Ewald Horwath

The epidemiology and cross-national presentation of obsessive-compulsive disorder.

One of the challenges facing modern psychiatry is to determine to what extent the diagnostic categories clinicians have represent valid constructs. Epidemiologic studies are helpful in this regard when their findings are consistent across various cultural or geographic settings or with those of clinical studies. The cross-national epidemiologic data on OCD reviewed in this article are remarkable for their consistency in rates, age at onset, and comorbidity across diverse countries, a fact which lends additional support to the validity of the diagnosis of OCD. The variability in symptom presentation across national sites suggests that cultural factors may affect the symptom expression; however, why the rates of OCD and other psychiatric disorders are so much lower in Taiwan than in other sites, including another Asian site, is unclear. Epidemiologic studies of adolescents and of adults have shown similar prevalence of OCD and substantial comorbidity with major depression and other anxiety disorders. Studies of adolescent populations indicate that OCD symptoms are fairly common among adolescents but not necessarily predictive of developing the full disorder within 1 year of follow-up. Family studies have suggested an association between OCD and TS and other CMT disorders. Clinical studies have suggested an association between Sydenhams chorea and OCD. These various studies provide a growing body of knowledge regarding the nature of OCD. Together with evidence of the substantial demand on mental health services by those afflicted with OCD, the epidemiologic data make a compelling case for additional efforts to improve the understanding and treatment of this troubling disorder.

The validity of major depression with atypical features based on a community study

This article reports on evidence for the validity of major depression (MDD) with atypical features (defined as overeating and oversleeping) as a distinct subtype based on cross-sectional and 1-year prospective data from the Epidemiologic Catchment Area study. MDD with atypical features, when compared to MDD without atypical features, was associated with a younger age of onset, more psychomotor slowing, and more comorbid panic disorder, drug abuse or dependence, and somatization disorder. These differences could not be explained by differences in demographic characteristics or by symptom severity. This study, based on a community sample, found that major depression with atypical features may constitute a distinct subtype.

What are the public health implications of subclinical depressive symptoms

Longitudinal data from a community study of 9900 adults in the United States show that persons with depressive symptoms, as compared to those without such symptoms, were 4.4 times more likely to develop a first onset major depression over one year. The attributable risk, a measure which reflects both the relative risk associated with depressive symptoms (4.4) and the prevalence of exposure to that risk (24%) and is a useful measure for documenting burden of a risk to the community, indicated that more than 50% of first onset major depressions are associated with prior depressive symptoms. Since depressive symptoms have a high prevalence in the community, but are often unrecognized and untreated in clinical practice, we conclude that their identification and the development of effective treatments could have public health implications for the prevention of associated social morbidity, service utilization and major depression.

HIV-1 infection at two public psychiatric hospitals in New York City.

Seroprevalence for HIV-1 was anonymously evaluated between November 1989 and July 1991 among severely mentally ill patients at two public psychiatric hospitals in New York City. The study population consisted of new admissions and long-stay patients aged 18-59. Of 1116 eligible patients, usable samples were obtained from routine blood drawings on 971 (87%). Seroprevalence was comparable among men (5.2%) and women (5.3%). Age did not predict seropositivity. Men with a recorded history of homosexual behaviour or injection drug use were, respectively, 1.8 and 2.0 times more likely to be seropositive than men without these histories. Women with a recorded history of injection drug use were 4.0 times more likely to be seropositive than women without such a history. Ethnicity was not predictive for men, but Black women were 2.4 times more likely to be HIV-1 positive than non-Black women. Severely mentally ill inpatients had a substantial rate of HIV-1 seropositivity, indicating a need for additional testing, education and counselling efforts for this population.

Panic disorder with smothering symptoms: Evidence for increased risk in first-degree relatives

Kleins (1993: Arch Gen Psychiatry 50:306–317) “false suffocation alarm” theory of spontaneous panic attacks posits that central receptors compare CO2, O2, and lactate levels and trigger panic when an impending “false” state of suffocation is detected. Several investigators have found abnormalities of respiratory physiology in subjects with panic disorder. Twin and family studies have suggested that both panic disorder and tidal volume response to CO2 are inherited. We hypothesized that, if smothering symptoms are a marker for a hypersensitive suffocation detector and if this hypersensitivity is familial, then relatives of panic subjects with smothering symptoms would have higher rates of panic with smothering than relatives of panic subjects without smothering. We conducted a family study involving 104 panic disorder probands and 247 of their interviewed first‐degree relatives. Probands and their relatives were interviewed using the Schedule for Affective Disorders and Schizophrenia—Lifetime Version for Anxiety Disorders to determine their panic disorder and smothering symptom status. Relatives of panic probands with smothering symptoms had an almost threefold higher risk for panic and an almost sixfold higher risk for panic with smothering symptoms when compared with relatives of panic probands without smothering. We conclude that panic disorder with smothering symptoms may be a subtype of panic disorder associated with increased familial risk and may be a group of interest to genetic investigators. These findings provide the first empiric evidence from a family study in support of Kleins false suffocation alarm theory of spontaneous panics. Depression and Anxiety 6:147–153, 1997.

Ataques de nervios: Proposed diagnostic criteria for a culture specific syndrome

The authors propose a set of diagnostic criteria and report two cases of ataque de nervios, a syndrome of brief duration seen primarily in Spanish-speaking people of the Caribbean. Following a psychosocial stressor, the afflicted person demonstrates impulsivity, dissociation and communication and perceptual disturbances. The symptoms often begin in the presence of the family, allow a temporary relinquishing of social roles, and result in the mobilization of the social network in support of the person. Further research is needed to improve our understanding of this culture specific syndrome and its relationship to psychiatric disorder.

Patterns of Illness in Parent-Child Pairs Both Hospitalized for Either Schizophrenia or a Major Mood Disorder

Results are reported of a blind rediagnosis of a consecutive series of parent-child pairs hospitalized with a diagnosis of schizophrenia or mood disorder. Patterns of illness in pairs meeting DSM-III-R criteria for either disorder were examined by contrasting the two generations on their respective distributions of diagnoses, and means of age at onset and severity of illness. While no case of mood disorder was found in the children of schizophrenic parents, 50% of the children of parents with psychotic mood disorders presented with schizophrenia. The offspring also had an earlier age at onset of illness than did their parents.

Asceticism: Creative Spiritual Practice or Pathological Pursuit?

Asceticism in a religious context refers to a voluntary and sustained practice of self-denial in which immediate or sensual gratifications are renounced in order to attain a higher spiritual state (Kaelber 1987). Virtually all of the major world religions have within them a way in which the individual, through ascetic practices, can strive to achieve a more thorough absorption in the sacred. Although many psychiatrists might consider any ascetic or religious practice to be pathological, others take a more neutral view by emphasizing that religious or mystical practice can also be adaptive and creative (Group for the Advancement of Psychiatry 1976).

Familial aggregation of delusional depression: Re-examination in a recent family study

Background: Delusional (D‐MDD) and nondelusional depression (ND‐MDD) differ in clinical presentation, biological abnormalities, course of illness, and treatment response. Family data, however, have been less consistent regarding differential risk both for any major depression (MDD) and specifically D‐MDD in relatives of D‐MDD probands. In an earlier family study, we observed a 1.5‐fold increase in rates of any MDD, specificity of transmission of D‐MDD, and increased rates of bipolar disorders in relatives of D‐MDD compared to relatives of ND‐MDD probands. In a new family study, we attempted to replicate these findings.

Comparison of RDC, DSM‐III, DSM‐III‐R diagnostic criteria for generalized anxiety disorder

The diagnosis of generalized anxiety disorder (GAD) has been controversial since its inception. It remains unclear whether more stringent diagnostic criteria, such as in DSM-III-R, have improved the validity of GAD. Family studies suggest that GAD aggregates at least weakly in families of probands with GAD, and support the separation of panic disorder (PD) and GAD. Therefore, we can use a family study design to examine the validity of GAD. Independent familial transmission of GAD supports the validity of GAD. We report here the risk of GAD according to RDC, DSM-III, and DSM-III-R criteria in the first-degree relatives of probands from four diagnostic groups: panic disorder, panic disorder with major depression, early-onset major depression (MDD), and normal controls. We did not find an elevated risk of DSM-III or DSM-III-R GAD in the relatives of any of the ill proband groups compared to the relatives of the never mentally ill when controlling for proband comorbidity for GAD. In contrast, RDC GAD aggregates in the first-degree relatives of probands from both of the PD proband groups (with and without MDD) compared to relatives of the normal control group. The inclusion of cases of subsyndromal panic attacks that did not meet the strict RDC for panic disorder as meeting the less restrictive RDC for GAD may partially account for the familial aggregation of RDC panic disorder and RDC GAD. RDC GAD seems to identify one or more syndrome(s) that may be on the familial spectrum of panic disorder. This syndrome may represent a mild or early variant of panic disorder. We also found a trend for RDC and DSM-III GAD to aggregate in the first-degree relatives of the MDD proband group compared to the relatives of the never mentally ill controls. These data suggest that GAD demonstrates more independent familial transmission from PD and MDD when defined by DSM-III-R criteria than when defined by RDC or DSM-III, and thus support the validity of DSM-III-R GAD.