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COURTESY CIELO DIAZ

THE LEADER IN NEWS AND MEETING COVERAGE
THE LEADER
IN NEWS
AND
MEETING
COVERAGE

D ECEMBER

2009

TREAT PTSD, SUBSTANCE ABUSE AT SAME TIME, PAGE 18

Clinical Psychiatry News

www.clinicalpsychiatrynews.com The Leading Independent Newspaper for the Psychiatrist—Since 1973

Independent Newspaper for the Psychiatrist—Since 1973 V O L . 37, N O . 12 “There’s

VO L .

37, N O.

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“There’s some need to assert the importance of childhood origin” of ADHD in the DSM-V, Dr. F. Xavier Castellanos says.

of ADHD in the DSM-V, Dr. F. Xavier Castellanos says. ADHD Work Group Weighing Options BY

ADHD Work Group Weighing Options

BY ROBERT FINN

H ONOLULU — The publica-

tion of DSM-V will likely in- clude substantial changes in the diagnostic criteria of attention- deficit/hyperactivity disorder. However, the nature of many

of those changes has not yet been finalized, according to three members of the work group who delivered a progress report to a packed—and very lively—audience at the annual meeting of the American Acad- emy of Child and Adolescent Psychiatry. Dr. F. Xavier Castellanos of New York University pointed

out that many aspects of the di- agnosis work well now. “There’s

a lot about ADHD that’s not

broken,” he said. “It turns out that the 18 criteria that we have as a whole work rather well. They are clinically useful; they’ve been validated innu- merable times across multiple cultural settings.” One likely change is the cur-

rent requirement that the pa- tient’s symptoms cause signifi-

cant impairment before the age of 7 years, though the work group believes that eliminating the age requirement entirely would not be a good idea. “We want to differentiate this from something that occurs at age 55 following a stroke or age 25 following a psychotic break,” said Dr. Castellanos, Brooke and

Daniel Neidich professor of child and adolescent psychiatry at the university. “There’s some need to assert the importance of child-

The greatest sen-

timent is toward moving the age

to age 12. And most re-

criteria

hood

cently, we discussed not simply requiring that some impairment

be present by age 12, but in one way, shape, or form the diagno- sis should be in place by age 12. Again, this is very tentative, but that was the most recent discus- sion on the topic.” Another likely change will be the ability to diagnose ADHD in

See ADHD page 28

 

I N S I D E

Psychiatrists Stand Firm

Possible cut in Medicare payments criticized.

PAGE

4

Firm Possible cut in Medicare payments criticized. PAGE 4 Reframing Stimulant Abuse Amelia M. Arria, Ph.D.,
Firm Possible cut in Medicare payments criticized. PAGE 4 Reframing Stimulant Abuse Amelia M. Arria, Ph.D.,

Reframing Stimulant Abuse

Amelia M. Arria, Ph.D., and Dr. Robert L. DuPont issue a challenge to doctors.

PAGE

6

PTSD and the DSM-V

Adding negative mood states to criteria considered.

PAGE

22

negative mood states to criteria considered. PAGE 22 Helping Patients At End of Life Dr. Carl

Helping Patients At End of Life

Dr. Carl C. Bell says psychiatrists’ facility must go beyond prescribing.

PAGE

40

New Data Point to Extent of Trauma At Virginia Tech

More than 15% of students had PTSD.

BY DAMIAN M C NAMARA

A TLANTA — Research is starting to demonstrate the ex- tent to which the differential loss and trauma experienced by students and staff at Virginia Tech on the morning of a shooting rampage more than 2 years ago relates to risk for post- traumatic stress disorder and development of mental illness in general. Russell Jones, Ph.D., professor of psychology at Virginia Tech, presented findings of two fol- low-up surveys of nearly 5,000 students and 1,700 faculty and staff conducted in the wake of the shootings by student Seung

Hui Cho. In two separate inci- dents on April 16, 2007, Mr. Cho killed 32 people and wounded 17 others on the school campus in Blacksburg, Va. Students, faculty, and staff members were surveyed a few months later, in July and August of 2007, to estimate the extent of exposure and psychological reactions. In those surveys, re- spondents indicated their initial awareness and proximity to the shooting incidents at Ambler Johnson Hall and/or Norris Hall on that day. A total of 77% of students said they were aware of the first incident, and 98% were aware of the second See Trauma page 4

Aripiprazole Approved for Autism-Related Irritability

BY ELIZABETH

MECHCAT IE

T he Food and Drug Admin- istration’s approval of the

atypical antipsychotic aripipra- zole for the treatment of irri- tability associated with autistic

disorder in children and adoles- cents aged 6-17 years provides physicians with one more op- tion for this indication—which includes symptoms of aggres- sion toward others, deliberate self-injuriousness, temper tantrums, and quickly chang- ing moods.

Risperidone (Risperdal), also an atypical antipsychotic, was approved in 2006 for the same indication for children aged 5-16 years. Aripiprazole, marketed as Abilify by the manufacturers, Bristol-Myers Squibb Co. and Otsuka Pharmaceutical Co., was initially approved by the FDA in 2002 for schizophrenia. Aripiprazole has been approved for several other adult and pe- diatric indications, including treatment of schizophrenia in adolescents aged 13-17 years,

See Aripiprazole page 53

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28 CHILD/ADOLESCENT PSYCHIATRY

Will Diagnosis Keep Subtypes?

ADHD from page 1

a child who also has a pervasive devel- opmental disorder (PDD). “It turns out that between 40% and 70% of individu- als who meet criteria for the autism spectrum also have very substantial prob- lems with hyperactivity and attention,” Dr. Castellanos said. “There’s a very strong desire, especially on the part of in- dividuals who are engaged in the autism community, to do away with this exclu- sion.”

Dr. Castellanos observed that some children with mild PDD can have a pri- mary ADHD. Standard ADHD treat- ments tend to work well in these chil- dren. On the other hand, in more severe PDD cases, the treatment response tends to be idiosyncratic. But the most significant unanswered question is whether the ADHD diagno- sis will continue to have subtypes. Cur- rently, there are three: ADHD that’s pre-

DECEMBER 2009 • CLINICAL PSYCHIATRY NEWS

dominantly hyperactive/compulsive, ADHD that’s predominantly inattentive, and ADHD combined type. Certain changes are all but definite, said Dr. David Shaffer of Columbia Uni- versity, New York. For example, in the DSM-V, a strong effort will be made to differentiate between “impairment” and severity of a disorder. “We really separated ourselves from the rest of medicine by saying you couldn’t have a disorder unless you were impaired,” said Dr. Shaffer, Irving Philips professor of child psychiatry at the uni- versity. “We all know that there are

some people who persist with a very ac- tive and unimpaired life even though they have very severe illness.” Reviews of the literature and a meta- analysis of 490 studies involving more than 25,000 patients call into question the validity of the various subtypes that are currently used, said Joel Nigg, Ph.D., director of the division of psychology at Oregon Health and Science University, Portland. “A major concern for our work group is: Are these subtypes valid, and what do we do about the inattentive but not hyperactive children?” he said. “We have to decide if we don’t have subtypes

DECEMBER 2009 • WWW.CLINICALPSYCHIATRYNEWS.COM

CHILD/ADOLESCENT PSYCHIATRY

29

at all whether we’re going to go back to a three-, two-, or one-dimensional symp- tom list.” In studies published since the release of DSM-IV, “The two-factor structure of inattention and hyperactivity/impulsiv- ity had fairly good support,” Dr. Nigg said, “with the caveat that the three-fac- tor model, with impulsivity as a separate factor, does have some improvement in fit over the two-factor model. But the correlation between hyperactivity and impulsivity is so high that that’s proba- bly of academic interest more than clin- ical utility.” Arguing against distinct sub-

types are nine studies that show no dif- ference in response to medication in children diagnosed ADHD-combined versus ADHD-inattentive. Furthermore, longitudinal studies have demonstrated that the subtypes are not stable over time. A child’s subtype might change many times over the years, and less than 40% of children maintain the same di- agnosis at two time points. “The subtypes are more like state type than trait type,” Dr. Nigg said. Moreover, studies have shown that most differences in symptoms between subtypes lie on a continuum, with arbi-

trary cut points separating one diagno- sis from the other. There is one excep- tion to a purely dimensional model, however. Social dysfunction appears to be worse in patients with ADHD inat- tentive than in patients with ADHD combined. A purely dimensional model would predict the opposite. According to Dr. Nigg, the work group is considering three options. The first is to eliminate subtypes entirely, but to de- fine two dimensions of the disorder. “[This] would clearly require aggressive revision of the text to remind clinicians of the importance of heterogeneity in pre-

remind clinicians of the importance of heterogeneity in pre- sentation and the differential predictive power of

sentation and the differential predictive power of inattention versus hyperactivi- ty in terms of the predominant presen- tation of the child,” Dr. Nigg said. The second option is to keep the sub- types but to make other aggressive text revisions reminding clinicians that the subtypes are not stable. “Option 3 is to do something creative with the research appendix that will al- low us to stimulate research on sub- types,” Dr. Nigg said. In discussing the work group’s report, Dr. Gabrielle A. Carlson, director of child and adolescent psychiatry at Stony Brook State University of New York, said that some of these distinctions are more important to academic researchers than to clinicians. Turning to the audience, Dr. Carlson asked how many of those present would fail to give a child an ADHD diagnosis if he or she had only 10 symptoms. Among several hundred clinicians, only one raised her hand. Then, turning to the three work group members, Dr. Carlson said: “We don’t really give a crap about 10 symp-

Reviews of the literature and a meta-analysis of 490 studies involving more than 25,000 patients call into question the validity of various subtypes of ADHD that are currently used.

toms versus 12 symptoms. Because part of the reason is people are coming in, and they want help for problems. And if you’re a decent clinician, you’re used to kind of hearing what the symptom con- stellation sounds like.” She asked Dr. Castellanos why the work group had not included members who had a primarily clinical practice. “I don’t think that anyone ever thought, ‘well, we’ll get rid of the clinicians,’ ” he replied. “But that’s effectively what happened.” He cited the fact that service on the work group was voluntary and carried no monetary stipend, a condition that

favors salaried academics. Another bar- rier to clinicians might have been the extensive conflict-of-interest verifica- tions required of all potential members. On the issue of subtypes, Dr. Carlson said it is important to be able to tell par- ents something that makes sense. And then you have to assist him or her in get- ting an individualized education plan that will be helpful and develop a sensible treatment plan. In her view, maintaining subtypes would be important for that. “I also promise you that nobody gives a crap what you’re going to put in the text. Nobody reads the text,” she said to laughter and applause. “I realize the amount of time and ef- fort and energy that goes into doing

what you’re

But I also think

you need to understand that you’re mak- ing clothes for people who have to wear them. And if you don’t have a place for us to put the kids that we see, there are unintended consequences of where

those kids get put.”