Psychiatric Annals

Editorial 

‘Severity’ in Psychiatric Disorders

Jan Fawcett, MD

Abstract

This month’s issue, guest-edited by Laura N. Antar, MD, PhD; and Eric Hollander, MD, includes a case challenge series of children presenting with autism spectrum disorder. These cases are very helpful in understanding the presentation and treatment options available for these patients, as well as the limitation of data on evidence-based treatments in this population.

Dr. Antar states, “In a patient with autism spectrum disorder (ASD), depression frequently presents as an increase in ASD symptoms. What it is important to note is not the symptoms themselves, but their heightened intensity.” I think this is a beautiful example of using symptom severity to help arrive at an appropriate treatment — in this case the addition of fluoxetine, which produced an excellent effect for her patient.

I understand the necessity of using the number of symptoms as a proxy for severity in the DSM III and IV, but I worry that an emphasis on counting criteria symptoms may distract a clinician from noticing individual symptom severity, which may prove a more effective guide to treatment than meeting syndromal criteria.

It has been shown that the severity of anxiety, a noncriteria symptom, is correlated with poor outcomes and risk of suicidal behaviors in mood disorders.1 There is emerging evidence that depressive symptom components as well as their severity may respond differentially to different pharmacologic mechanisms.

For example, a report by Fournier and colleagues2 found that the efficacy of antidepressants (paroxetine and imipramine) separated from placebo only in patients attaining 22 or more on the HamD rating scale. Summed symptom severity was associated with treatment response better than symptom number (5 of 9 for major depressive episode).

In addition, a recent study by Martinotti and colleagues3 has shown a preferential response of the anhedonia component of major depression to agomelantine (which affects melatonergic and 5HT2c receptors). Seeing beyond current DSM categorical diagnoses to the severity of symptom components may be the pathway to more effective pharmacologic treatments.

As I often do on these pages, I’d like to share with you a moment that inspired me to appreciate this marvelous gift we call “consciousness.”

It was a Saturday morning. I found myself caught by a wave of delightfully buoyant energy. I knew I wanted to ride it before it was displaced by the business of living.

While using my rowing machine, I watched Ringo Starr being interviewed on television for his 72nd birthday. He looked great and made a “V” with his fingers, said “Peace and Love,” and that if anyone wanted to join him in celebration of his birthday, that they do the same.

Soon after, as I drove to get breakfast, the sun was out, but rain clouds ringed the sky. I put the top down — to attract rain — which we need in Santa Fe, and enjoyed the expanse of the sky, with the roiling dark clouds and the mist on the mountains alternating in the beautiful layers. Voilà, it started to rain! At a red light, I put up the top. I felt so alive, so buoyant, so appreciative of the beauty around me.

As I paid for my breakfast, I smiled at the young girl at the counter, held up two of my fingers in a “V” and said, “Peace and love from Ringo Starr who is 72 today.” She looked at me quizzically, but also made the sign.

I drove home full of awareness. Precious rain was still falling by the time I got home. Wow! I was still in this heightened appreciative state. I just wanted to share the moment with you before it faded away; I…

This month’s issue, guest-edited by Laura N. Antar, MD, PhD; and Eric Hollander, MD, includes a case challenge series of children presenting with autism spectrum disorder. These cases are very helpful in understanding the presentation and treatment options available for these patients, as well as the limitation of data on evidence-based treatments in this population.

Dr. Antar states, “In a patient with autism spectrum disorder (ASD), depression frequently presents as an increase in ASD symptoms. What it is important to note is not the symptoms themselves, but their heightened intensity.” I think this is a beautiful example of using symptom severity to help arrive at an appropriate treatment — in this case the addition of fluoxetine, which produced an excellent effect for her patient.

Severity vs. Syndromal Criteria

I understand the necessity of using the number of symptoms as a proxy for severity in the DSM III and IV, but I worry that an emphasis on counting criteria symptoms may distract a clinician from noticing individual symptom severity, which may prove a more effective guide to treatment than meeting syndromal criteria.

It has been shown that the severity of anxiety, a noncriteria symptom, is correlated with poor outcomes and risk of suicidal behaviors in mood disorders.1 There is emerging evidence that depressive symptom components as well as their severity may respond differentially to different pharmacologic mechanisms.

For example, a report by Fournier and colleagues2 found that the efficacy of antidepressants (paroxetine and imipramine) separated from placebo only in patients attaining 22 or more on the HamD rating scale. Summed symptom severity was associated with treatment response better than symptom number (5 of 9 for major depressive episode).

In addition, a recent study by Martinotti and colleagues3 has shown a preferential response of the anhedonia component of major depression to agomelantine (which affects melatonergic and 5HT2c receptors). Seeing beyond current DSM categorical diagnoses to the severity of symptom components may be the pathway to more effective pharmacologic treatments.

Peace and Love: Happy Birthday Ringo

As I often do on these pages, I’d like to share with you a moment that inspired me to appreciate this marvelous gift we call “consciousness.”

It was a Saturday morning. I found myself caught by a wave of delightfully buoyant energy. I knew I wanted to ride it before it was displaced by the business of living.

While using my rowing machine, I watched Ringo Starr being interviewed on television for his 72nd birthday. He looked great and made a “V” with his fingers, said “Peace and Love,” and that if anyone wanted to join him in celebration of his birthday, that they do the same.

Soon after, as I drove to get breakfast, the sun was out, but rain clouds ringed the sky. I put the top down — to attract rain — which we need in Santa Fe, and enjoyed the expanse of the sky, with the roiling dark clouds and the mist on the mountains alternating in the beautiful layers. Voilà, it started to rain! At a red light, I put up the top. I felt so alive, so buoyant, so appreciative of the beauty around me.

As I paid for my breakfast, I smiled at the young girl at the counter, held up two of my fingers in a “V” and said, “Peace and love from Ringo Starr who is 72 today.” She looked at me quizzically, but also made the sign.

I drove home full of awareness. Precious rain was still falling by the time I got home. Wow! I was still in this heightened appreciative state. I just wanted to share the moment with you before it faded away; I hope I did it justice: “V” and peace and love to you.

References

  1. Goldberg D, Fawcett J. The importance of anxiety in both major depression and bipolar disorder. Depress Anxiety. 2012;29(6):471–478. doi:10.1002/da.21939 [CrossRef] . doi:10.1002/da.21939 [CrossRef]
  2. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303(1):47–53 doi:10.1001/jama.2009.1943 [CrossRef]
  3. Martinotti G, Sepede G, Gambi F, et al. Agomelatine versus Venlafaxine XR in the treatment of anhedonia in major depressive disorder: a pilot study. J Clin Psychopharmacol. 2012;32(4):487–491. doi:10.1097/JCP.0b013e31825d6c25 [CrossRef]

10.3928/00485713-20120806-01

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