Definition of psychiatric

disorder
History. Classification. Prevalence.
Comorbidity. Epidemiology.
 Definition
DSM criteria of abnormal behavior: A behavior is
considered as abnormal if it is statistically rare,
deviates from society's unwritten rules (norms), it is
counter-productive to the individual and affects
individual's mental well-being

Statistically rare behavior

Statistically rare behavior
Statistically rare behavior

Deviates from the norm

Deviates from the norm
Deviates from the norm

It's counter-productive
It's counter productive
It's counter productive

Affects the mental well-being

Affects the mental well-being
Affects the mental well-being

Normal Abnormal Normal

 Definition
DSM criteria of abnormal behavior: A behavior is
considered as abnormal if it is statistically rare,
deviates from society's unwritten rules (norms), it is
counter-productive to the individual and affects
individual's mental well-being
Neuroscience: Mental disorders are a diverse group of brain
disorders that primarily affect emotion, higher cognition and
executive function

Philosopher: There is no such thing as mental illness

in any culture, and that there could not be, because the
very notion of mental illness is based on a fundamental
mistake or set of mistakes.
Wikipedia: Mental disorder or mental illness are terms
used to refer to a psychological or physiological pattern
that occurs in an individual and is usually associated with
distress or disability that is not expected as part of
normal development or culture
 Diagnostic Systems
Diagnostic and Statistical Manual of Mental Disorders
(DSM)
Publisher: American Psychiatric Association
Last Version: IV-TR
Covers only Mental Disorders

International Classification of Diseases (ICD)

Publisher: World Health Organization
Last Version: 10
Covers all medical diagnosis (chapter 5: mental disorders)
 ICD-10
[International Statistical Classification of Diseases and Related
Health Problems]
International Classification System. Coding of all kind of diseases and
mental disorders.
22 Categories
Examples:

Certain infectious and parasitic diseases

Diseases of the blood and blood-forming organs and certain

disorders involving the immune mechanism

Endocrine, nutritional and metabolic diseases

Mental and behavioural disorders

Diseases of the nervous system

Diseases of the eye and adnexa

Diseases of the ear and mastoid process

 DSM
Categorical classification system

Mood disorders

Factitious disorders
16 Main Categories: Impulse-control
Anxiety disorders

Disorders usually first diagnosed in infancy, disorders not

childhood, or adolescence

Somatoform disorders elsewhere classified

Delirium, dementia, and amnestic and other

Sleep Disorders
Adjustment disorders
cognitive disorders
Dissociative disorders

Mental disorders due to a general medical condition

Sexual and gender identity
not elsewhere classified disorder

Substance-related disorders
Eating disorders

Schizophrenia and other psychotic disorders

Personality disorders
Example: Major Depressive Episode.
5 or more of these symptoms / 2 weeks:

Depressed mood most of the day

Markedly diminished interest or pleasure in all
Significant weight loss when not dieting or weight gain
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished ability to think or concentrate, or indecisiveness, nearly every day
Recurrent thoughts of death
 Diagnostic Systems
DSM
Example

Multi-axial system
Axis I: Clinical, developmental and
learning disorders Axis I: Major
Axis II: Personality disorders and Depressive Disorder
mental retardation
Axis II: None
Axis III: Medical conditions and
physical disorders. Axis III: Cancer
Axis IV: Psychosocial and Axis IV: His mother
environmental factors contributing to died 2 weeks ago
the disorder
Axis V: 80%
Axis V: Global Assessment of
Functioning (on a scale from 100 to 0)
 The Timeline...
DSM-V is expected.
Ideally it will include
International International Statistical experimental criterion
Classification of Classification of sets aiming at
Causes of Death Diseases, Injuries and incorporating new
adopted in Paris. Causes of Death (v.6). DSM-II. No DSM-IV. genetic and
Little mention of Contains a whole major Conservative neurobiological
Mental Disorders section for mental differences to Revision of findings
disorders. the DSM-I DSM-III

1893 1918 1948 1952 1968 1980 1994 2000 2011

Statistical Manual
First DSM. Focused
for the use of DSM-III. Use
on diagnosis. Brief DSM-IV-TR.
Institutions for the of field-tested
descriptions of each Text is
Insane. 22 criteria to
disorder. Influenced revised, but
categories, mainly achieve
from psychoanalytic the diagnostic
referred to the reliability. No
thinking criteria are
somatic causes of theories of
not
behavioral disorders aetiology
 Criticism of DSM
Use of categories

DSM uses categories, but drugs do not respect the

boundaries of the disorders.

Many disorders are better conceptualized as dimensional

traits.

Normal Abnormal/Mental Disorder

Different levels of symptoms. More or less severe cases.

Not Otherwise Specified category is used very often!

Co-morbidity
A large fraction of patients qualifies for multiple
diagnoses.
Possible explanations:
 Mental Disorders and
Neuroscience
Need for integration of Neuroscience into DSM-V

Arbitrary boundaries between mental and neurological disorders.

Overlapping practice patterns between neurology and psychiatry.

Use of neurological techniques in order to treat mental disorders (e.g. deep brain
stimulation)

Both treat higher brain functions (e.g. autism, Alzheimer's disease, ADHD)

Biological basis of many mental disorders (e.g. schizophrenia, bipolar disorder)

Need to build a new dimensional diagnostic system.

Ultimate goal: a diagnostic classification system for mental disorders based not only on
symptomatology but also on aetiology and pathophysiology of the disorders.
 How can Neuroscience help?
Neurogenetics

Significant influence of genes
(twin studies/adoption studies etc)
Many studies tried to identify the
role of genetic factors in
development of disorders.

Interaction between multiple
genetic factors that cause a
common symptom in different
mental disorders (e.g. gene
catechol-O-methyltransferase =>
metabolism of neurotransmitters
like dopamine=> schizophrenia-
like symptoms)

New technologies will provide
 How can Neuroscience help?
Neuroimaging

Anatomical abnormalities
(e.g. less gray matter in
schizophrenics)
Future diagnostic
classifications

Contribution to experimental
therapies
a. Localization of abnormal
activations
b. Direct therapy in these
brain regions
(e.g. Experimental treatment
of depression with stimulation
 How can Neuroscience help?
Example: Phenylketonuria [1 in 15,000 births]
autosomal recessive genetic disorder
deficiency in the PAH enzyme

Discovery of phenylketones in urine of some

mentally retarded individuals

Anatomical differences (brain size ~80% of normal)

1950: More specific reports

White matter abnormalities (spongy change)

Pallor of myelin staining

Demyelination

Demyalination is caused after the birth

More accurate detection of PKU

Dietary Therapy (low in phenylalanine)

Today: Animal Models
 Prevalence of Mental Disorders in
Europe
Prevalence rates of mental disorders in 6 E.U. Countries:
Belgium, France, Germany, Italy, the Netherlands and Spain

Lifetime Prevalence
Total Males Females
Any Mental Disorder 25,00% 21.8% 28.1%
Any Mood Disorder 14,00% 9.5% 18.2%
Any Anxiety Disorder 13.6% 9.5% 17.5%
Any Alcohol Disorder 5.2% 9.3% 1.4%
Total Males Females
Major Depression 12.8% 8.9% 16.5%
Dysthymia 4.1% 2.6% 5.6%
GAD 2.8% 2.0% 3.6%
Social Phobia 2.4% 1.9% 2.9%
Specific Phobia 7.7% 4.9% 10.3%
PTSD 1.9% 0.9% 2.9%
Agoraphobia 0.9% 0.6% 1.1%
Panic Disorder 2.1% 1.6% 2.5%
Alcohol Abuse 4.1% 7.4% 1.0%
Alcohol Dependence 1.1% 1.8% 0.4%

ESEMeD/MHEDEA 2000 Investigators

 Prevalence of Mental Disorders in
Europe
Prevalence rates of mental disorders in 6 E.U. Countries:
Belgium, France, Germany, Italy, the Netherlands and Spain

12-month Prevalence

Declining rates
with
Age age
Group
18-24 13.7%
25-34 11.2%
35-49 9.6%
50-64 9.8%
>65 5.8%

Higher rates for

unmarried/divorced
Marital Status
Married 8.7%
Previously married 10.9%
Never married 11.8%

ESEMeD/MHEDEA 2000 Investigators

 Prevalence of Mental Disorders in
Europe
Prevalence rates of mental disorders in 6 E.U. Countries:
Belgium, France, Germany, Italy, the Netherlands and Spain

12-month Prevalence

Higher rates for higher

education levels
Education Any Mental Disorder Any Alcohol Disorder
0-4 Years 8.9% 0.2%
5-8 Years 7.0% 0.5%
9-12 Years 9.1% 0.9%
>13 Years 9.0% 1.2%

Higher rates in urban areas

Urbanicity
Rural 8.6%
Mid-size urban 9.9%
Large Urban 10.5%

ESEMeD/MHEDEA 2000 Investigators

 Prevalence of major psychiatric
disorders
Example: Depression

Depression ranks 5th across women

and 7th across men as a cause of
morbidity (World Bank, 1993)

WHO: in 2020 depression will be the

second most important cause of
disability.

The cultural background is likely to

determine whether depression will be
experienced and expressed in
psychological and emotional terms or
in physical terms.

Bhugra & Mastrogianni, 2004

 Prevalence of major psychiatric
disorders
Example: Depression

WHO, 1996: 10.4% received a current

depressive episode diagnosis

Co-morbidity: Depression, Anxiety, Alcohol

Misuse or Dependence, Panic Disorder,
Obsessive-Compulsive Disorder

Differences in prevalence across

cultures/countries
i. Different levels of awareness and
recognition
ii. Popular perceptions about the role of
doctor in each country
iii. Different pathways to health system (i.e.
medical care must be paid in Nigeria)
iv. Social stigma
v. Methodological Issues (lack of appropriate
instruments)

Bhugra & Mastrogianni, 2004

 Prevalence of major psychiatric
disorders
Example: Depression Ethnic
Minorities

USA

No differences between African
Americans and White Americans
(when demographic, sociocultural
and socio-economic factors are
controlled)

Puerto Ricans: higher depression
rates

Asian Americans: lower prevalence
of depression

UK

In general, higher prevalence rates
of depression on minority groups
Bhugra & Mastrogianni, 2004
 Prevalence of major psychiatric
disorders
Example: Depression Diagnosis

Depression is under-recognized throughout the world. Primary care

physicians detect only 50% of the cases

UK

Asians: visit their practitioner more frequently, but is less likely to
have their psychological difficulties identified (complaints about
somatic symptoms)

Indian women: 17% recognition

USA

Physicians are less likely to detect depression among African
American and Hispanic patients

Australia

Asians: lower rate of diagnosis (similar rate of self-reported
symptoms)
 Prevalence of major
psychiatric disorders
Example: Depression Diagnosis
 Summary
Two main categorical systems:

DSM (mental disorders)

ICD (diseases and mental disorders)

Need for integration of Neuroscience in the

future versions of these categorical systems

Diagnosis

Treatment

Future Studying

Prevalence & Epidemiology

450 million people suffer from mental disorders

Most common: mood disorders

More women than men

Development during youth

Urban Areas > Rural Areas

Different rates around the world

Social factors (culture, language, minorities etc)