Bottom-Up and Top-Down Paradigms for Psychopathology: A Half-Century Odyssey.

Bottom-up paradigms prioritize empirical data from which to derive conceptualizations of psychopathology. These paradigms use multivariate statistics to identify syndromes of problems that tend to co-occur plus higher-order groupings such as those designated as internalizing and externalizing. Bottom-up assessment instruments obtain self-ratings and collateral ratings of behavioral, emotional, social, and thought problems and strengths for ages 1½-90+. Ratings of population samples provide norms for syndrome and higher-order scales for each gender, at different ages, rated by different informants, in relation to multicultural norms. The normed assessment instruments operationalize the empirically derived syndromes and higher-order groupings for applications to clinical services, research, and training. Because cross-informant agreement is modest and no single informant provides comprehensive assessment data, software compares ratings by different informants. Top-down paradigms prioritize conceptual representations of the nature and structure of psychopathology, as exemplified by psychodynamic, DSM/ICD, and HiTOP paradigms. Although these paradigms originated with observations, they tend to prioritize conceptual representations over empirical data.

Biotypes of functional brain engagement during emotion processing differentiate heterogeneity in internalizing symptoms and interpersonal violence histories among adolescent girls.

Youth exposed to early life interpersonal violence (IPV) demonstrate heterogeneous clinical symptoms. Studies based on univariate methods suggest that neurocircuitry related to emotion processing explains heterogeneity in internalizing symptoms. Here, we use a multivariate, data-driven method of identifying distinct functional brain activation profiles (i.e., "biotypes") and test whether these biotypes differentiate internalizing symptoms among IPV-exposed youth. 114 adolescent girls (n = 38 with no IPV exposure or psychopathology; n = 76 with IPV exposure and heterogeneous internalizing symptoms), aged 11-17, completed an emotion processing task during fMRI. To identify distinct biotypes of brain engagement profiles, data-driven clustering analysis was applied to patterns of voxel activation, constrained within a mask of distributed regions implicated in emotion processing. Resulting biotypes (BT1-3) were compared on measures of IPV exposure and internalizing symptoms, as well as symptom reduction during Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) among a subset of participants (n = 21). Cluster analyses identified three biotypes, differentiated by engagement of medial prefrontal, anterior insula, hippocampus, parietal, and ventral visual cortex during emotion processing. BT1 exhibited low levels of IPV exposure and internalizing symptoms. BT2 exhibited elevated levels of IPV, except sexual assault, and demonstrated moderate severity across internalizing symptom domains. BT3 exhibited elevated severity across all IPV and internalizing symptom domains. Greater symptom reduction during TF-CBT was associated with increased pre-to post-treatment changes in similarity with BT1. These results demonstrate distinct profiles of emotion processing neurocircuitry that differentiate heterogeneity in internalizing symptoms in IPV-exposed adolescent girls.

Nomenclature Used by Family Caregivers to Describe and Characterize Neuropsychiatric Symptoms.

BACKGROUND AND OBJECTIVES: Neuropsychiatric symptoms (NPS) are a core feature of Alzheimer's disease and related dementias that are characterized by a fluctuating course. NPS are challenging to manage and contribute to high rates of burden among family caregivers. Successful information exchange between clinicians and family caregivers is critical for facilitating effective management of NPS. However, this communication is often challenging due to inconsistent terminology and classification of symptoms and limited understanding of how family caregivers recognize and describe symptoms. The objective of this study was to examine the language family caregivers' use to describe and contextualize NPS. RESEARCH DESIGN AND METHODS: Descriptive qualitative study of 20 family caregivers in a mostly urban county in the Midwestern United States using semistructured interviews. Caregiver descriptions of NPS were analyzed using directed content and text analysis to examine terminology, followed by a thematic analysis approach to examine contextualization of NPS. RESULTS: Caregivers employed shared terminologies to describe NPS that differed substantially from clinical terminology used to classify symptoms. Caregivers frequently engaged sense-making as a strategy to explain NPS. This sense-making served to contextualize patterns in behavior and was characterized by explanatory, situational, and strategy-oriented frameworks for understanding behavior in terms of its purpose and meaning. Caregivers' descriptions of NPS reflected broad overlap between individual NPS (i.e., agitation and care resistance) that would generally be considered clinically distinct symptoms. DISCUSSION AND IMPLICATIONS: Nomenclature surrounding NPS may vary considerably between family caregivers and clinicians, and should be evaluated in partnership with people with dementia and their caregivers to ensure supportive interventions and resources are responsive to caregivers' interpretation of symptoms and sense-making.

Profiling acquired pedophilic behavior: Retrospective analysis of 66 Italian forensic cases of pedophilia.

Neurological disorders can be mis-diagnosed as psychiatric ones. This might happen to pedophilia emerging as a symptom of brain insult (i.e. acquired pedophilic behavior). This paper aims to delineate a behavioral profile that might help to identify defendants whose pedophilic behavior is likely to be the consequence of a neurological disorder. Through a systematic review of the literature, seventeen clinical and behavioral variables of the modus operandi and victimology that can distinguish between acquired and developmental pedophilic behavior have been collected. Seven of these were found to be consistent behavioral indicators (i.e. red flags) for acquired pedophilia. Cluster hierarchical analysis on the seventeen variables collected through the systematic review of the literature on cases of acquired pedophilic behavior was applied to a new dataset including 66 Italian closed cases of pedophilia. Stepwise regression and correlation analyses were carried out to further examine the differences between the clusters identified in the cluster analysis. Results revealed that the new sample was partitioned into two clusters. Individuals with ascertained acquired pedophilia were grouped together. The clusters widely differed for the prevalence of red flags (mean number of red flags in each cluster: 2.14 ±â€¯0.79 vs 4.96 ±â€¯0.93, p < 0.001), while no between cluster difference emerged for the other clinical and behavioral variables. Regression analysis provided a robust model that included the three most significant red flags that explain over 64.5% of the variance (absence of masking, spontaneous confession and offenders older age). An organic origin of pedophilic behavior should be suspected if red flags are present in a defendant charged with pedophilia. In those cases, an in depth trans-disciplinary neuroscientific investigation is advocated. The behavioral profile identified might help to provide a proper assessment of defendants.

In search of disorders: internalizing symptom networks in a large clinical sample.

BACKGROUND: The co-occurrence of internalizing disorders is a common form of psychiatric comorbidity, raising questions about the boundaries between these diagnostic categories. We employ network psychometrics in order to: (a) determine whether internalizing symptoms cluster in a manner reflecting DSM diagnostic criteria, (b) gauge how distinct these diagnostic clusters are and (c) examine whether this network structure changes from childhood to early and then late adolescence. METHOD: Symptom-level data were obtained for service users in publicly funded mental health services in England between 2011 and 2015 (N = 37,162). A symptom network (i.e. Gaussian graphical model) was estimated, and a community detection algorithm was used to explore the clustering of symptoms. RESULTS: The estimated network was densely connected and characterized by a multitude of weak associations between symptoms. Six communities of symptoms were identified; however, they were weakly demarcated. Two of these communities corresponded to social phobia and panic disorder, and four did not clearly correspond with DSM diagnostic categories. The network structure was largely consistent by sex and across three age groups (8-11, 12-14 and 15-18 years). Symptom connectivity in the two older age groups was significantly greater compared to the youngest group and there were differences in centrality across the age groups, highlighting the age-specific relevance of certain symptoms. CONCLUSIONS: These findings clearly demonstrate the interconnected nature of internalizing symptoms, challenging the view that such pathology takes the form of distinct disorders.

A data-driven method for identifying shorter symptom criteria sets: the case for DSM-5 alcohol use disorder.

BACKGROUND: Although the DSM is a widely used diagnostic guide, lengthy criteria sets can be problematic and provide the primary motivation to identify short-forms. Using the 11 diagnostic criteria provided by the DSM-5 for alcohol use disorder (AUD), the present study develops a data-driven method to systematically identify subsets and associated cut-offs that yield diagnoses as similar as possible to use all 11 criteria. METHOD: Relying on data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), our methodology identifies diagnostic short-forms for AUD by: (1) maximizing the association between the sum scores of all 11 criteria with newly constructed subscales from subsets of criteria; (2) optimizing the similarity of AUD prevalence between the current DSM-5 rule and newly constructed diagnostic short-forms; (3) maximizing sensitivity and specificity of the short-forms against the current DSM-5 rule; and (4) minimizing differences in the accuracy of the short-form across chosen covariates. Replication is shown using NESARC-Wave 2. RESULTS: More than 11 000 diagnostic short-forms for DSM-5 AUD can be created and our method narrows down the optimal choices to eight. Results found that 'Neglecting major roles' and 'Activities given up' could be dropped with practically no change in who is diagnosed (specificity = 100%, sensitivity ⩾ 99.6%) or the severity of those diagnosed (κ = 0.97). CONCLUSIONS: With a continuous improvement model adopted by the APA for DSM revisions, we offer a data-driven tool (a SAS Macro) that identifies diagnostic short-forms in a systematic and reproducible way to help advance potential improvements in future DSM revisions.

Contemporary Nomenclatures of Suicidal Behaviors: A Systematic Literature Review.

Addressing the lack of comparability of research results around the world, a systematic literature review of existing nomenclatures was conducted. After distinguishing the concepts of nomenclature and classification, 13 contributions to nomenclature of suicidal behavior are described and summarized using outcome and intent as guiding concepts for analysis. The issue of what is being defined in nomenclatures is fundamental and impacts the way intent and outcome are used. The existing confusion between classification and nomenclature stems from conflicting purposes of the nature of definition; that is, to communicate concepts versus to be descriptive of reality.

Types of Smokers Who Seek Smoking Cessation Treatment According to Psychopathology.

Psychopathology and psychological distress have been shown to be related to poor smoking cessation outcomes and abstinence maintenance. Thus, it is important to identify individuals with high levels of psychopathology before undergoing smoking cessation treatment in order to increase their likelihood of success. OBJECTIVE: The primary aim of the present study was to analyze whether we could classify smokers by using self-reported measures of psychopathology. In addition, a secondary aim was to examine if there were significant differences among the groups of smokers regarding sociodemographic information, nicotine dependence, and cessation rates at the end of treatment and at 6- and 12-month follow-ups. METHODS: Participants were 281 smokers seeking smoking cessation treatment. Participants were classified into different smoking groups by using a 2-step cluster analysis based on baseline scores on the Restructured Clinical (RC) scales of the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF), Beck Depression Inventory-II (BDI-II), and State-Trait Anxiety Inventory (STAI). RESULTS: Smokers were classified into 3 groups according to levels of psychopathology: Low (n = 158), Intermediate (n = 78), and High (n = 45). Smokers in the High Group were more likely to present higher levels of psychopathology and to continue smoking at the end of treatment when compared with the two other clusters. In addition, smokers classified in this group were more likely to be nicotine dependent and from a low social class. CONCLUSIONS: A subgroup of smokers can be easily identified through self-report measures of psychopathology. Furthermore, these individuals were more likely to continue smoking at the end of treatment. This suggests that this group with high levels of psychopathology might benefit from future interventions that are more intensive or cessation treatments targeted to their specific characteristics.

The Structure of Psychopathology in Early Adolescence: Study of a Canadian Sample: La structure de la psychopathologie au début de l'adolescence: étude d'un échantillon canadien.

OBJECTIVE: The current study investigates the correlational structure of psychopathology in a large sample of Canadian adolescents and highlights the association between the psychopathological dimensions and gender. METHOD: Data came from 3826 Canadian adolescents aged 12.8 ± 0.4 y. Five alternative dimensional models were tested using confirmatory factor analysis, and the association between gender, language, and the mean level of psychopathological dimensions was examined using a multiple-indicators multiple-causes model. RESULTS: A bifactor model with 1 general psychopathology factor and 3 specific dimensions (internalizing, externalizing, thought disorder) provided the best fit to the data. Results indicated metric invariance of the bifactor structure with respect to language. Females reported higher mean levels of internalizing, and males reported higher mean levels of externalizing. No significant sex differences emerged in liability to thought disorder or general psychopathology. The presence of a general psychopathology factor increased the association between gender and specific dimensions. CONCLUSIONS: The current study is the first to highlight the bifactor structure including a specific thought disorder factor in a Canadian sample of adolescents. The findings further highlight the importance of transdiagnostic approaches to prevention and intervention among young adolescents.

Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to Classify Suicidal Behaviors.

Efforts to better understand and prevent suicide have increasingly pointed to the prospective assessment of suicidal behaviors in clinical trials. These assessments are aided by instruments such as the Columbia-Suicide Severity Rating Scale (C-SSRS), which have sought to improve the conceptual uniformity and ease by which suicidal behaviors are classified. At the same time, assessment and classification of suicidal behaviors has been a longtime challenge in the field. To aid users of the C-SSRS, this article illustrates the use of the C-SSRS in instances where classification complexities arise. Illustrations are presented based on cases encountered during a clinical trial for a suicide prevention intervention. Key decision points are summarized and classification issues that warrant consideration for future refinement of such decisions are discussed.

Cross-Domain Symptom Development Typologies and Their Antecedents: Results From the UK Millennium Cohort Study.

OBJECTIVE: Typologies of symptom development have been used to identify individuals with different symptom development in the externalizing and internalizing domains of child psychopathology separately despite the domains' high comorbidity and shared common etiologic risk. This study identified typologies of development jointly across the 2 symptom domains in childhood and investigated their associated antecedents with a specific focus on the comparisons between overall severity of symptoms and symptom expression in one or the other domain. METHOD: Latent class analysis identified groups based on emotional and behavioral symptoms assessed at 3, 5, 7, and 11 years in the UK Millennium Cohort Study (N = 15,439). Different sociodemographic, family structure and environment, birth, infancy, and early childhood antecedents were examined. RESULTS: Five groups were identified: 1. low symptoms (57%), 2. moderate behavioral (21%), 3. moderate emotional (12.5%), 4. high emotional and moderate behavioral (5.5%), and 5. high behavioral and moderate emotional (4%). Higher symptoms were predicted by larger numbers of antecedents and risk factors compared with the low symptom group and compared with moderate and high levels of symptoms in either domain (groups 5 versus 2 and 4 versus 3). Comparisons of groups with similar overall symptom levels but different dominant symptom domain (groups 2 versus 3 and 4 versus 5) indicated that apart from gender and ethnicity, there were few unique antecedents of whether children mainly internalize or externalize their symptoms. CONCLUSION: It is possible and useful to define groupings or typologies jointly across externalizing and internalizing symptom development in childhood. Although numerous antecedents predict the experience of symptoms, there are few unique antecedents that differentiate individuals with similarly high levels of psychopathology expressed mainly as internalizing or externalizing symptoms. Identification of at-risk children and delivery of early intervention might benefit from a decreased focus on symptom domain with possible downstream effects through the life course for most common psychiatric disorders.

Thematic Mapping Maps Much Territory But Needs Stronger Evidence-based Coordinates: A Commentary.

Thematic mapping (TM) is a transtheoretical, transdiagnostic, pattern-focused method of case formulation. It involves systematically gathering a broad range relevant client information, collecting representative behavioral episodes, using inductive and deductive reasoning to identify themes and subthemes that characterize a client's dysfunctional patterns, and then developing a treatment plan to address them. The TM method includes debiasing steps to minimize clinician judgment errors and addresses a client's cultural context. TM was developed in response to several "case misconceptualizations" that the authors contend have created a crisis in the field of case conceptualization. This commentary critiques the case misconceptualizations and the TM method is evaluated. Acknowledging multiple innovations of TM, the commentary recommends a stronger evidence-based focus, and discusses the benefits of theory-guided case formulation, reasons to consider diagnosis in case formulation, and research as a means to resolve case misconceptualizations.

Grouping Youth With Similar Symptoms: A Person-Centered Approach to Transdiagnostic Subgroups.

OBJECTIVES: The present study extracted symptom profiles based on parent and youth report on a broad symptom checklist. Profiles based on parent-reported symptoms were compared to those based on adolescent self-report to clarify discrepancies. METHOD: The current study used archival data from 1,269 youth and parent dyads whose youth received services at a community mental health center. The mean age of the sample was 14.31 years (standard deviation = 1.98), and the youth sample was half male (50.1%) and primarily Caucasian (86.8%). Latent profile analysis was used to extract models based on parent and self-reported emotional and behavioral problems. RESULTS: Results indicated that a 5-class solution was the best fitting model for youth-reported symptoms and an adequate fit for parent-reported symptoms. For 46.5% of the sample, class membership matched for both parent and youth. CONCLUSION: Latent profile analysis provides an alternative method for exploring transdiagnostic subgroups within clinic-referred samples.

Pathological laughter and crying: A case series and proposal for a new classification.

BACKGROUND: Disorders of laughter and crying (DLC) are seen in several neuropsychiatric conditions. Their nomenclature remains under debate. METHODS: We present the clinical and imaging findings of 17 patients with DLC and introduce a new classification based on phenomenology and pathogenesis. According to intensity and frequency of laughter and crying (observed behavioral output), patients were divided into hypoactive or hyperactive DLC and subdivided into 5 subtypes: sensory (positive and negative), motor (positive and negative), and mixed. The sensory subtype is represented by disorders of "feeling processing," whereas the motor subtype is represented by disorders of "emotion processing." "Positive" and "negative" describe elicitation by irritative vs destructive lesions, respectively. RESULTS: Among the patients studied, DLC resulted from ischemic stroke (n = 12), intracerebral hemorrhage (n = 2), gunshot wound (n = 1), amyotrophic lateral sclerosis (n = 1), or vestibular migraine (n = 1). Ten patients had lesions in the brainstem, 4 in the cerebral hemispheres, and 2 in sub-cortical-diencephalic structures. Six patients had negative motor DLC, 5 had positive sensory DLC, 4 had negative sensory DLC, and 2 had positive motor DLC. Phenomenology changed or progressed to mixed DLC in 7 patients. CONCLUSIONS: This novel phenomenological and pathomechanistic nomenclature explains all subtypes of DLC in neurologic, medical, and psychiatric conditions. Future studies are needed to validate it prospectively.

Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department.

BACKGROUND: Classification of Psychiatric Emergency Presentations (PEP) is not sufficiently clear due to their inherent high inter-subjectivity and lack of validated triage instruments. In order to improve current classification of psychiatric emergency presentations (PEP) at Emergency Departments, we implemented and validated the Color-Risk Psychiatric Triage (CRPT), an instrument for classifying PEP risk by sorting one to five color/risk levels and one to thirty-two possible conditions arranged by risk. METHODS: Users who visited the Emergency Department (ED) of a Mexican psychiatric hospital from Dec 1st, 2008 to Dec 1st, 2009 were included. One CRPT was assessed by an ED psychiatrist to each patient upon their arrival to ED. Some patients were randomly assessed simultaneously with an additional CRPT and a Crisis and Triage Rating Scale (CTRS) to test validity and reliability of the CRPT. RESULTS: A total of 7,631 CRPT assessments were included. The majority of PEP were non-urgent (74.28 %). For the validation phase n = 158 patients were included. CRPT score showed higher concurrent validity than CRPT color/risk. CRPT level/risk and score showed highest concurrent validity within dangerousness domain of CTRS (r = 0.703, p < 0.0001). CRPT and CTRS scores showed similar predictive validity (p < 0.0001). High intraclass correlation coefficient (0.982) and Cohen's Kappa (0.89) were observed for CRPT score (r = 0.982, p < 0.0001). CONCLUSIONS: CRPT appeared to be a useful instrument for PEP classification due to its concurrent validity, predictive validity and reliability. CRPT score showed higher correlations than the CRPT color/risk. The five levels of risk provided by the CRPT appear to represent a simple and specific method for classifying PEP. This approach considers actual or potential risk, rather than severity, as the main factor for sorting PEP, which improves upon the current approach to emergency classification that is mainly based on the criterion of severity. Regardless of the triage procedure, emergency assessments should no longer classify PEP as "not real emergencies."

Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition.

BACKGROUND: Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome. The International Psychogeriatric Association formed an Agitation Definition Work Group (ADWG) to develop a provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies. A consensus definition will facilitate communication and cross-study comparison and may have regulatory applications in drug development programs. METHODS: The ADWG developed a transparent process using a combination of electronic, face-to-face, and survey-based strategies to develop a consensus based on agreement of a majority of participants. Nine-hundred twenty-eight respondents participated in the different phases of the process. RESULTS: Agitation was defined broadly as: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related). A majority of the respondents rated all surveyed elements of the definition as "strongly agree" or "somewhat agree" (68-88% across elements). A majority of the respondents agreed that the definition is appropriate for clinical and research applications. CONCLUSIONS: A provisional consensus definition of agitation has been developed. This definition can be used to advance interventional and non-interventional research of agitation in patients with cognitive impairment.

The new approach to classification: rethinking cognition and behavior in epilepsy.

There has been considerable debate surrounding the benefits and drawbacks of the new approach to classifying the epilepsies released by the ILAE Commission on Classification and Terminology (2005-2009). This new approach has significant implications for the way we conceptualize and assess cognition and behavior in epilepsy; however, as yet, there has been limited discussion of these issues in the field. The purpose of this Targeted Review is to spark this discussion by encouraging researchers and clinicians to think about the changes that the new approach may bring. These may include (i) reframing the way we think about the comorbidities of epilepsy, (ii) more precisely characterizing the cognitive and behavioral phenotypes of electroclinical syndromes, (iii) more carefully mapping the longitudinal trajectory of cognitive and behavioral features relative to the timing of seizures, and (iv) considering the links between cognitive, behavioral, and neurological phenotypes in the new classification scheme. It is hoped that such changes will aid translation of the advances in cognitive and behavioral neuroscience into routine clinical practice by providing purer markers of disease and more targeted treatments. A Special Issue canvassing such issues will be forthcoming that will consider current knowledge of the cognitive and behavioral features of the epilepsies from the view of the new classification scheme.

Heterogeneous symptom patterns of sexually abused children in treatment: understanding the complexity of the problem.

A major challenge for clinicians and researchers is the heterogeneity of the severity and type of symptoms presented by sexually abused youth, including those who are subclinical on traditional clinical measures but still present to treatment. Most research continues to treat sexually abused youth as a single population and has not assessed the outcomes or symptom trajectories of various groups of sexually abused youth. Participants included 107 sexually abused children and their nonoffending parents presenting to a cognitive-behavioral group treatment. A cluster analysis using child- and parent-report measures revealed four profiles, including Subclinical, Highly Distressed, Problem Behaviors, and Self-Reported Distress clusters. Hierarchical linear modeling was used to create separate child- and parent-report models of weekly symptomatology to examine differential change over the course of treatment. Contrary to expectation, there was little variation in the weekly rates of change for the different symptom groups; however, all groups evidenced a decrease in symptoms over the course of treatment, including the Subclinical cluster.