Changes in the DSM Diagnostic Concept of Schizophrenia:From 1980 to 2013 / 신경정신의학

Schizophrenia has been conceptualized as a biologically caused mental disease. However, its causes and pathophysiology have not yet been clearly defined. Unlike physical diseases that are defined using specific biomarkers, mental disorders, such as schizophrenia, are usually diagnosed using the diagnostic criteria established by the consensus of a professional committee. The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association is widely used as the authoritative guide for the diagnosis of mental disorders, including schizophrenia. If the cause and pathophysiology of a disease are uncertain, a diagnostic concept should be considered valid only when the course, prognosis, or treatment response is generally predictable and consistent. However, patients with schizophrenia who are diagnosed based on the criteria defined by the DSM frequently display varied disease courses and outcomes. This strongly suggests that the current diagnostic concept of schizophrenia in the DSM fails to meet the standards for a valid diagnosis. Although this limitation has been recognized since the DSM-III was published, many psychiatrists today mistakenly believe that the diagnostic concept in the DSM looks at schizophrenia as an explicit disease rather than as a concept. In this review article, we analyze the historical changes in the concepts and diagnostic criteria of schizophrenia. We believe that this will help us to better understand the nature of the current diagnostic approach and also improve our understanding of how the DSM should be used in research and everyday clinical practice.

Characteristics of Patients Presenting to a Psycho-Oncology Outpatient Clinic

Objective@#We aimed to determine the overall profile of patients in a psycho-oncology clinic and the differences in their characteristics according to the cancer site. @*Methods@#The charts of 740 patients aged under 81 years were reviewed. The data from 586 completed questionnaires were subjected to multiple comparison analyses using one-way analysis of variance to examine the demographic and clinical differences according to the cancer site. @*Results@#Most (n=532, 71.9%) patients were referred. Most new patients (n=426, 96.6%) received a psychiatric diagnosis; the most common diagnosis was depressive disorder (n=234, 31.6%). Likewise, depressive disorder accounted for the majority of diagnoses in all groups except for the digestive system cancer group in which sleep-wake disorder was the most prevalent. The female genital cancer group showed a higher level of anxiety symptoms than other groups, except for breast and haematolymphoid cancer groups, and psychological distress than all other groups. @*Conclusion@#There appear to be delays in the referral of cancer patients seeking psychiatric help to a psycho-oncology clinic. Along with tailoring approaches by cancer site, thorough evaluation and appropriate management of sleep-wake and anxiety symptoms are important for digestive system and female genital cancer patients, respectively.

Characteristics of Patients Presenting to a Psycho-Oncology Outpatient Clinic

Objective@#We aimed to determine the overall profile of patients in a psycho-oncology clinic and the differences in their characteristics according to the cancer site. @*Methods@#The charts of 740 patients aged under 81 years were reviewed. The data from 586 completed questionnaires were subjected to multiple comparison analyses using one-way analysis of variance to examine the demographic and clinical differences according to the cancer site. @*Results@#Most (n=532, 71.9%) patients were referred. Most new patients (n=426, 96.6%) received a psychiatric diagnosis; the most common diagnosis was depressive disorder (n=234, 31.6%). Likewise, depressive disorder accounted for the majority of diagnoses in all groups except for the digestive system cancer group in which sleep-wake disorder was the most prevalent. The female genital cancer group showed a higher level of anxiety symptoms than other groups, except for breast and haematolymphoid cancer groups, and psychological distress than all other groups. @*Conclusion@#There appear to be delays in the referral of cancer patients seeking psychiatric help to a psycho-oncology clinic. Along with tailoring approaches by cancer site, thorough evaluation and appropriate management of sleep-wake and anxiety symptoms are important for digestive system and female genital cancer patients, respectively.

Characteristics of Delirium in Patients with Hearing Disturbances / 신경정신의학

OBJECTIVES: Several studies have delineated the relationship between hearing disturbances and the prevalence or characteristics of psychotic symptoms; however, most of those studies focused on psychiatric patients and not general inpatients. Delirium has a high incidence among general inpatients, and patients with delirium are easily affected by psychotic symptoms that lead to irritable behaviors. This study examined the relationship between hearing disturbance and psychotic symptoms among patients with delirium. METHODS: At the Asan Medical Center in Seoul, South Korea, this study examined 27 inpatients who had both delirium and hearing disturbances between January 1, 2009 and December 31, 2018, and 146 inpatients at the Asan Medical Center who had delirium but no hearing disturbances between July 1, 2018 and December 31, 2018. This study investigated whether the two groups showed differences in the prevalence and characteristics of delirium symptoms, particularly psychotic symptoms. In addition, the correlation between clinical characteristics of delirium and the recommended dosage of antipsychotics was analyzed in patients who had been diagnosed with delirium and had hearing disturbances. RESULTS: Compared to inpatients who only had delirium, those who had both delirium and hearing disturbances had a significantly higher prevalence of hallucination and delusion. CONCLUSION: The prevalence of psychotic symptoms, such as hallucination and delusion, was higher in patients who had both delirium and hearing disturbances, which is in line with the results from previous studies on psychiatric patients. Physicians should focus on improving communication with such patients by employing non-verbal communication methods.

Antidepressant Prescription Patterns in Bipolar Disorder: a Nationwide, Register-based Study in Korea

BACKGROUND: The role of antidepressants (ADs) in bipolar disorder is long-standing controversial issue in psychiatry. Many clinicians have used ADs as a treatment for bipolar depression, and the selection of therapeutic agents is very diverse and inconsistent. This study aimed to examine recent AD prescription patterns for patients with bipolar disorder in Korea, using the nationwide, population-based data. METHODS: This study utilized the Korean nationwide, whole population-based registry data of the year 2010, 2011, and 2013. All prescription data of the ADs, antipsychotics, and mood stabilizers of the sampled patients diagnosed with bipolar disorder (n = 2,022 [in 2010]; 2,038 [in 2011]; 2,626 [in 2013]) were analyzed for each year. RESULTS: Annual prescription rate of ADs was 27.3%–33.6% in bipolar disorder, which was gradually increasing over the 3-year period. The combination pattern of ADs and antipsychotic drugs tended to increase over 3 years. The proportion of females and the prevalence of comorbid anxiety disorder were significantly higher in AD user group in all three years. Among individual ADs, escitalopram was prescribed most frequently, and fluoxetine and bupropion were prescribed to the next many patients. The mean duration of bipolar depressive episodes was 135.90–152.53 days, of which ADs were prescribed for 115.60–121.98 days. CONCLUSION: Our results show prescription rate of ADs in bipolar disorder was maintained at substantial level and increased in recent 3 years. More empirical data and evidence are needed to establish practical treatment consensuses.

The Association of the 2nd to 4th Digit Ratio with the Age of Onset and Metabolic Factors in Korean Patients with Schizophrenia

OBJECTIVES: The ratio of second to fourth digit length (2D : 4D) could be a potential epigenetic marker of sexual dimorphism reflecting prenatal testosterone exposure. Testosterone is known to affect the development of the brain through an epigenetic mechanism. The purpose of this study was to investigate the effects of exposure to fetal testosterone on the metabolic syndrome based on 2D : 4D of schizophrenia patients and the relationship with the age of onset of schizophrenia. METHODS: A total of 214 schizophrenia patients participated in this study. The participant's physical and blood tests were performed according to the American National Cholesterol Education Program's Third Amendment of the Metabolic Syndrome Diagnostic Criteria, and the 2D : 4D was measured by the method designed by McFadden. Data were statistically analyzed by t-test, Pearson's correlation analysis and multiple regression model analysis. RESULTS: 2D : 4D was significantly higher in female than male in both hands, and there was a statistically significant negative correlation between 2D : 4D and the age of onset of schizophrenia in male. However, 2D : 4D did not show statistically significant correlation with metabolic factors. CONCLUSIONS: Fetal testosterone suggests the possibility of affecting the age of onset of schizophrenia through the epigenetic mechanism, but there is no clear relationship with metabolic factors.

Prevalence of Metabolic Syndrome in Patients with Schizophrenia in Korea: A Multicenter Nationwide Cross-Sectional Study

OBJECTIVE: We designed a nationwide study with limited exclusion criteria to investigate the prevalence of metabolic syndrome (MetS) in Korea and its relationship with antipsychotic medications. METHODS: This multicenter, cross-sectional, and observational study included patients diagnosed with schizophrenia or schizoaffective disorder. Sixteen hospitals enrolled 845 patients aged 18 to 65 years prescribed any antipsychotic medication between August 2011 and August 2013. MetS was diagnosed using the criteria of the modified Adult Treatment Panel III of the National Cholesterol Education Program with the Korean abdominal obesity definition (waist circumference ≥85 cm in women, ≥90 cm in men). RESULTS: The prevalence of MetS in all patients was 36.5% and was significantly higher in men than women (men, 40.8%; women, 32.2%) and was significantly correlated with age [odds ratio (OR) 1.02] and duration of illness (OR 1.03). The prevalence of MetS across antipsychotic drugs in the major monotherapy group was as follows: 18.8% for quetiapine, 22.0% for aripiprazole, 33.3% for both amisulpride and paliperidone, 34.0% for olanzapine, 35% for risperidone, 39.4% for haloperidol, and 44.7% for clozapine. CONCLUSION: The prevalence of MetS is very high in patients with schizophrenia or schizoaffective disorder. Screening and monitoring of MetS is also strongly recommended.

Validation of a Video Based Scale for Measuring Social Cognition in Schizophrenia / 신경정신의학

OBJECTIVES: Social cognition plays an important role in psychiatric symptoms and prognosis in patients with schizophrenia. Diagnostic scales are predominantly text-based or intended for the evaluation of theoretical concepts, with limited usefulness in clinical settings. We therefore developed a video based social cognition scale. METHODS: Our scale consists of 20 video clips portraying frequently experienced social interactions in real life. Patients were asked which interactions were socially unnatural and the reasons for lies told by actors. Our scale was validated and social cognition and its relationship with symptoms was evaluated using item response theory. RESULTS: A total of 209 participants (schizophrenia, 101 ; bipolar disorder, 49 ; healthy controls 59) were enrolled. Our scale showed high reliability and concurrent validity compared with the order subtest of the short form of the Weschler Adult Intelligence scale. Internal validity also was high (Cronbach's alpha=0.904). Most items were easy to answer and highly discriminative. The test information curve showed our scale to be more informative in patients with low social cognition ability. CONCLUSION: Our scale may aid in the study of pathology and social cognition deficits in patients with schizophrenia.

Effectiveness and Safety of Electroconvulsive Therapy in Clinical Practice / 신경정신의학

OBJECTIVES: There is little research on the practice and effectiveness of electroconvulsive therapy (ECT) in Korea. This study investigated the practice pattern, effectiveness, and safety of ECT. METHODS: This chart review study included electronic medical records of 180 patients treated with ECT between January 2007 and December 2013 at the Asan Medical Center. Symptomatic improvement was assessed using Clinical Global Impression (CGI) scale. Treatment response was defined as CGI improvement scale score of 2 or less. Re-hospitalization was used as an indicator of recurrence. Safety was assessed by spontaneous reports from patients. RESULTS: One hundred and eighty patients underwent 1539 sessions of modified ECT. Their most frequent diagnosis was major depressive disorder (n=74, 41.1%). The most common indication for ECT was poor response to medication (n=177, 75.3%). Treatment response rate was 66.9% in acute phase group and 63.8% in the patients with poor response to medication. The recurrence rate at six months after the end of the course was 29.6%. Memory impairment or amnesia was the most common adverse effect. CONCLUSION: There was a remarkable improvement following ECT in patients who responded poorly to medications, and most adverse effects were tolerable and temporary. The present study suggests that ECT could be a useful treatment option.

Giant esophageal schwannoma / 영남의대학술지

Esophageal schwannoma is a very rare submucosal tumor. We report successful management of esophageal schwannoma in a 41-year-old man who complained of progressively worsening dysphagia. A huge submucosal tumor was found via endoscopy and a chest computed tomography scan. Esophagectomy was performed with no post-operative complications. Post-operative immunohistochemistry staining showed a positive result for S-100 and negative results for c-kit and CD34. The post-operative mild dysphagia persisted, and the follow-up endoscopic findings revealed anastomosis site stenosis. Approximately 2 months later, we performed endoscopic balloon dilatation. We report herein a case of esophageal schwannoma with reviews.

Admission Status Conversion from Voluntary into Involuntary, Is It Illegal / 신경정신의학

OBJECTIVES: The current Korean Mental Health Act (KMHA) indicates that a patient, who voluntarily gave their permission for admission into a mental health facility, has the right to be discharged upon personal request. However, there is no clause in the KMHA that allows a change in a patient's voluntary status under special circumstances. The purpose of this study was to investigate problems that may arise from the lack of such a clause ; problems that can result in misinterpretation and lead to the prohibition of voluntary admission status conversion. METHODS: Previous cases presented to the National Human Rights Commission of Korea were investigated in order to determine the current state in Korean psychiatric practice regarding the conversion from voluntary to involuntary admission status. In addition, examples of similar mental health legislation in use by the United Nations (UN), World Health Organization (WHO), and several advanced countries pertaining to such conversions were investigated. These examples were used as models for making recommendations for possible changes to the KMHA. RESULTS: From 2010 to 2014, more than 220 petitions were filed with the National Human Right Commission of Korea. The petitions involved voluntarily institutionalized patients who had their requests for discharge rejected. Based on mental health regulations of the UN, WHO, and such countries as the United States, England, Canada, Australia, and Japan, the KMHA should include a provision that, upon receiving a discharge request, allows for discharge refusal if the voluntarily admitted patient is considered not mentally fit. CONCLUSION: The results suggest that the absence of a regulation allowing admission status conversion in the current KMHA is inappropriate. Rectification of this absence is urgently needed.

Eradication Rates of First-line and Second-line Therapy for Helicobacter pylori Infection in Gyeongnam Province

BACKGROUND/AIMS: The eradication rates of Helicobacter pylori has been decreasing over the years and it is different among the regions. The aim of this study was to investigate the rates of first-line and the second-line eradication of H. pylori over the last 5 years in a single institute of Changwon and Gyeongsangnam-do, Korea. MATERIALS AND METHODS: Eradication rates of first-line triple regimen in 1,164 patients and second-line quadruple regimen in 223 patients who received H. pylori eradication treatment from January 2008 to December 2012 at Changwon Fatima Hospital were evaluated retrospectively. The patients for second-line quadruple therapy were divided into three groups according to the dosage of medications. RESULTS: The overall eradication rates of first-line and second-line therapy were 70.5% and 81.2%, respectively. There was no decreasing tendency in the eradication rate of first-line therapy for 5 years (P=0.573). However, annul eradication rates of second-line therapy significantly decreased (P=0.001, linear by linear association). In second-line therapy, patients treated with high dose bismuth and metronidazole had higher eradication rates than those treated with low dose bismuth and metronidazole (P=0.039). CONCLUSIONS: The effectiveness of the first-line and second-line therapy for H. pylori was suboptimal. In addition, there was a decreasing tendency in the eradication rates of second-line therapy over the past 5 years in Changwon and Gyeongsangnam-do province. Alternative regimens or high dose therapy should be considered for first-line and second-line therapy.

Prenatal, Perinatal and Developmental Risk Factors of Attention-Deficit Hyperactivity Disorder

OBJECTIVES: The purpose of this study was to examine the prenatal, perinatal and developmental risk factors of attention-deficit hyperactivity disorder (ADHD), compared to unaffected siblings (SIB), and typically developing children (TC). METHODS: Subjects with ADHD, their SIB, and TC were recruited from the child psychiatry outpatient clinic of the Asan Medical Center Children's Hospital. The parents of the children completed questionnaires on perinatal and developmental risk factors. RESULTS: Fifty-eight subjects with ADHD (41 boys, 7.7+/-1.3 years), 21 SIB (8 boys, 8.2+/-1.8 years), and 22 TC (8 boys, 8.5+/-2.1 years) were included. The ADHD group showed higher rates of maternal stress during pregnancy than the SIB group (p=.002), and the ADHD group showed higher rates of familial psychiatric history than the TC (odds ratio, 8.76 ; 95% confidence interval, 1.69 to 45.45). CONCLUSION: These findings suggest that among perinatal and developmental factors, maternal stress during pregnancy contribute to the development of ADHD. Future prospective studies will be needed in order to determine the causal relationship between perinatal risk factors and development of ADHD.

Liver abscess and septic complications associated with advanced gastric cancer / 영남의대학술지

Pyogenic liver abscess with metastatic septic complications is a rare and serious infectious disease if not treated properly. Pyogenic liver abscesses are caused by bacterial, fungal, or parasitic organisms. Escherichia coli used to be the predominant causative agent, but Klebsiella pneumoniae emerged as a major cause in the 1990s. Liver abscesses are caused by hepatic invasion via many routes, such as, the biliary tree, portal vein, hepatic artery, direct extension, or penetrating trauma. Furthermore, diabetes mellitus and malignant conditions are established important risk factors of K. pneumoniae liver abscesses and of septic metastasis, and several recent studies have asserted that K. pneumoniae liver abscess might be a presentation of occult or silent colon cancer. We report a case of K. pneumoniae liver abscess, metastatic septic pulmonary embolism, and endophthalmitis associated with diabetes and advanced gastric cancer.

Obstructive Jaundice Due to Compression of the Common Bile Duct by Variant Right Hepatic Artery / 대한췌담도학회지

Extrahepatic bile duct can be compressed by right hepatic artery (RHA) and cause a variety of hepatobiliary symptoms. This condition is referred to as RHA syndrome. A 20-year-old man was admitted because of jaundice. No stones or tumor were visible on CT scan and endoscopic retrograde cholangiopancreatography. However, RHA was seen traversing and compressing the mid common bile duct (CBD) with resultant upstream dilatation. The patient was diagnosed with obstructive jaundice due to compression of the CBD by variant RHA originating from gastroduodenal artery. After separation and mobilization of the variant RHA, obstructive jaundice was resolved. Herein, we report a case of a variant form of RHA syndrome that was successfully managed by surgery.

Acute Pancreatitis Associated with Intraductal Tubulopapillary Neoplasm of the Pancreas / 이화의대지

Intraductal tubulopapillary neoplasm (ITPN) of the pancreas has been recently reported. It is very rare, therefore clinical behavior and prognosis has not yet been characterized. We experienced a case of ITPN of the pancreas which presented with acute pancreatitis and treated with Whipple's operation. Histopathologic finding showed papillary hyperplasia with carcinomatous change. The tumor recurred after 47 month of operation, and she underwent total pancreatectomy. Pathologic finding revealed tubulopapillary growth with high grade dysplasia. Immunohistochemial staining was not performed, however gross and microscopic findings were compatible with ITPN of the pancreas. We report a case of ITPN of the pancreas.

Acute Pancreatitis Associated with Intraductal Tubulopapillary Neoplasm of the Pancreas / 이화의대지

Intraductal tubulopapillary neoplasm (ITPN) of the pancreas has been recently reported. It is very rare, therefore clinical behavior and prognosis has not yet been characterized. We experienced a case of ITPN of the pancreas which presented with acute pancreatitis and treated with Whipple's operation. Histopathologic finding showed papillary hyperplasia with carcinomatous change. The tumor recurred after 47 month of operation, and she underwent total pancreatectomy. Pathologic finding revealed tubulopapillary growth with high grade dysplasia. Immunohistochemial staining was not performed, however gross and microscopic findings were compatible with ITPN of the pancreas. We report a case of ITPN of the pancreas.

The Development of Questionnaire for Relapse Assessment in Psychotic Disorder / 신경정신의학

OBJECTIVES: The aims of this study were to develop an instrument for detection of relapse in psychotic disorder and to validate the instrument. METHODS: A total of 55 outpatients with psychotic disorder (schizophrenia, schizoaffective disorder, bipolar disorder) and 46 of their caregivers were enrolled. We developed the Questionnaire for Relapse Assessment in Psychotic disorder (QRAP), a self/report inventory. The patients and caregivers drew up the QRAP at two different time points, 'current' and 'the best state during the past three months'. In addition, we rated other established scales in order to evaluate psychotic and mood symptoms of patients. We divided patients into two groups, stable (n=30) and impending relapse (n=35) and evaluated the effectiveness of QRAP by calculating sensitivity and specificity. RESULTS: For all patients and caregivers, QRAP total score at 'current' was higher than 'the best state during the past three months' and showed significant positive correlation with other established scales. As expected, QRAP total score at 'current' in the impending relapse group was higher than that of the stable group. With cut off criteria 1, the QRAP demonstrated 80.0% sensitivity and 56.3% specificity in caregivers and effectively detected impending relapse. CONCLUSION: The results of our study suggest the effectiveness of QRAP as an instrument for detection of relapse in patients with psychotic disorder.

Comparative Study of Personality Traits in Patients with Bipolar I and II Disorder from the Five-Factor Model Perspective

OBJECTIVE: The distinguishing features of Bipolar I Disorder (BD I) from Bipolar II Disorder (BD II) may reflect a separation in enduring trait dimension between the two subtypes. We therefore assessed the similarities and differences in personality traits in patients with BD I and BD II from the perspective of the Five-Factor Model (FFM). METHODS: The revised NEO Personality Inventory (NEO-PI-R) was administered to 85 BD I (47 females, 38 males) and 43 BD II (23 females, 20 males) patients. All included patients were in remission from their most recent episode and in a euthymic state for at least 8 weeks prior to study entry. RESULTS: BDII patients scored higher than BD I patients on the Neuroticism dimension and its four corresponding facets (Anxiety, Depression, Self-consciousness, and Vulnerability). In contrast, BD II patients scored lower than BD I patients on the Extraversion dimension and its facet, Positive emotion. Competence and Achievement-striving facets within the Conscientiousness dimension were significantly lower for BD II than for BD I patients. There were no significant between-group differences in the Openness and Agreeableness dimensions. CONCLUSION: Disparities in personality traits were observed between BD I and BD II patients from the FFM perspective. BD II patients had higher Neuroticism and lower Extraversion than BD I patients, which are differentiating natures between the two subtypes based on the FFM.

Korean Medication Algorithm for Bipolar Disorder 2010: Comparisons with Other Treatment Guidelines / 대한정신약물학회지

The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) was developed in 2002 and thereafter revised in 2006. It was secondly revised in 2010 (KMAP-BP 2010). The aim of this study was to compare KMAP-BP 2010 with other recently published treatment algorithm and guidelines for bipolar disorder. The authors reviewed the 4 recently published guidelines and treatment algorithms for bipolar disorder [The British Association for Psychopharmacology Guideline for Treatment of Bipolar Disorder, Canadian Network for Mood and Anxiety Treatments Guidelines for the Management of Patients with Bipolar Disorder, The World Federation Society of Biological Psychiatry Guideline for Biological Treatment of Bipolar Disorder and National Institute for Health and Clinical Experience (NICE) Clinical Guideline] to compare the similarities and discrepancies between KMAP-BP 2010 and the others. In aspects of treatment options, most treatment guidelines had some similarities. But there were notable discrepancies between the recommendations of other guidelines and those of KMAP-BP in which combination or adjunctive treatments were favored. Most guidelines advocated new atypical antipsychotics as first-line treatment option in nearly all phases of bipolar disorder and lamotrigine in depressive phase and maintenance phase. Lithium and valproic acid were still commonly used as mood stabilizers in manic phase and strongly recommended valproic acid in mixed or psychotic mania. Mood stabilizers or atypical antipsychotics were selected as first-line treatment option in maintenance treatment. As the more evidences were accumulated, more use of atypical antipsychotics such as quetiapine, aripiprazole and ziprasidone were prominent. This review suggests that the medication strategies of bipolar disorder have been reflected the recent studies and clinical experiences, and the consultation of treatment guidelines may provide clinicians with useful information and a rationale for making sequential treatment decisions. It also has been consistently stressed that treatment algorithm or guidelines are not a substitute for clinical judgment; they may serve as a critical reference to complement of individual clinical judgment.