Introduction, Nosology, and History. William W. Eaton, PhD Johns Hopkins University

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2 Introduction, Nosology, and History William W. Eaton, PhD Johns Hopkins University

3 Nosology Target outcomes Recent evolution of diagnosis Epistemology and epidemiology The problem of onset 3

4 History Generations in psychiatric epidemiology Diagnosis in surveys Screening 4

5 Introduction and Nosology Section A

6 Descriptive Epidemiology of Seven Psychiatric Disorders Diagnosis Lifetime prevalence Interquartile range Number of studies Annual incidence per 1000 Autism NA Attention Deficit NA Conduct Disorder 5.4 NA 1 NA Eating Disorders Agoraphobic Disorder Panic Disorder Social Phobic Disorder Alcohol Disorder Major Depression Schizophrenia Bipolar Disorder Dementia Data from: Eaton (2001), The Sociology of Mental Disorders, 3rd ed. 6

7 Lifetime prevalence Prevalence: proportion of the population with the disorder Lifetime proportion who have, or have ever had, the disorder Point proportion who have the disorder now Period proportion who have the disorder during a stated period of time 7

8 Lifetime Incidence Incidence: rate at which new cases form Attack Rate rate at which cases form, during a stated period of follow-up, from a population of individuals who do not have the disorder at baseline First Lifetime Incidence rate at which cases form, during a stated period of follow-up, from a population of individuals who have never had the disorder at baseline 8

9 Stress-Reactive Neurosis 9

10 Definitions for Epistemologic Approach Syndrome Co-occurrence of signs and symptoms Reliability Consistency of measurement Continued 10

11 Definitions for Epistemologic Approach Syndrome Co-occurrence of signs and symptoms Reliability Consistency of measurement Validity Measuring what is supposed to be measured Continued 11

12 Definitions for Epistemologic Approach Syndrome Co-occurrence of signs and symptoms Reliability Validity Consistency of measurement Measuring what is supposed to be measured Construct validity Agreement with theoretical predictions across a range of theories, and across a range of modalities of measurement 12

13 Epistemology and Epidemiology Adapted from: Mc Hugh and Slavney, The Perspectives of Psychiatry, 3rd edition 13

14 Table 14

15 Prevalence of Disorder in Past Six Months ECA Program 12 % Phobia Alcohol A/D Dysthymia Depression Cognitive Impairment Drug A/D Obsessive-Compulsive Panic Anti-Social Personality Schizophrenia Mania Somatization Schizophreniform 15 Data from: Eaton (1994), Int J Methods Psychiatr Res.,

16 Prevalence of Disorder in Past Six Months ECA Program 12 % Untreated Treated 6 Phobia Alcohol A/D Dysthymia Depression Cognitive Impairment Drug A/D Obsessive-Compulsive Panic Anti-Social Personality Schizophrenia Mania Somatization Schizophreniform 16 Data from: Eaton (1994), Int J Methods Psychiatr Res.,

17 Symptom Groups Related to Depressive Disorder Lifetime Prevalence in Percent Any occurrence ever Worst Episode of Depression Dysphoric Episode Anhedonia Appetite Sleep Slow or restless Fatigue Guilt Concentration Thoughts of Death Episode of Depressive Syndrome: Symptoms in 1 or more groups 12.0 Symptoms in 2 or more groups 11.8 Symptoms in 3 or more groups 10.6 Symptoms in 4 or more groups 9.6 Symptoms in 5 or more groups 7.6 Source: Baltimore Epidemiologic Catchment Area Followup 17

18 Epistemology and Epidemiology Adapted from: Mc Hugh and Slavney, The Perspectives of Psychiatry, 3rd edition 18

19 Onset Section B

20 Onset Adapted from: Nesseroade, J.R., The Warp and the Woof of the Development Fabric, in Visions of Development, the Environment, and the Aesthetics: The Legacy of Joachim F. Wohlwill, edited by R. Downs, L. Liben, and D.S. Palermo, Erlbaum,

21 Continuities: Incidence as Intensification Adapted by Bill Eaton from Lilienfeld and Stolley (1994), Foundations of Epidemiology, 3rd ed., Continued 21

22 Continuities: Incidence as Intensification Adapted by Bill Eaton from Lilienfeld and Stolley (1994), Foundations of Epidemiology, 3rd ed., 22

23 Cross Section Association of Depressed Mood and Somatic Symptoms of Depression r = 0.0 Depressed Mood Somatic Symptoms 23

24 Acquisition of Symptoms r =.0 Somatic Symptoms Time (Years) 24 Continued Depressed Mood

25 Acquisition of Symptoms r =.0 r =.2 Somatic Symptoms precursors prodrome disorder Time (Years) 25 Continued Depressed Mood

26 Acquisition of Symptoms r =.3 r =.0 r =.2 Somatic Symptoms precursors prodrome disorder Time (Years) 26 Continued Depressed Mood

27 Acquisition of Symptoms r =.4 r =.3 r =.0 r =.2 Somatic Symptoms precursors prodrome disorder Time (Years) 27 Depressed Mood

28 New Syndrome r =.3 r =.5 r =.4 r =.0 r =.2 Somatic Symptoms precursors prodrome disorder Time (Years) 28 Depressed Mood

29 Concepts For Describing Onset Precursor complaint or behavior A complaint or behavior from the domain of content of a disorder that predicts full onset, but imperfectly Prodromal sign or symptom A sign or symptom from the domain of content of a disorder that predicts full onset, with perfect certainty 29

30 Etiologically Relevant Period Diagnosis Visible Signs and Symptoms Induction Period Latency Clinical Presentation Irreversibility Etiologically Relevant Period (Rothman) Incubation (Armenian) 30 Cause Time Precursors Prodrome

31 DIS/DSM-III Major Depressive Disorder Cumulative Percent with Onset 100 Prodromal Period for New Cases Epidemiologic Catchment Area Program Onset of Problem Adapted from Eaton, et al. (1995), Am J Psychiatry Onset of Disorder Age in Years 31

32 Incidence as Change in Causal Structure Causes Natural History Prevalence A Incidence B Duration Prevalence C Recurrence 32

33 History Section C

34 Generations in Psychiatric Epidemiology 19th Century Jarvis Commission Generation One Facility surveys Specific diagnoses Exemplars Chicago (Faris and Dunham) New Haven (Hollingshead and Redlich) Continued 34

35 Generations in Psychiatric Epidemiology Generation Two Household surveys Overall caseness rating Exemplars Midtown Manhattan (Srole, Langner, et al.) Stirling County (Leighton, et al.) Generation Three Diagnostic Surveys Exemplars ECA, NCS Continued 35

36 Lunacy and Idiocy in Massachusetts in 1854 Report of the Jarvis Commission Lunatics Idiots Total Paupers Number 1, ,125 Prevalence/ Independents Number 1, ,102,551 Prevalence/ Total Number 2,622 1,089 1,124,676 Prevalence/ Data from: Commission on Lunacy, 1855: Table IV, VIII, XIX, XXI, and frequencies, on page

37 Urban Areas 37

38 Manic Depressive Rates in Chicago ( ) 38

39 Manic-Depressive Insanity 39

40 Social Class and Mental Disorder in the New Haven Study Level of Social Class Neurosis I-II III IV V Prevalence Incidence Psychosis Prevalence Incidence Rates* per 1,000 * Prevalence rate is point prevalence; incidence rate is annual. Data from: Hollingshead and Redlich, 1958, Table

41 Midtown Manhattan Social Class and Stress in Manhattan.80 Mental Health Risk Compared to an Average Person Lower class Upper class Middle class Stress Score Redrawn from Figure 14.2 of Langner and Michael,

42 ECA 42

43 DIS Probe Structure 43

44 ECA Total True Prevalence 44