Child,Adolescent and Adult Psychiatric Disorders in Africa: Implications for Psychological Interventions

The authors start by critically discussing some core features of Western psychiatric diagnosis, and present the cultural formulation as one approach to ensure that the cultural aspects of the diagnostic process are addressed, followed by a summary of what is known about the causes of psychiatric disorder. Five arguments are presented that provide support for the importance of psychiatric disorders in Africa: prevalence rates are high; psychiatric disorder is associated with a considerable burden from disability; in most cases, adults with psychiatric disorders experienced the onset of their disorder in childhood or youth; psychiatric disorders are strongly associated with medical conditions; and effective interventions exist for the majority of people suffering from psychiatric disorders. Against this background, current mental health services in Africa are reviewed. Finally, some suggestions are provided for how those providing psychological interventions can contribute to addressing the challenges posed by psychiatric disorders in Africa.     

Child psychopathology risk factors for drug abuse: overview.

Introduces the special section on Child Psychopathology Risk Factors for Substance Use Disorders. This article summarizes important principles, the current literature, contributions to this section, and issues for future research. Psychopathological conditions are strongly associated with substance use disorders, and some childhood psychopathological conditions may constitute precursors to this comorbidity. Conduct disorder constitutes a strong risk factor for substance use disorders, and bipolar disorder, although more rare, may also constitute a significant risk. Data for other child psychiatric conditions are mixed or lacking; however, important subgroups may be at risk and merit further attention. Underlying characteristics, such as temperament and self-regulation, merit further study as possible explanatory variables. Such studies hold the key for targeting and improving preventive and therapeutic interventions.     

Primary prevention of secondary disorders: A proposal and agenda

This paper calls for consideration of a new class of preventive interventions designed explicitly to prevent comorbidity of psychiatric disorders. Epidemiologic data show that successful interventions of this type could be extremely valuable, as up to half of lifetime psychiatric disorders and an even larger percent of chronic and seriously impairing disorders occur to people with a prior history of some other disorder. Furthermore, a review of etiologic hypotheses concerning the causes of comorbidity suggests that interventions aimed at primary prevention of secondary disorders might be feasible. However, more basic risk factor research is needed on the causes of comorbidity before we can make a clear assessment of feasibility and discover promising intervention targets. A number of methodological problems arise in carrying out this type of formative research. These problems are reviewed and suggestions are offered for solutions involving innovations in measurement, design, and data analysis.     

Attachment dimensions as predictors of medical hospitalizations in individuals with DSM IV cluster B personality disorders

This study investigates predictors of health service utilization in individuals with cluster B personality disorders. We hypothesized an association of severity of psychopathology (that is, global psychosocial functioning and psychiatric comorbidity) and attachment style with the length of medical hospitalizations in this population. Forty-one female subjects were interviewed regarding their diagnoses, level of functioning and service utilization. Attachment style was assessed with a self-report questionnaire. Our findings indicate that degree of psychiatric comorbidity and level of psychosocial functioning do not predict length of hospital stays, whereas preoccupied attachment predicted 23.9% of the variance in the length of hospitalizations. We conclude that the quality of interpersonal relatedness appears to be a better predictor of health service use than severity of pathology in patients with cluster B personality disorders.     

Examining the impact of psychiatric diagnosis and comorbidity on the medical lethality of adolescent suicide attempts

Specific psychiatric diagnoses and comorbidity patterns were examined to determine if they were related to the medical lethality of suicide attempts among adolescents presenting to an urban general hospital (N=375). Bivariate analysis showed that attempters with substance abuse disorders had higher levels of lethality than attempters without substance abuse. Regression results indicated having depression comorbid with any other diagnosis was not associated with medical lethality. However, having a substance abuse disorder was associated with higher suicide attempt lethality, highlighting the importance of substance abuse as a risk factor for lethal suicide attempts in adolescents. This finding stimulates critical thinking around the understanding of suicidal behavior in youth and the development and implementation of treatment strategies for suicidal adolescents with substance abuse disorders.     

A Systematic Review of Psychiatric and Psychosocial Comorbidities of Genetic Generalised Epilepsies (GGE)

Psychiatric disorders and associated poor psychosocial outcomes are recognised to be a common sequelae of epilepsy. The extent to which this is true of genetic generalised epilepsies (GGE), particularly syndromes other than juvenile myoclonic epilepsy (JME) is unclear. This systematic review synthesises findings regarding psychiatric and associated comorbidities in adults and children with GGE. Systematic review yielded 34 peer-reviewed studies of psychiatric and psychosocial outcomes in adults and children with GGE. Clinically significant psychiatric comorbidity was reported in over half of all children and up to a third of all adults with GGE. There was no evidence to support the presence of personality traits specific to JME or other syndromes; rather rates mirrored community samples. A small number of studies report poor psychosocial outcomes in GGE, however the interpretation of these findings is limited by paucity of healthy comparison groups. Some evidence suggests that anti-epileptic drug polytherapy in children and seizure burden at all ages may constitute risk factors for psychopathology. Findings highlight the importance of early screening so as not to overlook early or developing symptoms of psychopathology.     

Intimate Relationships and Psychopathology

Relationship functioning and individual mental health and well-being are strongly associated with one another. In this article, we first review the cross-sectional and longitudinal associations between relationship discord and various types of psychopathology, We then review findings suggesting that relationship discord is associated with poorer outcome for individual-based treatments for psychopathology and that, generally, relationship discord does not improve following individual-based treatments for psychopathology. Finally, we present a model for conceptualizing work with couples in which one partner has a psychiatric disorder and review the efficacy of couple-based interventions in the treatment for psychiatric disorders, with a focus on substance-related, mood, and anxiety disorders.     

Comorbidity of drug abuse treatment

Research has suggested that comorbidity, the concurrence of substance abuse disorders with other psychiatric disorders, may have prognostic value and important implications for the treatment of substance abuse. Knowledge of the prevalence of comorbid disorder is important because it will enable treatment services to be appropriately configured and designed for clinical drug treatment populations. The form and duration of comorbidity may be influenced by a variety of factors, which include the class of drug being abused, the duration of drug use, the individual sensitivity to drug effects, and whether the drug effects are acute or due to withdrawal or residual conditions. This paper addresses three important scientific questions: (1) What is the prevalence of comorbid disorders in a drug abuser population? (2) What is the stability of psychiatric diagnoses in a drug abuser population? (3) Does the existence of a comorbid disorder influence the outcome of drug abuse treatment?     

The Comorbidity of Conduct Problems and Depression in Childhood and Adolescence

An extensive body of research documents the high prevalence of comorbidity among child and adolescent disorders in general and between conduct problems and depression in particular. These problems co-occur at significantly higher rates than would be expected by chance and their comorbidity may have significant implications for nosology, treatment, and prognosis. Four main hypotheses have been put forth to account for these high rates of comorbidity. First, comorbidity may be a result of shortcomings associated with referral or informant biases. Second, comorbidity may be an artifact of overlapping definitional criteria. Third, one disorder may cause the other disorder by influencing the developmental trajectory and placing an individual at increased risk for further difficulties. Finally, comorbidity between two disorders may be explained by shared underlying causal or risk factors. The purpose of this review is to explore these possibilities, concentrating primarily on the common risk factors of parent psychopathology, emotion regulation, and cognitive biases that may underlie the co-occurrence of these two disorders. Based on our review, we propose a model for the development of comorbidity between these two disorders.     

An examination of the construct validity of posttraumatic stress disorder with veterans using a revised criterion set

Ongoing concerns exist in the literature regarding the construct of posttraumatic stress disorder (PTSD) and how to best conceptualize and measure this disorder. We compared the traditional DSM-IV PTSD symptom criteria (i.e., symptoms from clusters B, C, and D) to a revised criterion set that omits overlapping mood and other anxiety symptoms on PTSD prevalence, PTSD diagnostic caseness, associated psychiatric comorbidity, functional status, and structural validity using a cross-sectional, multi-site primary care sample of 747 veterans. After removing items theorized to overlap with mood and other anxiety disorders, PTSD prevalence was identical using both criterion sets (i.e., 12%). Overall, there were few statistically significant differences in PTSD caseness, associated psychiatric comorbidity, functional status, and structural validity across the two diagnostic criterion sets. These data provide further support that removing items that overlap with other psychiatric disorders does not significantly impact the prevalence of PTSD, its associated comorbidity and functional impairment, or its structural validity. Although the revised criterion set represents a more parsimonious model, the current study findings generally support the strong construct validity of PTSD. The implications of these study findings for research and clinical practice are discussed.     

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.This study was supported by grant MN-46584 from the National Institute of Mental Health.     

The association of perimenopausal mood disorders with other reproductive-related disorders

Data regarding the increased incidence of psychiatric illness during midlife in women are still conflicting. However, there is a growing consensus that certain groups of women may in fact be at higher risk for mood symptoms and psychiatric disorders during the perimenopausal transition. Mood symptoms during the perimenopause may be related to mood disorders during other periods of hormonal fluctuation throughout a woman's reproductive lifecycle. Elucidating these associations may advance the understanding of mood disorders during the perimenopausal transition. The epidemiology and treatment of perimenopausal mood symptoms compared with the epidemiology and treatment of mood disorders during the late luteal phase of the menstrual cycle, pregnancy, and postpartum. Common risk factors associated with mood disorders during these periods of hormonal changes or instability include poor lifestyle habits, a history of hormonally related mood disorders, stress and negative life events, ethnicity, and comorbidity. Reproductive-related mood disorders also are subject to an improvement in symptoms in response to treatment with selective serotonin reuptake inhibitors. As the morbidity associated with mood disorders during midlife may be quite significant, and as life expectancy continues to increase, recognition, prevention, and treatment of perimenopausal affective illness is becoming increasingly essential.     

Pattern of comorbidity among anxious and odd personality disorders: the case of obsessive-compulsive personality disorder

The aim of this study was to examine the pattern of comorbidity among obsessive-compulsive personality disorder (OCPD) and other personality disorders (PDs) in a sample of 400 psychiatric inpatients. PDs were assessed using the Semistructured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Odds ratios (ORs) were calculated to determine significant comorbidity among OCPD and other axis II disorders. The most elevated odds ratios were found for the cooccurrence of OCPD with cluster A PDs (the "odd" PDs, or paranoid and schizoid PDs). These results are consistent with those of previous studies showing a higher cooccurrence of OCPD with cluster A than with cluster C ("anxious") PDs. In light of these observations, issues associated with the nosologic status of OCPD within the Diagnostic and Statistical Manual of Mental Disorders clustering system remain unsettled.     

Psychiatric Comorbidity in Children with Autism Spectrum Disorders: A Comparison with Children with ADHD

The present study was conducted with the aim to identify comorbid psychiatric disorders in children with autism spectrum disorders (ASD) (n = 40) and to compare those comorbidity rates to those in children with attention deficit hyperactivity disorder (ADHD) (n = 40). Participants were clinically referred children aged 7–18 years. DSM-IV classifications were used for the primary diagnosis (ASD/ADHD), while comorbid psychiatric disorders were assessed using a structured diagnostic interview, the structured clinical interview for DSM-IV, childhood diagnoses (KID-SCID). Twenty-three children with ASD (57.5 %) had at least one comorbid disorder, whereas 16 children with ADHD (40.0 %) were classified as having at least one comorbid disorder. No group differences were found with respect to this comorbidity rate or for the rate of comorbid externalizing disorders (ODD and/or CD). However, children with ASD had more comorbid internalizing disorders compared to children with ADHD. More specifically, children with ASD had higher rates of anxiety disorders, but not mood disorders. No associations between comorbidity and age or between comorbidity and the intelligence quotient was found. It is important for clinicians to always be aware of, and screen for, comorbidity, and to consider treatment for these comorbid disorders. In addition, research should focus on establishing valid and reliable screening tools as well as effective treatment options for these comorbid disorders.     

Suicidal behavior among urban,African American young adults

The objectives of the present study were four-fold. First, to determine the lifetime, last year, and 6-month prevalence and demographic correlates of suicidal behavior in a defined population of urban, African American young adults. Second, to determine the degree of mental health service utilization among attempters. Third, to study the comorbidity between mental disorders and suicidal behavior, along with the variation in the numbers and types of psychiatric disorders associated with attempts versus ideation only. Fourth, to examine gender differences in the psychiatric diagnoses associated with attempts and ideation. Data relevant to each of these objectives were gathered through structured interviews of 1,157 economically disadvantaged, African American young adults. Lifetime, last year, and 6-month prevalence rates for attempts were 5.3%, 1.2%, and 0.4%, respectively, whereas the lifetime and 6-month prevalence of ideation were 14% and 1.9%, respectively. Approximately two thirds of those who reported lifetime ideation, and a similar proportion of those who reported lifetime attempts, had a history of at least one lifetime psychiatric disorder. There were no gender differences in terms of the degree of risk for suicidal behavior (ideation or attempts) associated with any of the comorbid psychiatric diagnoses assessed. Despite the severity of most attempts, few attempters received mental health services in their lifetime or at the time of their most recent attempt.     

Mixed anxiety and depression

We review evidence from community, primary care, and psychiatric samples to determine whether there are a group of patients who have mixed symptoms of anxiety and depression that are below diagnostic thresholds for either group of disorders. A review of the data strongly suggests that such a group of patients exists and that, despite lacking sufficient symptoms to meet diagnostic thresholds from the revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987), they often have significant impairment in social and vocational functioning. Because many of these patients also suffer from medically unexplained somatic symptoms, they may be more likely to frequently use nonpsychiatric medical care. Longitudinal studies suggest that persons with mixed anxiety-depression symptoms may represent a population who are at increased risk for more severe mood and anxiety disorders.     

The Prevalence of Anxiety Disorders Among Adults with Asthma: A Meta-Analytic Review

Research estimating the comorbidity of asthma and anxiety disorders has produced highly disparate findings and little consensus. This study is a meta-analytic review of data from 15 independent studies of the co-occurrence of adult asthma and anxiety disorders and was conducted to provide more precise comorbidity estimates. Aggregating across studies, the average prevalence of any anxiety disorder among adults with asthma was 34%, indicating a strong relationship between the two conditions in general. More specifically, the prevalence of panic attacks (25%), panic disorder (12%), agoraphobia (12%), and generalized anxiety disorder (9%) were considerably higher among adults with asthma than in the general population. However, additional analyses yielded prevalence estimates for specific phobia (10%), social phobia (7%) and posttraumatic stress disorder (6%) comparable to or lower than rates observed in the population at large. Attention to psychiatric symptoms should be a crucial component of asthma management, as anxiety disorders appear to be highly prevalent among persons with asthma and may be associated with increased asthma morbidity.

The use of antidepressants in functional gastrointestinal disorders: new uses for old drugs

Since their introduction 50 years ago, antidepressants have been used in a wide variety of settings involving gastrointestinal (GI) disease. In the 1950s, antidepressants were shown to have some efficacy for the treatment of peptic ulcer disease. This is most likely due to their antihistaminic and anticholinergic effects. Since then, more efficacious and more disease-specific treatments have become available. In the last 20 years, antidepressants have been increasingly used for the treatment of functional gastrointestinal disorders such as irritable bowel syndrome, noncardiac chest pain, and other functional GI disorders. This article will review the rationale for the use of antidepressant drugs for the treatment of functional GI disorders. The role of psychiatric comorbidity in functional GI disorders, the impact of antidepressants on GI motility and visceral sensation, and the ability of these agents to produce improvements in the global well-being and overall quality of life will be reviewed. Finally, guidelines for prescribing and barriers to a patient's acceptance of these agents will be discussed.     

Associations Among Anxiety Disorders and Non-anxiety Disorders,Functional Impairment and Medication in Children and Adolescents

This is a study of comorbid anxiety disorders and how they affect the clinical picture of comorbid cases. The sample consisted of 576 Spanish children aged 8 to 17 years receiving psychiatric outpatient consultation that were evaluated using a semi-structured diagnostic interview for both parents and children. A specific association of homotypic comorbidity among anxiety disorders that was independent of the presence of other disorders was found. There was heterotypic comorbidity between anxiety and depressive disorders, ADHD, anorexia and tic disorders. Relationships between non-anxiety disorders were, in general, independent of anxiety, but anxiety moderated the relationship between ADHD-Conduct disorder and Conduct disorder-enuresis. Comorbid anxiety increased difficulties in social interaction, was related with higher global impairment and had an impact on consultation and medication. Anxiety disorder comorbidity should be well recognized in order not to disregard the treatment of all present disorders.