Context and Diagnosis

Which Philosophy to Guide Psychiatry
Prof. dr. J. van Os
Nature, 2011
Societal Changes
Psychiatric beds - Western Europe
Psychiatric hospital beds per 100000
500
400
Health gains are meaningless if
there is no opportunity
Austria
Belgium
Cyprus
Denmark
Finland
France
Germany
Greece
Iceland
Ireland
Italy
Luxembourg
Malta
Netherlands
Norway
Portugal
Spain
Sweden
United Kingdom
300
200
Therefore: combat Stigma
100
Source: WHO
0
1970
The European AO Situation
**
*
**
*
*
1980
1990
2000
2010
UK Decommissioning of ACT
AO Dimensions
In Order to Introduce FACT?
Admission prevention
Social Participation
Crisis management,
medication-based
symptom reduction
Empowerment and
Social participation
Team organisation
Treatment content
?
Treatment Beyond Symptoms
User-run Recovery Programme
7
control
user-run
6
5
*
4
3
*
2
1
Am J Psychiatry, 2013
100%
Proportion
NNT=5
12 months 24 months
50%
PR
CC
0%
Obtained
Goal
Confidence
Symptoms
Empowerment
Loneliness
Boevink, Kroon, van Vugt, Delespaul, van Os, submitted
Psychiatric Rehabilitation (PR) vs Control Condition (CC)
NNT=5
QoL
Societal
Participation
Living
Independently
Swildens, van Busschbach, Michon, Kroon, Koeter, Wiersma & van Os, 2012
Supported Employment
Supported Employment per Country
Proportion at least one day worked
Psychiatric Stereotyping
Victimisation
Diagnosis
Pressure to assume diseased brain identity
Stigma
Burns et al, Lancet, 2007
Psychiatric Stereotyping
Self-stigma
Care dependence
The Journal “Science”
Schizophrenia is a “devastating
brain disease”
Nature, Science, PNAS, JAMA etc
Diagnosis is Greatest Disadvantage
The Swedish Model
NØ DIAGNOSES?
Thornicroft et al, Lancet, 2009
Calling People Things
From DSM-IV to DSM-5
Peter Kinderman, EBMH, 2013
Stereotypen in discussie rond DSM5
(Commerciële) Media
(Commerciële) Big Pharma
(Semi-commerciële) De GGz
De verzekeraar
De neurowetenschap
De betrokkenen
De patiënten
Media Stereotypes
Media
Stereotypes
Media Stereotypes
Waarom een Diagnose?
Diagnose Schizofrenie
Zwakke relatie met
behandeling
Zwakke relatie met
prognose
Fuzzy Boundaries
Mental Disorders are Fuzzy Sets
Fuzzy typologies
sets
Diagnostic
What is ill?
1980
2012
Cat1
Cat2
well
Cat3
Verschuivende Grenzen Ziekte
Bloeddruk
Bloedsuiker
Eenzelvigheid
Somberheid
Activiteit
ill
Marktwerking in de GGZ onder DSM4
Ernstig
4%
8%
Hypertensie
Diabetes
?
€2.000.000.000
GGZ
€6.000.000.000
Depressie
ADHD
Autisme
Kwetsbaar
Zelfmanagement
De Handel in Diagnosen
Overdiagnosis & Overtreatment:
PUBMED trends
Er is geen medicatie voor autisme
GGZ consumptie voor autisme is
wel spectaculair gerezen
Heeft te maken met vergoedingen
verbonden aan DSM diagnose
Onderbehandeling & Overbehandeling
ONDERbehandeling
OVERbehandeling
Diagnostic Paradigm
Level 1
Verzekeraars beperken risico
Level 2
Level 3
The Dominant Paradigm
Level 1
Level 2
Biological
DSM / ICD
CATEGORY
Mechanismbased
Mental
Symptombased
Level 3
Biological
DSM / ICD
CATEGORY
Mechanismbased
Medisch Zien en Handelen
‘-OMES, ‘-OMICS and Psychiatry
Nature, 2013
Biology: Organ Model in Neuroscience
Biology: “hardware” alterations?
World Psychiatry, 2013
Kidney
Brain
Urine
Mind
Mental: “software” alterations?
Eg lesions in the neural substrate
Environmental Effects?
World Psychiatry, 2013
eg maladaptive operating rules acquired by (environmental) learning
Nature, 2010



Mental Mechanism: Being Different
Developmental Trauma
Childhood Trauma and Psychosis
The Guiding Model
OR case-control: 2.72, (18 studies; N=pat: 2048, con: 1856)
OR population-based: 2.99 (8 studies; N=35546)
OR (quasi)-prospective studies: 2.75 (10 studies; N=41803)
Context and Diagnosis
Macro-level
Exercise
sensitive
Contextual Psychiatry
Micro-level
Environment
Stress-reactive
24-hrs BP
monitoring
Preserved
nocturnal dip
Neural
function
Experience
DSM5 / ICD11 Categoriëen
CAT1
CAT2
CAT3
CAT4
How to Model Psychopathology
CAT5
Latent Construct
Depr
Salience
Disorg
Cognition
Drive
DSM5 “schizophrenia”
The Symptom Network
One thing leads to another
Pos
Cog
Neg
Paranoia
Affective
dysregulation
Dis
Dep
Insomnia
Hartmann et al, BJPsych, in press
Mood  Psychosis
0.5
Effect size on
psychotic experiences
Freeman et al, J Psychiatr Res, 2010
A Novel Diagnostic Approach?
EDSP (n=3024) & NEMESIS (n=7076)
Risk need
for care
0.4
0.3
0.2
clarified.
0.1
0
Van Rossum et al, 2011; Regeer et al, 2006
Number of depressive symptoms
McGorry and Van Os, Lancet, 2013
Precision Diagnosis: Staging and Mental Causation
PsyMate®
Stage of non-specific
mental distress
(Mobile Precision Diagnostics)
Stage of specific
mental syndrome
Syndrome 1
Syndrome 3
Syndrome 2
McGorry & Van Os, Lancet, 2013
Mental state 1
Mental state 2
Context 1
Fusar-Poli & Van Os, Acta Psych Scan, 2012
Mental state 1
Mental state 2
Context 2
Experience Sampling Method (ESM)
www.PsyMate.eu
Precision Diagnosis
“HUB”
Beep 1
Positive
Beep 2
DAY 1
Beep 3
DAY 2
Beep 4
+ event
̶ event
Irritable
Low
DAY 3
Beep 5
DAY 4
(day 4 in detail)
Beep 6
DAY 5
Beep 7
DAY 6
Beep 8
DAY X
Beep 9
Paranoia
Beep 10
Van Os et al, Psychological Medicine, in press
Symptoms represent complex mental state dynamics
Wigman et al, PLoS One, in press
1
Stages of Severity
& Specificty
2
PATIENT A
3
4
5
Stage 1
Level of
psychosis
6
1
1
2
event
activity
work exercise
THC
company
event
4
3
2
5
4
3
5
6
6
Stage 2
PATIENT B
1
Level of
psychosis
2
4
voices
voices
6
Stage 3
Wigman et al, in preparation
1
3
2
5
4
6
1
3
2
5
4
3
5
6
Intervention at “Hub” level
Early Intervention
Functioning
Situated Therapeutics
Life course
MindMaastricht RCT
Proof of Principle: Anhedonia Treatment
Ability to use natural rewards in daily life
Positive
affect
Sample: 130 participants with SMI and subthreshold
symptoms of depression
6 days Experience Sampling Mindfulness Training
Control
6 days Experience Sampling FU 6 months
FU 12 months
Geschwind et al, J. Consulting & Clinical Psychology, 2011
PA Persistence over Time
Positive Emotions
Positive Emotions
Daily‐Life Reward Intervention
Flow of Daily Life
Flow of Daily Life
PsyMate RCT: Add-on to pharmacotherapy
Emotional resilience in SMI: RCT
Sample: 102 subjects with depression or residual symptoms
PsyMate feedback
Type Activiteiten
Positive emotions per activity
TAU + PsyMate + feedback
active relaxation activity
passive relaxation activity
Baseline
PsyMate
doing nothing or resting
talking
self care
Pseudo‐intervention
TAU + PsyMate
Post
PsyMate
eating/drinking
on the way
Control
household activities
active relaxation
talking
eating/drinking
household activities
passive relaxation
self care
on the way
doing nothing/resting
not at all 1
2
3
4
5
6
7 much
Depressive symptoms
FU 1,2,3 & 6 months
TAU
Positive emotions
Wichers et al, 2011; Wichers et al, 2012
REMOD Trial Results NA
REMOD Trial Results PA
Is damage to the neural substrate
necessary for mental dysfunction?
Contextual Psychiatry
Environment
Mental
Truth
Knowledge
Biology
Beliefs
Neural
function
Experience
Fin