Issues for DSM-V: Clinical Staging: A Heuristic Pathway to Valid Nosology and Safer, More Effective Treatment in Psychiatry
2007; American Psychiatric Association; Volume: 164; Issue: 6 Linguagem: Inglês
10.1176/ajp.2007.164.6.859
ISSN1535-7228
Autores Tópico(s)Personality Disorders and Psychopathology
ResumoBack to table of contents Previous article Next article EditorialFull AccessIssues for DSM-V: Clinical Staging: A Heuristic Pathway to Valid Nosology and Safer, More Effective Treatment in PsychiatryPatrick D. McGorry M.D., Ph.D.Patrick D. McGorry M.D., Ph.D.Published Online:1 Jun 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Clinical staging is a proven strategy whose value is clear in the treatment of malignancies and many other medical conditions in which the quality of life and survival rely on the earliest possible delivery of effective interventions, yet it has not been explicitly endorsed in psychiatry (1 – 4) . Clinical staging differs from conventional diagnostic practice in that it defines the progression of disease in time and where a person lies along this continuum of the course of illness. It enables the clinician to select treatments relevant to earlier stages because such interventions may be more effective and less harmful than treatments delivered later in the illness course (5) . Although staging links treatment selection and prediction, its role in the former is more crucial than in the latter, particularly since early successful treatment may change the prognosis and thus prevent progression to subsequent stages. A disorder that is potentially severe and may progress if untreated is likely to be most appropriate for staging. Treatment and particularly early treatment should also demonstrably increase the chances of cure or at least of reducing mortality and disability. This could include many or even most psychiatric disorders. Defining discrete stages according to progression of disease creates a prevention-oriented framework for understanding pathogenesis and evaluation of interventions. The key outcomes are prevention of progression to more advanced stages or regression to an earlier stage. This requires an accurate understanding of the broad social, biological, and personal risk and protective factors that influence movement across stages. We need to know the relative potency of such risk factors and whether they are malleable by current interventions. The burgeoning arena of gene-environment interactions (6) is directly relevant; these environmental variables such as substance abuse, psychosocial stressors, cognitive style, medication adherence, and social isolation may interact with genetic and other biological risk factors at a particular time in the pathogenesis of the illness. A clinical staging model, which maps the relationship of biological change to stage of illness, may help to validate or redefine clinical boundaries, distinguish true pathophysiology from epiphenomena or sequelae, and enable much existing data to be better understood. In the clinical arena, we are already able to see that improved outcomes based on a staging approach are more readily achievable (7 – 10) . For schizophrenia and related psychotic disorders, the progression from prodromal symptoms to the first psychotic episode to chronic psychosis and cognitive and social deterioration is by no means inevitable. Many people who reach one stage may not progress to the next and may even remit from their illness entirely. Although such spontaneous remissions were well known even before neuroleptic treatment became available, we are now in a position to assess if specific interventions, including medication and psychosocial interventions, increase the number of persons who are saved from the progression toward chronic psychosis and deterioration. The specification of the characteristics of specific stages of schizophrenia in DSM-V would provide a framework for the comparison of results from preventive efforts across many different centers and may ultimately have implications for other psychiatric disorders. Address correspondence and reprint requests to Dr. McGorry, ORYGEN Research Centre, University of Melbourne, Locked Bag 10, Parkville, 3052, Victoria, Australia; [email protected] (e-mail). The author reports no competing interests. The author thanks Professors Henry Jackson, Alison Yung, Ian Hickie, and Christos Pantelis for their contributions and Dr. Rosemary Purcell for her help in preparing the article. Editorials discussing other DSM-V issues can be submitted to the Journal at http://mc.manuscriptcentral.com/appi-ajp. Submissions should not exceed 500 words. References1. Fava GA, Kellner R: Staging: a neglected dimension in psychiatric classification. Acta Psychiatr Scand 1993; 87:225–230Google Scholar2. McGorry P: A treatment-relevant classification of psychotic disorders. Aust NZ J Psychiatry 1995; 29:555–584Google Scholar3. McGorry PD: Early intervention in psychotic disorders: beyond debate to solving problems. Br J Psychiatry 2005; 48(suppl):s108–s110Google Scholar4. McGorry PD, Hickie IB, Yung AR, Pantelis C, Jackson HJ: Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Aust NZ J Psychiatry 2006; 40:616–622Google Scholar5. Sackett DL, Haynes RB, Guyatt GH, Tugwell P: Clinical Epidemiology: A Basic Science for Clinical Medicine. London, Little, Brown, 1991Google Scholar6. Caspi A, Moffitt TE: Gene-environment interactions in psychiatry: joining forces with neuroscience. Nat Rev Neurosci 2006; 7:583–590Google Scholar7. Craig TK, Garety P, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, Dunn G: The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 2004; 329:1067Google Scholar8. Petersen L, Jeppesen P, Thorup A, Abel MB, Ohlenschlaeger J, Christensen TO, Krarup G, Jorgensen P, Nordentoft M: A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ 2005; 331:602Google Scholar9. Morrison AP, French P, Walford L, Lewis SW, Kilcommons A, Green J, Parker S, Bentall RP: Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial. Br J Psychiatry 2004; 185:291–297Google Scholar10. McGorry PD, Nordentoft M, Simonsen E (eds): Introduction to "early psychosis: a bridge to the future." Br J Psychiatry 2005; 187(suppl):s1–s3Google Scholar FiguresReferencesCited byDetailsCited ByIs it possible to stage schizophrenia? A systematic review11 May 2022 | Translational Psychiatry, Vol. 12, No. 1Association of cognitive performance with clinical staging in schizophrenia spectrum disorders: a prospective 6-year follow-up studySchizophrenia Research: Cognition, Vol. 28Time for united action on depression: a Lancet–World Psychiatric Association CommissionThe Lancet, Vol. 399, No. 10328Comportements prédictifs d'un risque de transition psychotiqueBulletin de l'Académie Nationale de Médecine, Vol. 206, No. 3Personalised Prevention: Increasing or Decreasing Over-Medicalisation, Overdiagnosis and Overtreatment?8 March 2022Consensus on nomenclature for clinical staging models in bipolar disorder: A narrative review from the International Society for Bipolar Disorders (ISBD) Staging Task Force23 July 2021 | Bipolar Disorders, Vol. 23, No. 7Triple grief cycle of cancelled events: the emotional crisis aftermath17 May 2021 | International Journal of Contemporary Hospitality Management, Vol. 33, No. 7Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment5 May 2021 | Personality and Mental Health, Vol. 15, No. 3Predictors of social and role outcomes in first episode psychosis: A prospective 12‐month study of social cognition, neurocognition and symptoms10 October 2020 | Early Intervention in Psychiatry, Vol. 15, No. 4Exploration of symptom dimensions and duration of untreated psychosis within a staging model of schizophrenia spectrum disorders17 June 2020 | Early Intervention in Psychiatry, Vol. 15, No. 3Integrating clinical staging and phenomenological psychopathology to add depth, nuance, and utility to clinical phenotyping: a heuristic challengeThe Lancet Psychiatry, Vol. 8, No. 2Pluripotential Risk and Clinical Staging: Theoretical Considerations and Preliminary Data From a Transdiagnostic Risk Identification Approach8 January 2021 | Frontiers in Psychiatry, Vol. 11Expanding the search for emerging mental ill health to safeguard student potential and vocational success in high school: A narrative review5 February 2020 | Early Intervention in Psychiatry, Vol. 14, No. 6Onset and transition of and recovery from adverse development: Study methodology5 November 2019 | Early Intervention in Psychiatry, Vol. 14, No. 5Transcending false dichotomies and diagnostic silos to reduce disease burden in mental disorders18 July 2020 | Social Psychiatry and Psychiatric Epidemiology, Vol. 55, No. 9Staging and profiling for schizophrenia spectrum disorders: Inter-rater reliability after a short training courseProgress in Neuro-Psychopharmacology and Biological Psychiatry, Vol. 99Models Predicting Psychosis in Patients With High Clinical Risk: A Systematic Review24 March 2020 | Frontiers in Psychiatry, Vol. 11The Behavior and Mind Health (BeMIND) study: Methods, design and baseline sample characteristics of a cohort study among adolescents and young adults5 December 2019 | International Journal of Methods in Psychiatric Research, Vol. 29, No. 1New paradigms to study psychosis riskChild and Adolescent Psychiatric Clinics of North America, Vol. 29, No. 1Brain connectivity alterations in early psychosis: from clinical to neuroimaging staging4 February 2019 | Translational Psychiatry, Vol. 9, No. 1Altered Cellular White Matter But Not Extracellular Free Water on Diffusion MRI in Individuals at Clinical High Risk for PsychosisYingying Tang, Ph.D., Ofer Pasternak, Ph.D., Marek Kubicki, M.D., Ph.D., Yogesh Rathi, Ph.D., Tianhong Zhang, M.D., Ph.D., Junjie Wang, Ph.D., Huijun Li, Ph.D., Kristen A. Woodberry, M.S.W., Ph.D., Lihua Xu, Ph.D., Zhenying Qian, B.A., Anni Zhu, B.A., Susan Whitfield-Gabrieli, Ph.D., Matcheri S. Keshavan, M.D., Margaret Niznikiewicz, Ph.D., William S. Stone, Ph.D., Robert W. McCarley, M.D., Martha E. Shenton, Ph.D., Jijun Wang, M.D., Ph.D., Larry J. Seidman, Ph.D.24 June 2019 | American Journal of Psychiatry, Vol. 176, No. 10Early Detection and Preventive Intervention in Schizophrenia: From Fantasy to RealityJeffrey A. Lieberman, M.D., Scott A. Small, M.D., Ragy R. Girgis, M.D.1 October 2019 | American Journal of Psychiatry, Vol. 176, No. 10A systematic review of clinical guidelines on choice, dose, and duration of antipsychotics treatment in first- and multi-episode schizophrenia21 June 2019 | International Review of Psychiatry, Vol. 31, No. 5-6JAMA Psychiatry, Vol. 76, No. 11Integration of Literature Across Countries: Challenges, Opportunities, and Implications for Future Research23 August 2019The Lancet Psychiatry, Vol. 6, No. 3Revista de Psiquiatría y Salud Mental, Vol. 12, No. 2Revista de Psiquiatría y Salud Mental (English Edition), Vol. 12, No. 2Psychological Medicine, Vol. 49, No. 2Early Intervention in Psychiatry, Vol. 13, No. 3Early Intervention in Psychiatry, Vol. 13, No. 6Uncanny Mirroring: A Developmental Perspective on the Neurocognitive Origins of Self-Disorders in Schizophrenia10 December 2019 | Psychopathology, Vol. 52, No. 5Medical Journal of Australia, Vol. 211, No. S9Is recurrence in major depressive disorder related to bipolarity and mixed features? Results from the BRIDGE-II-Mix studyJournal of Affective Disorders, Vol. 229World Psychiatry, Vol. 17, No. 2L'Encéphale, Vol. 44, No. 6Early Intervention in Psychiatry, Vol. 12, No. 3Cautioning Health-Care Professionals13 February 2017 | OMEGA - Journal of Death and Dying, Vol. 74, No. 4The Lancet Psychiatry, Vol. 4, No. 3Progress in Neuro-Psychopharmacology and Biological Psychiatry, Vol. 75Schizophrenia Research, Vol. 185Early Intervention in Psychiatry, Vol. 11, No. 1Borderline Personality Disorder and Emotion Dysregulation, Vol. 4, No. 1Journal of Personality Disorders, Vol. 31, No. 5L'Évolution Psychiatrique, Vol. 81, No. 1Journal of Psychiatric Research, Vol. 73Schizophrenia Research, Vol. 170, No. 1Schizophrenia Research, Vol. 174, No. 1-3Epidemiology and Psychiatric Sciences, Vol. 25, No. 6Early Intervention in Psychiatry, Vol. 10, No. 1International Journal of Bipolar Disorders, Vol. 4, No. 1PLOS ONE, Vol. 11, No. 4Korean Journal of Schizophrenia Research, Vol. 19, No. 2The Lancet Psychiatry, Vol. 2, No. 9L'Encéphale, Vol. 41, No. 1Early Intervention in Psychiatry, Vol. 9, No. 1Revista Brasileira de Psiquiatria, Vol. 37, No. 4Personality Disorder in Childhood and Adolescence comes of Age: a Review of the Current Evidence and Prospects for Future Research30 November 2014 | Scandinavian Journal of Child and Adolescent Psychiatry and Psychology, Vol. 3, No. 1The impact of mental state disorder and personality on social functioning in patients engaged in community mental health care30 August 2013 | Australasian Psychiatry, Vol. 22, No. 1Psychological Medicine, Vol. 44, No. 1Early Clinical Phenotypes and Risk for Serious Mental Disorders in Young People: Need for Care Precedes Traditional Diagnoses in Mood and Psychotic Disorders1 January 2013 | The Canadian Journal of Psychiatry, Vol. 58, No. 1British Journal of Psychiatry, Vol. 202, No. s54PLoS ONE, Vol. 8, No. 3Cumulative morbidity and prognostic staging of illness in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)26 September 2012 | Australian & New Zealand Journal of Psychiatry, Vol. 46, No. 11Examination of Anomalous Self-ExperienceJournal of Nervous & Mental Disease, Vol. 200, No. 7Palliative models of care for later stages of mental disorder: maximizing recovery, maintaining hope, and building morale6 February 2012 | Australian & New Zealand Journal of Psychiatry, Vol. 46, No. 2Revista Brasileira de Psiquiatria, Vol. 34British Journal of Psychiatry, Vol. 201, No. 6New era or false dawn?25 October 2011 | Personality and Mental Health, Vol. 5, No. 4Evidencia de neuroimagen y de tratamiento respecto a los estadios clínicos en los trastornos psicóticos: del estado mental de riesgo a la esquizofrenia crónicaPsiquiatría Biológica, Vol. 18, No. 3Pre-Emptive Intervention in Psychosis: Agnostic Rather than Diagnostic1 July 2011 | Australian & New Zealand Journal of Psychiatry, Vol. 45, No. 7Neurotoxicity Research, Vol. 19, No. 2Clinical Psychology Review, Vol. 31, No. 3Journal of Affective Disorders, Vol. 131, No. 1-3Schizophrenia Research, Vol. 127, No. 1-3Revista Brasileira de Psiquiatria, Vol. 33, No. suppl 2Young Rural People at Risk for Schizophrenia: Time for Mental Health Services to Translate Research Evidence into Best Practice of Care1 October 2010 | Australian & New Zealand Journal of Psychiatry, Vol. 44, No. 10Risk syndromes, clinical staging and DSM V: New diagnostic infrastructure for early intervention in psychiatrySchizophrenia Research, Vol. 120, No. 1-3Neurotoxicity Research, Vol. 18, No. 3-4Journal of Affective Disorders, Vol. 123, No. 1-3Schizophrenia Research, Vol. 119, No. 1-3Schizophrenia Research, Vol. 123, No. 2-3Psychological Medicine, Vol. 40, No. 3Early Intervention in Psychiatry, Vol. 4, No. 2Early Intervention in Psychiatry, Vol. 4, No. 3Annals of General Psychiatry, Vol. 9, No. 1Predictors of Adherence to Cognitive-Behavioural Therapy in First-Episode Psychosis1 October 2009 | The Canadian Journal of Psychiatry, Vol. 54, No. 10Diagnosis and the staging model of psychosisSchizophrenia Research, Vol. 110, No. 1-3Expert Review of Neurotherapeutics, Vol. 9, No. 7European Archives of Psychiatry and Clinical Neuroscience, Vol. 258, No. S2Schizophrenia Research, Vol. 99, No. 1-3Schizophrenia Research, Vol. 105, No. 1-3British Journal of Psychiatry, Vol. 193, No. 6 Volume 164Issue 6 June, 2007Pages 859-860THE AMERICAN JOURNAL OF PSYCHIATRY June 2007 Volume 164 Number 6 Metrics PDF download History Published online 1 June 2007 Published in print 1 June 2007
Referência(s)