gt;Shaffer also explained the genesis of the proposed new childhood disorder, temper dysregulation with dysphoria (TDD).&lt;/p&gt;
&lt;p&gt;&quot;About 40% to 60% of the cases [seen by child psychiatrists] will be children who are doing things that other people don&apos;t want them to do,&quot; he said. Many of these are children who are &quot;stubborn and resistant and disobedient and moody.&quot;&lt;/p&gt;
&lt;p&gt;There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness, according to Shaffer.&lt;/p&gt;
&lt;p&gt;Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, although they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults.&lt;/p&gt;
&lt;p&gt;He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.&lt;/p&gt;
&lt;p&gt;Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms, such as anxiety or insomnia, that may appear to larger or smaller degrees in many different mental illnesses.&lt;/p&gt;
&lt;p&gt;Darrel Regier, MD, MPH, the APA&apos;s research director, said such checklists &quot;don&apos;t always fit the reality that someone with a mental disorder experiences.&quot; Often, a symptom like insomnia isn&apos;t on the checklist for a particular disorder, he said, &quot;but they can still affect patients&apos; lives and affect the treatment planning.&quot;&lt;/p&gt;
&lt;p&gt;Incorporating quantitative dimensional assessments should allow clinicians to develop treatment and response-monitoring plans better tailored to individual patients&apos; needs, Regier said.&lt;/p&gt;
&lt;p&gt;But Lieberman foresaw problems with the dimensional assessments. &quot;I don&apos;t think [they] will add anything but confusion,&quot; she said in an e-mail. &quot;As it is now, people don&apos;t really make use of the subcategories that there are to describe severity of symptoms. Instead, I see this as a tool that insurance companies could well co-opt to try to deny benefits.&quot;&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Gender Identity Disorder Stays&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. At this point, the draft retains the designation but with some changes, officials said.&lt;/p&gt;
&lt;p&gt;People who consider themselves &quot;transgendered&quot; have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic  --  that is, they have the wrong genitalia and hormonal balance.&lt;/p&gt;
&lt;p&gt;At the APA&apos;s annual meeting last May, members of the transgender community &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/APA/14270&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/APA/14270&quot; target=&quot;_blank&quot;&gt;made a case&lt;/a&gt; for dropping gender identity disorder from DSM-V, but keeping some kind of &quot;gender variance&quot; diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party payment for gender transition treatments, they said.&lt;/p&gt;
&lt;p&gt;William Narrow, MD, the APA&apos;s research director for DSM-V, told reporters that the draft does remove the term &quot;disorder&quot; from the condition when applied to children, renaming it as &quot;gender incongruence.&quot;&lt;/p&gt;
&lt;p&gt;For adults, gender identity disorder will remain in DSM-V but with substantially altered diagnostic criteria, Narrow said.&lt;/p&gt;
&lt;p&gt;But APA officials said the organization planned more discussions with members of the transgender community.&lt;/p&gt;
&lt;p&gt;Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials.&lt;/p&gt;
&lt;p&gt;Final revisions will be submitted in 2012 for approval by the APA&apos;s two governing bodies, the Assembly and the board of trustees.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_405"
                     title="Difficult Childhood Lingers in the Mind (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/18312?impressionId=1265782021373"
                     
      &lt;p&gt;Adversities faced in childhood have effects on mental health far into the future, researchers affirmed.&lt;/p&gt;
&lt;p&gt;Mental illness in adulthood was increasingly likely the more traumas faced in childhood, Ronald C. Kessler, PhD, of Harvard, and colleagues reported in the February issue of the &lt;em&gt;Archives of General Psychiatry&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Childhood difficulties potentially explained 32.4% of all the psychiatric disorders examined, they said, based on analyses of the National Comorbidity Survey Replication.&lt;/p&gt;
&lt;p&gt;Adversities relating to family dysfunction  --  substance-abusing parents, sexual or physical abuse in the home, neglect, etc.  --  appeared to have the strongest link to onset and persistence of psychiatric disorders, they reported.&lt;/p&gt;
&lt;p&gt;These findings match folk wisdom and decades of research into the negative effects of child maltreatment, commented John McGrath, MD, PhD, of the Queensland Centre for Mental Health Research in Wacol, Australia, and colleagues in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;But the lack of specificity between certain exposures to particular mental health outcomes  --  such as the death of one&apos;s mother leading to depression  --  was notable, the editorialists said.&lt;/p&gt;
&lt;p&gt;&quot;Thus, childhood trauma upsets the orderly psychological and biological cascades of development, leaving the affected individual at increased risk of a wide range of adverse mental health outcomes,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Rather than continue to rehash the epidemiology, it&apos;s time to focus on prevention and intervention, McGrath&apos;s group emphasized.&lt;/p&gt;
&lt;p&gt;&quot;It is unrealistic to think that we could protect all children from all adversities, but can we identify factors that bolster resilience and focus our efforts on the most vulnerable subgroups?&quot; they asked.&lt;/p&gt;
&lt;p&gt;The researchers examined joint associations of 12 retrospectively reported childhood adversities with lifetime incidence of disorders meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria in the National Comorbidity Survey Replication I, a cross-sectional survey of a nationally-representative sample of adults in 9,282 American households.&lt;/p&gt;
&lt;p&gt;Among the respondents, 53.4% reported at least one childhood adversity, most commonly parental divorce (17.5%), family violence (14.0%), family economic problems (10.6%), and parental mental illness (10.3%).&lt;/p&gt;
&lt;p&gt;These adversities were all individually and significantly linked to first onset of psychiatric disorders with odds ratios of 1.5 to 1.9 for dysfunctional family factors (physical abuse, sexual abuse, neglect, parental mental illness, parental substance abuse, parental criminality, or family violence) and 1.0 to 1.5 for other factors like life-threatening childhood physical illness, extreme poverty, parental divorce, or loss of or separation from parents.&lt;/p&gt;
&lt;p&gt;Despite some apparent but not significantly meaningful variation in type of adversity with type of psychiatric disorder, the researchers said they could rule out that all types were the same for future mental health risk (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Problems tended to cluster, though. Among people who faced one adversity in childhood, 51.2% to 95.1% faced others as well, depending on the adversity.&lt;/p&gt;
&lt;p&gt;Risk of mental illness rose with number of issues faced in childhood from an odds ratio of 1.3 for one up to 3.4 for six and 3.2 for seven or more adversities.&lt;/p&gt;
&lt;p&gt;&quot;This subadditive pattern has important implications for intervention because it means that prevention or amelioration of only a single childhood adversity in youths exposed to many childhood adversities is unlikely to have important preventive effects,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;Overall, childhood adversities were projected to account for 44.6% of childhood-onset disorders, 32.0% of adolescent-onset disorders, and 28.6% of adult-onset disorders.&lt;/p&gt;
&lt;p&gt;The researchers also looked at persistence through the second part of the National Comorbidity Survey Replication which went beyond just core diagnostic assessment in 5,692 respondents.&lt;/p&gt;
&lt;p&gt;In a complex multivariate interactive analysis, childhood adversity from dysfunctional family factors appeared significantly linked to persistence in a given year (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) whereas the number of factors was not significant.&lt;/p&gt;
&lt;p&gt;These significant factors were parental mental illness, physical abuse, sexual abuse, and neglect, but they carried modest effects individually with odds ratios of 1.2.&lt;/p&gt;
&lt;p&gt;But in one simulation, not being exposed to childhood trauma would only increase the time since the most recent episode of psychiatric illness by 1.6%, suggesting &quot;quite modest&quot; substantive importance in determining persistence.&lt;/p&gt;
&lt;p&gt;&quot;These results indirectly suggest that the public health implications of childhood adversities are greater for primary than for secondary prevention because the associations of childhood adversities with disorder onset are much stronger than the associations with persistence,&quot; Kessler&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that recall bias may have limited their study such that the results could be considered an &quot;upper bound&quot; for the real association and that the study could not prove causality.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The National Comorbidity Survey Replication is supported by a grant from the National Institute of Mental Health with supplemental support from the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, a grant from the Robert Wood Johnson Foundation, and the John W. Alden Trust.&lt;/p&gt;&lt;p&gt;The analyses were supported by a grant from the NIMH; the John D. and Catherine T. MacArthur Foundation; the Pfizer Foundation; grants from the U.S. Public Health Service; an award from the Fogarty International Center; the Pan American Health Organization; Eli Lilly; Ortho-McNeil Pharmaceutical; GlaxoSmithKline; and Bristol-Myers Squibb.&lt;/p&gt;&lt;p&gt;Kessler reported financial conflicts of interest with GlaxoSmithKline, Kaiser Permanente, Pfizer, sanofi-aventis, Shire Pharmaceuticals, Wyeth-Ayerst, Eli Lilly, Bristol-Myers Squibb, Johnson &amp;amp; Johnson Pharmaceuticals, and Ortho-McNeil Pharmaceutical.&lt;/p&gt;&lt;p&gt;The editorialists reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_263"
                     title="Handedness Linked to ADHD (CME/CE)"
                     score="0.001"
                     href="http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/18113?impressionId=1265782021373"
                     
      &lt;p&gt;Ambidextrous 5-year-olds are more likely to develop attention deficit-hyperactivity disorder symptoms later on as compared with right- and left-handed children, according to a study by a team of Swedish researchers.&lt;/p&gt;
&lt;p&gt;The findings are an indication that brain morphology and neural circuitry associated with handedness also affects cognitive and behavioral function, according to Alina Rodriguez, PhD, of Uppsala University in Sweden, and colleagues in an online report in &lt;em&gt;Pediatrics&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The conclusions emerged from a longitudinal study of 7,871 children in northern Finland born in 1986, of whom 87 were mixed-handed, 632 showed a left-hand preference, and the remainder were right-handed at age 5.&lt;/p&gt;
&lt;p&gt;Rodriguez and colleagues found that when these children were tested at age 8, teachers were about twice as likely to report hyperactivity (odds ratio 2.06, 95% CI 1.09 to 3.91) or a combination of inattention and hyperactivity (OR 2.16, 95% CI 1.21 to 3.86) in the mixed-handed children compared with the right-handed ones.&lt;/p&gt;
&lt;p&gt;Similar increases in rates of teacher assessments of probable psychiatric disturbance and in overall school performance, as well as in parental reports of language problems, were seen in the ambidextrous children.&lt;/p&gt;
&lt;p&gt;Moreover, these learning and behavioral problems persisted into adolescence.&lt;/p&gt;
&lt;p&gt;Cohort members were evaluated at age 16 by parents on ADHD symptoms and provided self-reports of language and math performance in school.&lt;/p&gt;
&lt;p&gt;Those classed as mixed-handed were more than three times as likely to suffer inattention (OR 3.53, 95% CI 1.65 to 7.53) or a combination of inattention and hyperactivity-impulsivity (OR 3.16, 95% CI 1.42 to 7.08) relative to right-handed 16-year-olds, according to their parents.&lt;/p&gt;
&lt;p&gt;Self-reported problems in Finnish language and math classes were also significantly more common in the mixed-handed youths (OR 1.85, 95% CI 1.00 to 3.43 for language; OR 2.55, 95% CI 1.48 to 4.37 for math).&lt;/p&gt;
&lt;p&gt;These effects were not seen in left-handed children, Rodriguez and colleagues reported.&lt;/p&gt;
&lt;p&gt;&quot;Mixed-handedness can be used as a marker of risk for difficulties and warrants additional evaluation,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Adjusting for gender and birth weight and gestational age reduced the strength of the association between mixed-handedness and behavioral and learning problems. The point estimates of odds ratios for inattention and/or hyperactivity declined 1.4 to 1.6 and statistical significance was lost.&lt;/p&gt;
&lt;p&gt;But that actually supports the hypothesis that brain abnormalities stemming from before birth underlie what they called &quot;atypical lateralization&quot; and subsequent learning and behavior problems, Rodriguez and colleagues indicated.&lt;/p&gt;
&lt;p&gt;&quot;Recent neuropsychological work related to patterns of brain organization and function corroborates our findings,&quot; they added.&lt;/p&gt;
&lt;p&gt;They cited research indicating that ADHD is associated with left-side motor deficits, apart from hand preference, as well as reduced attention to visual stimuli on the left versus right side. These observations suggest weaker right hemisphere function, Rodriguez and colleagues argued.&lt;/p&gt;
&lt;p&gt;Other studies have suggested that neural transmission can be asymmetric between hemispheres, they said.&lt;/p&gt;
&lt;p&gt;&quot;These studies together highlight the possible interconnection among mixed-handedness, neurotransmitter dysfunction in the right hemisphere, and ADHD symptoms,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;The authors pointed out that the &quot;impreciseness of handedness as a proxy for atypical lateralization is a limitation.&quot; Yet, the cost of direct assessment of the brain by imaging or electrical activity is &quot;prohibitive&quot; so handedness was a &quot;feasible alternative for large epidemiologic studies.&quot;&lt;/p&gt;
&lt;p&gt;And they said that even though the number of prevalence of mixed-handedness was low, &quot;it seems unlikely that those with right- or left-handedness were misclassified as mixed.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Academy of Finland, Sigrid Juselius Foundation, Thule Institute, University of Oulu, Finland, and the National Institute of Mental Health. Rodriguez also was supported by VINNMER.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_3_191"
                     title="First-Time Mothers at Risk for Postpartum Mental Disorders"
                     score="-0.007"
                     href="