[THE PSYCHIATRIC DIAGNOSIS GUIDE - DSM-5 - INNOVATIONS AND CRITICISM].

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA) as a guide for diagnosing psychiatric diseases and enables the alignment of psychiatric diagnoses with those of the psychologists, the social workers, the nursing staff and other mental health professionals. In addition, it helps bring cohesion to research, public health policy, education, the field of insurance and compensation and the legal system. After 14 years of hard work, the updated version of the DSM, the DSM-5, was published on May 2013. The current review aims to update the readers on the essence of the DSM and the methods of psychiatric diagnosing and to present the main changes in the field, as expressed in the 5th edition of the guide. In addition to details of those changes we included discussions of the criticisms brought against them. We hope that the review will contribute to broadening the readers' knowledge, broaden exposure and familiarity with the psychiatric lingo and to strengthening the professional ties between psychiatrists and professionals in other, tangential, medical fields.

[The European Psychiatric Association (EPA) guidance on suicide treatment and prevention]. / Az Európai Pszichiátriai Szövetség (European Psychiatric Association, EPA) úmutatója az öngyilkosság kezelésére és megelözésére.

UNLABELLED: Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive. DIAGNOSIS: An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. TREATMENT: Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. TREATMENT with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. TREATMENT with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT team: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. Family: The suicidal person independently of age should always be motivated to involve family in the treatment. Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. SAFETY: A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Effectiveness and safety of citalopram in hospitalized adolescents with major depression: a preliminary, 8-week, fixed-dose, open-label, prospective study.

OBJECTIVE: Citalopram is widely used in adolescents with major depressive disorder (MDD) and anxiety; however, data on efficacy and safety are still limited and inconsistent. The aim of this study was to evaluate both the efficacy and the safety of citalopram for treatment of MDD and anxiety symptoms in adolescent inpatients. METHODS: An open-label, prospective design of an 8-week trial with a fixed dose of 20 mg/d of citalopram was performed in 10 hospitalized adolescents. Clinical state was assessed by Hamilton Depression (HAM-D 17) and Hamilton Anxiety scales, Beck Depression Inventory (BDI), and the Clinical Global Impression-Severity Scale for depression. Suicidal risk was assessed by the Suicide Risk Scale. A 30% improvement in the rating scales was considered as being a response to the treatment. RESULTS: After 8 weeks, depression levels as measured by the HAM-D 17 (P = 0.002), the BDI (P = 0.011), and the Clinical Global Impression-Severity Scale (P = 0.002) showed significant improvement. So did anxiety levels, as measured by the Hamilton Anxiety (P = 0.026) at end point. Subjective depression level (BDI) decreased significantly between week 2 and 4 (Z = -2.36, P = 0.018), whereas objective depression level (HAM-D 17) decreased significantly between week 4 and 6 (Z = -2.53, P = 0.012). Suicide risk, as assessed by the Suicide Risk Scale, however, increased significantly after 8 weeks (P = 0.011). CONCLUSIONS: This pilot small-scale trial found that citalopram was effective for both depressive and anxiety symptoms in adolescents with MDD and that response started as early as the second week. However, suicidal risk was elevated for some of the subjects. Larger randomized placebo-controlled trials are needed.

Management of the suicidal patient in the era of defensive medicine: focus on suicide risk assessment and boundaries of responsibility.

Suicide is universal within the range of human behaviors and is not necessarily related to psychiatric morbidity, though it is considerably more prevalent among psychiatric patients. Considering the limitations of medical knowledge, psychiatrists cope with an unfounded and almost mythical perception of their ability to predict and prevent suicide. We set out to compose a position paper for the Israel Psychiatric Association (IPA) that clarifies expectations from psychiatrists when treating suicidal patients, focusing on risk assessment and boundaries of responsibility, in the era of defensive medicine. The final draft of the position paper was by consensus. The IPA Position Paper established the first standard of care concerning expectations from psychiatrists in Israel with regard to knowledge-based assessment of suicide risk, elucidation of the therapist's responsibility to the suicidal psychotic patient (defined by law) compared to patients with preserved reality testing, capacity for choice, and responsibility for their actions. Therapists will be judged for professional performance rather than outcomes and wisdom of hindsight. This paper may provide support for psychiatrists who, with clinical professionalism rather than extenuating considerations of defensive medicine, strive to save the lives of suicidal patients.

The impact of mental illness on sexual dysfunction.

Sexual dysfunction is prevalent among psychiatric patients and may be related to both the psychopathology and the pharmacotherapy. The negative symptoms of schizophrenia limit the capability for interpersonal and sexual relationships. The first-generation antipsychotics cause further deterioration in erectile and orgasmic function. Due to their weak antagonistic activity at D2 receptors, second-generation antipsychotics are associated with fewer sexual side effects, and thus may provide an option for schizophrenia patients with sexual dysfunction. Depression and anxiety are a cause for sexual dysfunction that may be aggravated by antidepressants, especially selective serotonin reuptake inhibitors (SSRIs). SSRI-induced sexual dysfunction may be overcome by lowering doses, switching to an antidepressant with low propensity to cause sexual dysfunction (bupropion, mirtazapine, nefazodone, reboxetine), addition of 5HT2 antagonists (mirtazapine, mianserin) or coadministration of 5-phosphodiesterase inhibitors. Eating disorders and personality disorders, mainly borderline personality disorder, are also associated with sexual dysfunction. Sexual dysfunction in these cases stems from impaired interpersonal relationships and may respond to adequate psychosexual therapy. It is mandatory to identify the specific sexual dysfunction and to treat the patients according to his/her individual psychopathology, current pharmacotherapy and interpersonal relationships.

Objective versus subjective assessment of methylphenidate response.

Subjective improvement-assessment in attention deficit/hyperactivity disorder (ADHD), following a single dose of methylphenidate (MPH) was compared to performance on the Test-of-Variables-of-Attention (TOVA). Self-perception was assessed with the clinical-global-impression-of-change (CGI-C). Participants included 165 ADHD subjects (M:F ratio 67%:33%) aged 5-18 (11.09 +/- 3.43) years. TOVA was administered before and after MPH challenge (0.3 mg/kg). Self-perception CGI-C scores were compared to the TOVA scores. An inverse correlation was found only between CGI-C and the TOVA-Commission-scores (r = -0.326, p < 0.001). We thus conclude that subjective reports are too unreliable to be used in order to assess MPH benefit in ADHD pediatric populations.

Addition of memantine to antipsychotic treatment in schizophrenia inpatients with residual symptoms: A preliminary study.

BACKGROUND: Schizophrenia is comprised of several debilitating symptoms. Antipsychotics offer an effective treatment for positive symptoms, while the negative signs and cognitive deficits are usually treatment-resistant. It was suggested that glutamate dysregulation may be involved in the neuropathology of schizophrenia, mainly through NMDA dysfunction. We hypothesized that addition of memantine, a weak non-selective NMDA receptor antagonist approved for dementia, to antipsychotics would improve the clinical status of un-remitted schizophrenia patients, notably the negative signs and cognitive deficits. METHODS: Seven schizophrenia patients, were included in a six-week open-label study, with weekly increasing dosage (5, 10, 15, 20 mg) of memantine added to their on-going antipsychotic treatment. RESULTS: We found a significant improvement of the PANSS score (baseline 116.28+/-21.9 vs. 97.86+/-24.48 after six weeks, t=5.98, p<0.001) with the most prominent improvement (21%) in negative signs sub-scale (baseline 40+/-6.38 vs. 31.71+/-7.76 after six weeks, t=5.87, p<0.001). Cognitive status, measured with the Neurobehavioral Cognitive Examination (NCSE) and Clock Drawing Test (CDT) showed no improvement. CONCLUSION: Memantine addition to antipsychotic treatment, in schizophrenia patients might improve their clinical status, primarily the negative signs, but not their cognitive deficits. Further research is needed to replicate these observations.

[Involuntary hospitalization and treatment: the interface between psychiatry and law].

Involuntary or compulsory hospitalization and treatment of mentally ill patients is one of the most distressing societal needs. The decision to hospitalize or treat an individual involuntarily must balance between three ethical issues: the patient's right to receive medical care, the patient's personal rights to liberty and dignity, and the protection of the public. The psychiatrist is concerned with the need for medical treatment, while the courts follow the letter of the law in order to ensure protection of the individual's rights, as well as those of the public. The interaction between the psychiatric (or medical) discipline and the judicial discipline comprises inherent difficulties, due to these differences in focus of concern and due to the differences in the language they use. In the civil compulsory hospitalization, it is the definition and prediction of dangerousness that comprises a potential discourse and misunderstanding between the psychiatric and the judicial system. It seems that both systems, as well as the patients, may benefit if the initial decision to hospitalize involuntarily is taken by the medical representatives (the District Psychiatrist, Hospital Director, three physicians, etc.) as an emergency procedure. The decision to continue the involuntary hospitalization should be taken by a judicial representative (or a committee), based on the psychiatric evaluation, within 72 hours instead of the 14 days as is currently stated in the Mental Health Law. The less restrictive alternative to hospitalization, compulsory outpatient treatment, is still controversial. This is an order "with no bite" and its implementation is determined, in effect, by the patient's goodwill and cooperation. There are no legal or other consequences for patients who do not comply with the outpatient treatment order. This is true for both civil and criminal outpatient orders. Without legal sanctions this model of outpatient treatment is not really "compulsory" and does not achieve its preventive goals.

Acute intermittent porphyria: psychosis as the only clinical manifestation.

Acute intermittent porphyria (AIP) is the most common of the four forms of neuroporphyria. AIP mimics a variety of disorders and thus poses a diagnostic quagmire. Abdominal pain occurs in 90-95% of the attacks. Some patients develop psychiatric symptoms such as psychosis similar to schizophrenia. The diagnostic difficulty may lead to under-diagnosis of patients who present with strictly psychiatric symptoms. This assumption is supported by a high prevalence of AIP in psychiatric hospitals. Therefore, we encourage a high index of suspicion for AIP in psychiatric patients in order to prevent false psychiatric diagnosis. In addition we discuss psychotropic drugs that may exacerbate acute attacks in undiagnosed patients. We report a case in which the diagnosis of AIP was clouded by the presence of only psychiatric symptoms. The clue for diagnosis was an anamnestic detail of the use of a porphyrogenic drug prior to the admission. The diagnosis of AIP was supported by excess of alpha aminolevulinic acid (ALA) and porphobilinogen (PBG) in urine concomitantly with a decrease in porphobilinogen deaminase (PBGD) activity in erythrocytes. The diagnosis was further strengthened by the fact that the patient's father was identified as an AIP carrier. However, in the absence of typical organic symptoms of porphyria, one cannot definitely rule out the presence of schizophrenia in this patient in addition to AIR

The impossible dialogue between psychiatry and the judicial system: a language problem.

The interface between psychiatry and law is complex and has the potential for gross misunderstanding. Each discipline has its own concerns with regard to the psychiatric patient, and there is a significant language gap between the two disciplines. The language of the medical discipline describes the patient's state on a continuum that ranges from extremely ill to completely healthy. The judicial language, on the other hand, is a binary language: the patient is either competent or incompetent, either dangerous or not dangerous. This article describes three potential areas for discourse in the Israeli context: involuntary hospitalization, criminal responsibility and legal representation of involuntarily hospitalized patients. The two systems can be complementary only if both sides make a serious effort to communicate and respect each other's principles and language.

Criminal responsibility in Asperger's syndrome.

BACKGROUND: Asperger's syndrome (AS) has been of much interest in the last two decades. Most people with AS are law abiding and are not involved in any violence. Over the years, however, there is increasing evidence of violent behavior and criminal acts committed by some people with AS. The characteristics of the link between AS and violation of the law requires identification and definition and the question regarding the criminal responsibility to be attributed to these offenders needs to be clarified. DATA: We present three cases that illustrate how the special characteristics of this syndrome and particularly the inability to assess social situations and appreciate others' point of view constitute the main cause for the violent behavior and the criminal offences. For this specific behavior, the AS patients lack the criminal intent or the intent to cause harm (mens rea), which is essential for criminal responsibility. Thus it is reasonable to consider some AS sufferers not criminally responsible for their actions and unfit to stand trial. This approach has been accepted by the courts. CONCLUSION: It can be inferred that people with AS may not be criminally responsible despite not suffering from a psychotic illness.

Selegiline in the treatment of sexual dysfunction in schizophrenic patients maintained on neuroleptics: a pilot study.

A double-blind, placebo-controlled crossover study was undertaken in 10 neuroleptic-treated male schizophrenic outpatients to assess the effect of coadministration of selegiline 15 mg/day for 3 weeks on their sexual dysfunction. Selegiline was not found to be effective in improving any domain of sexual functioning despite a significant decrease in prolactin levels (P < 0.05). This study emphasizes the complex nature of sexual dysfunction in schizophrenic-treated patients and the need for placebo-controlled trials for this condition.

[Non-compliance with medication as a common reason for admission to a closed psychiatric ward].

Noncompliance with pharmacologic treatment is common amongst patients suffering from chronic diseases. In psychiatric patients compliance is extremely important in order to prevent recurrence of the disease. Recurrence is associated with readmissions and increased costs to the health system. About 70% of patients suffering from schizophrenia will relapse within a year without medication. This study evaluates the causes of admission and diagnoses of 100 patients consecutively admitted to a closed psychiatric ward between 1.4.2000 and 23.6.2000. Fifty- four of these 100 admissions were associated with medication noncompliance in the last year. Noncompliance was not associated with psychiatric diagnosis, gender, type of medication or form of administration of the medication. The problem of noncompliance should be approached on two levels: the doctor-patient relationship and reorganization of mental health services. On the doctor-patient level, the therapist has to maintain a therapeutic alliance with the patient and his family and adjust the medication accordingly, in order to maximize the benefit and minimize side effects. On the health system level, mental health should be included in the National Health Insurance Law and the Health Funds should take responsibility for mental health as in other medical fields. This may enable the psychiatric patients to be under the care of their general practitioner in continuity with the psychiatric hospital. Thereby, resources should be transferred from the psychiatric hospitals to the community. The availability of the psychiatric community services and their links to the general healthcare system would increase compliance and reduce recurrence, readmissions and the stigma of patients suffering from psychiatric disorders.

Sexual function and behavior in social phobia.

BACKGROUND: Social phobia is a type of performance and interpersonal anxiety disorder and as such may be associated with sexual dysfunction and avoidance. The aim of the present study was to evaluate sexual function and behavior in patients with social phobia compared with mentally healthy subjects. METHOD: Eighty subjects participated in the study: 40 consecutive, drug-free outpatients with social phobia (DSM-IV) attending an anxiety disorders clinic between November 1997 and April 1999 and 40 mentally normal controls. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Liebowitz Social Anxiety Scale were used to quantitatively and qualitatively assess sexual function and behavior. RESULTS: Men with social phobia reported mainly moderate impairment in arousal, orgasm, sexual enjoyment, and subjective satisfaction domains. Women with social phobia reported severe impairment in desire, arousal, sexual activity, and subjective satisfaction. In addition, compared with controls, men with social phobia reported significantly more frequent paid sex (p < .05), and women with social phobia reported a significant paucity of sexual partners (p < .05). CONCLUSION: Patients with social phobia exhibit a wide range of sexual dysfunctions. Men have mainly performance problems, and women have a more pervasive disorder. Patients of both genders show difficulties in sexual interaction. It is important that clinicians be aware of this aspect of social phobia and initiate open discussions of sexual problems with patients.

Sildenafil citrate for the sexual dysfunction in antidepressant-treated male patients with posttraumatic stress disorder. A preliminary pilot open-label study.

BACKGROUND: Previous studies have suggested that posttraumatic stress disorder (PTSD) may be associated with pervasive sexual dysfunction. Sildenafil citrate was established as a highly effective and well-tolerated oral agent for the treatment of sexual dysfunction of various etiologies. There are no studies that have examined the efficacy of oral sildenafil in PTSD patients with sexual dysfunction. OBJECTIVE: The current study evaluated the impact of sildenafil added to an ongoing antidepressive treatment in male PTSD patients. METHODS: Ten consecutive male PTSD patients who complained of sexual dysfunction were enrolled in an open-label 4-week fixed-dose study of sildenafil citrate 50 mg/day p.r.n. Patients were evaluated at baseline and after treatment with the Clinician-Administered PTSD Scale (CAPS); sexual function assessments were performed using the International Index of Erectile Function. RESULTS: All patients completed the study and statistically significant improvement was observed in all evaluated domains of sexual functioning: erectile function (53.5%), orgasmic function (40.3%), sexual desire (53%), intercourse satisfaction (82%) and overall satisfaction (57.4%). Oral sildenafil treatment appeared to be well tolerated and no single patient stopped the treatment. Improvements in various CAPS subscales were also obtained; however, there was no significant correlation between improvement in sexual functioning and the changes in CAPS subscale scores. CONCLUSION: Sildenafil seems to be an efficacious, safe and well-tolerated treatment of sexual dysfunction in antidepressant-treated male PTSD patients.