Implications of comorbidity: lessons from epidemiological studies

Objective: The paper discusses conceptual, methodological and clinical issues of comorbidity from the perspective of more recent epidemiological studies. Further the potential causal and pathogenic role of temporally primary disorders for the onset of secondary disorders is evaluated. Results: The available data suggest so far that comorbidity (a) is not an artefact of assessment strategies, sampling or design features, (b) is specific in different disorders, (c) is particularly frequent in anxiety and affective disorders, (d) affects systematically the course of the comorbid conditions and (0 might be related to symptom progression models. Conclusions: Furthermore, evidence is presented that specific forms of primary anxiety disorders affect the risk for secondary depressive disorders, increase the likelihood of non-remission as well as the number of subsequent depressive episodes.Scopo: Lo studio affronta problemi concettuali, metodologici e clinici della comorbidità, alia luce dei piu recenti studi epidemiologici. Inoltre viene valutata la causa potenziale e il ruolo patogenetico dei disturbi temporaneamente primari per la comparsa dei disturbi secondari. Risultati: I risultati disponibili fino ad oggi suggeriscono che la comorbidità (a) non è un artefatto delle strategic di valutazione, del campionamento o del disegno, (b) è specifica nei differenti disturbi, (c) e particolarmente frequente nei disturbi affettivi e d'ansia, (d) influisce sistematicamente sull'andamento delle condizioni di comorbidita è (f) potrebbe essere correlata con modelli di evoluzione dei sintomi. Conclusioni: È inoltre evidente che forme specifiche di disturbi di ansia primaria comportano il rischio di sviluppare disturbi depressivi. secondari, aumentano la probability di non remissione cosi come il numero di successivi episodi depressivi

Patterns of Use and Their Relationship to DSM-IV Abuse and Dependence of Alcohol among Adolescents and Young Adults

First use and initiation of regular alcohol use has been frequently found to start in adolescence. However, only few studies have also investigated how many adolescents proceed during ages 14–24 to harmful drinking or even develop alcohol use disorders. This paper – using the EDSP baseline sample of 3,021 community respondents from the Munich area – examines the prevalence of use, abuse and dependence and investigates the dose/disorder relationship. Alcohol abuse was reported by 9.7% of respondents and alcohol dependence by 6.2%. Men were more likely to report an alcohol disorder than women, prevalence also increased in the older age cohorts. However, even among 14- to 17-year-olds a substantial proportion of respondents report high and regular consumption rates, the occurrence of abuse and dependence criteria and even a full dependence syndrome. There is however only a moderate association between average number of standard drinks consumed with the risk of developing abuse and dependence. In light of the substantial rates among adolescents and young adults the validity of DSM-IV alcohol disorder criteria is discussed

Smoking and Nicotine Dependence: Results from a Sample of 14- to 24-Year-Olds in Germany

This paper describes the distribution of dependence criteria and diagnoses in a sample of 14- to 24-year-olds from Munich, Germany (n = 3,021; 71% response rate), evaluates differences between nondependent and dependent smokers and examines associations of smoking with other substances, affective and anxiety disorders. Assessment was made using the M-CIDI. The lifetime prevalence of DSM-IV nicotine dependence in the total sample is 19%, rising to 52% among regular smokers. No gender differences were seen in the progression from regular smoking to nicotine dependence, although men were more likely than women to initiate regular use. Analysis of daily cigarette use identified a significant dose-response relationship with the number of endorsed DSM-IV dependence criteria with unsuccessful cut-backs being the most prevalent criterion. As compared to nondependent smokers, dependent smokers were more likely to associate negative health effects with smoking and to have a desire to change and attempt a change in their pattern of use. Regular use of nicotine was found to be significantly associated with other substance and nonsubstance disorders, although dependent regular use was more strongly associated with these disorders than nondependent regular use. These results indicate that daily smoking is a behavior which is resistant to change despite an expressed desire and repeated cut-back attempts. Although initiation of regular smoking among nonsmokers does not occur frequently after the early twenties, the risk for dependent smoking among regular users persists into adulthood and is associated with a range of mental disorders

Epidemiologie der Sozialen Phobie

Aus der Einleitung: "In den vergangenen 15 Jahren sind in verschiedenen Ländern der Welt größere epidemiologische Studien zur Häufigkeit psychischer Störungen in der Allgemeinbevölkerung durchgeführt worden, die auch eine grobe Abschätzung der Häufigkeit Sozialer Phobien erlauben. Ein Überblick über diese Studien ergibt allerdings auf den ersten Blick ein recht verwirrendes Bild, da die Prävalenzabschätzungen der verschiedenen Studien eine scheinbar widersprüchliche Befundlage erkennen lassen. Ältere - vor Einführung expliziter diagnostischer Kriterien für Soziale Phobi durchgeführte Studien aus den 60er und frühen 70er Jahren - schätzten die Prävalenz dieses Krankheitsbildes auf lediglich 1% (1). [...]

Klinische Psychologie und Verhaltenstherapie - zwischen Aufstieg und Erosion

Der Beitrag diskutiert Probleme der raschen Weiterentwicklung von Klinischer Psychologie und der Verhaltenstherapie im besonderen. Dabei werden drei Perspektiven angesprochen: (a) Binnenbeziehungen innerhalb des Fachs Klinische Psychologie sowie zu Nachbardisziplinen, (b) Transferprobleme wissen-schaftlicher Erkenntnisse von der Forschung zur Praxis und (c) Probleme der Fort– und Weiterbildung sowie der Qualitätssicherung in der Verhaltenstherapie. Als Beispiele von Fortschritt und Erosion werden diskutiert: (a) die Verhaltensmedizin, als Muster für gut abgestimmte und in die Klinische Psychologie als Fach integrierte Entwicklung, (b) die Gesundheitspsychologie für eine schlechte Interaktionskultur mit mangelhaftem gegen-seitigem Informatiûnstransfer und (c) die Psychotherapieszene als Beispiel für Erosionsprozesse in Forschung, Praxis sowie vor allem Fort– und Weiterbildung. Der Beitrag fordert eine wesentliche Stärkung des Fachs Klinische Psychologie als fachliche und organisatorische Klammer zwischen den auseinanderdriftenden Entwicklungen. Eine erfolgreiche Übernahme dieser universitär verankerten Koordinations- und Integrationsaufgabe erfordert allerdings gleichzeitig auch eine erhebliche Ausweitung personeller Ressourcen und fachlicher Kompetenzen. Eine zentrale neue Herausforderung für klinisch-psychologische Universitätsinstitute besteht auch in der Entwicklung von Qualitätssicherungsmaβnahmen. Der Beitrag empfiehlt in diesem Zusammenhang, vor allem in der Fort– und Weiterbildung den verstärkten Einsatz von Therapiemanualen sowie die Institutionalisierung von regelmäβigen Konsensuskonferenzen mit Empfehlungen zur Therapiedurchführung.This paper discusses progress and erosion aspects of c1inical psychology and behavior therapy in Germany from three interrelated perspectives: (a) the relationship of behavior therapy and c1inical psychology to other basic and applied psychological disciplines as weIl as neighboring disciplines, (b) the transfer problems from the scientific fields to practice, and (c) the problem of quality assurance in practice and postgraduate education. Specific emphasis is laid on a discussion of the field of behavioral medicine, as an example for well-integrated and coordinated research and practice activities; health psychology as an example for deficient communication patterns with clinical psychology and behavior therapy, and psychotherapy as an example for erosion in research, education and practice. The paper strongly recommends a more dominant steering role of clinical psychology as the most comprehensive scientific discipline. This steering role, however, would also require a considerably expanded infrastructure of clinical psychology departments in universities together with several mechanisms (competence enhancement, consensus conferences, development of postgraduate education guidelines, quality assurance activities, coordination) to be able to fulfill this mission. The paper also suggests the more frequent use of standardized treatment manuals in postgraduate courses

Der Langzeitverlauf unbehandelter Angststörungen: Wie häufig sind Spontanremissionen?

Der Langzeitverlauf und die Häufigkeit sogenannter spontaner Remissionen wurde anhand von 77 Fallen mit einer Lifetime-Diagnose einer Angststörung untersucht. Die 77 Angstfälle wurden als Teil der Münchner Follow-up-Studie im Rahmen einer allgemeinen Bevölkerungsuntersuchung im Jahre 1974 identifiziert und wurden über einen Zeitraum von sieben Jahren (bis 1981) weiter untersucht. Die Diagnosen wurden einerseits durch ein standardisiertes diagnostisches Instrument (den DIS), andererseits über eine klinisch-psychiatrische Nachuntersuchung (1981) abgesichert. In Ergänzung hierzu wurde der Verlauf der psychopathologischen Symptome sowie die psychologische und psychosoziale Integration der Versuchspersonen beurteilt. Ergebnisse: Die Lebenszeit-Prävalenz, irgendeine Anststörung zu entwickeln, betrug 13,9%. Einfache und soziale Phobien wiesen eine Prävalenz von 8,0%, Agoraphobie von 5,7%, Zwangsstörungen von 2,0% und Panikstörungen von 2,4% auf. Die Inzidenz, d.h. das Auftreten neuer Fälle im Zeitraum zwischen der Erst- und Zweituntersuchung war niedrig, mit Ausnahme für Panikstörungen (1,2%, bei einer Gesamtprävalenz von 2,4%) und Agoraphobie (1,3% bei einer Gesamtprävalenz von 5,7%). Die Komorbidität war sowohl innerhalb der Angststörungen wie auch bezüglich anderer psychischer Störungen erhöht. 62% hatten mehr als eine Angstdiagnose, Major Depression und Abhängigkeit von Alkohol oder Medikamenten waren die häufigsten komorbiden Störungen, die in der überwiegenden Mehrzahl deutlich nach dem Beginn der Angststörung auftraten. Spontanremissionen wurden auf drei unterschiedlichen Ebenen definiert, von denen ein Kombinationsmaβ als Hauptergebnis interpretiert wurde. Danach war die symptomatische Remission in alien Angstgruppen niedrig, während die psychosoziale Remissionsrate ein günstigeres Bild mit Remissionsraten zwischen 28,6% für Panikstörung und 53,1% für einfache und soziale Phobien ergab. Das kombinierte spontane Remissionsmaβ ergab für keine der Zwangsstörungen, nur 14,3% der Panikstörungen, 19,2% der Agoraphobien und 18,8% der einfachen und sozialen Phobie eine voile Remission. Die Ergebnisse unterstreichen, daβ Angststörungen zumeist in der Kindheit oder frühen Adoleszenz beginnen und dazu neigen, chronisch über den Groβteil des Lebens zu persistieren und nur selten zu remittieren

Comorbidity patterns in adolescents and young adults with suicide attempts

The role of comorbidity as a risk for suicide attempts is investigated in a random sample of 3021 young adults aged 14–24 years. The M-CIDI, a fully standardized and modified version of the Composite International Diagnostic Interview, was used for the assessment of various DSM-IV lifetime and 12-month diagnoses as well as suicidal ideation and suicide attempts. Of all suicide attempters, 91% had at least one mental disorder, 79% were comorbid or multimorbid respectively and 45% had four or more diagnoses (only 5% in the total sample reached such high levels of comorbidity). Suicide attempters with more than three diagnoses were 18 times more likely (OR = 18.4) to attempt suicide than subjects with no diagnosis. Regarding specific diagnoses, multivariate comorbidity analyses indicated the highest risk for suicide attempt in those suffering from anxiety disorder (OR = 4.3), particularly posttraumatic stress disorder followed by substance disorder (OR = 2.2) and depressive disorder (OR = 2.1). Comorbidity, especially when anxiety disorders are involved, increases the risk for suicide attempts considerably more than any other individual DSM-IV diagnoses

Familial risk factors in social anxiety disorder: calling for a family-oriented approach for targeted prevention and early intervention

Within the last decade, social anxiety disorder (SAD) has been identified as a highly prevalent and burdensome disorder. Both the characterization of its symptomatology and effective treatment options are widely documented. Studies particularly indicate that SAD aggregates in families and has its onset in early adolescence. Given the family as an important context for children’s cognitive, emotional and behavioural development, familial risk factors could be expected to significantly contribute to the reliable detection of populations at risk for SAD. Reviewing studies on familial risk factors for SAD argues for the importance of parental psychopathology and unfavourable family environment, but also denotes to several shortcomings such as cross-sectional designs, short follow-up periods, diverging methodologies and the focus on isolated factors. Using a prospective longitudinal study that covers the high-risk period for SAD, including a broader spectrum of putative risk factors may help to overcome many of the methodological limitations. This review sets out to develop a more family-oriented approach for predicting the onset and maintenance of SAD that may be fruitful to derive targeted prevention and early intervention in SAD

Prevalence, 20-month incidence and outcome of unipolar depressive disorders in a community sample of adolescents

Background. This article presents prospective longitudinal findings on prevalence, incidence, patterns of change and stability of depressive disorders in a community sample of 1228 adolescents. Methods. Data were collected at baseline and follow-up (20 months later) in a representative population sample of 1228 adolescents, aged 14–17 at baseline. Diagnostic assessment was based on the Munich Composite International Diagnostic Interview (M-CIDI). Results. The overall cumulative lifetime incidence of any depressive condition was 20·0% (major depressive disorder (MDD), 12·2%; dysthymia, 3·5%; subthreshold MDD, 6·3%), of which about one-third were incident depressions in the period between baseline and follow-up. Depressive disorders rarely started before the age of 13. Females were about twice as likely as males to develop a depressive disorder. Overall, the 20-month outcome of baseline depression was unfavourable. Dysthymia had the poorest outcome of all, with a complete remission rate of only 33% versus 43% for MDD and 54% for subthreshold MDD. Dysthymia also had the highest number of depressive episodes, and most psychosocial impairment and suicidal behavioural during follow-up. Treatment rates were low (8–23%). Subthreshold MDD associated with considerable impairment had an almost identical course and outcome as threshold MDD. Conclusions. DSM-IV MDD and dysthymia are rare before the age of 13, but frequent during adolescence, with an estimated lifetime cumulative incidence of 14%. Only a minority of these disorders in adolescence is treated, and more than half of them persist or remit only partly