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Introduction, Nosology, and History
William W. Eaton, PhD
Johns Hopkins University
Nosology
Target outcomes
Recent evolution of diagnosis
Epistemology and epidemiology
The problem of onset
3
History
Generations in psychiatric epidemiology
Diagnosis in surveys
Screening
4
Section A
Introduction and Nosology
Descriptive Epidemiology of Seven Psychiatric Disorders
Diagnosis
Lifetime
prevalence
Autism
Attention Deficit
Conduct Disorder
Eating Disorders
Agoraphobic Disorder
Panic Disorder
Social Phobic Disorder
Alcohol Disorder
Major Depression
Schizophrenia
Bipolar Disorder
Dementia
0.05
6.2
5.4
1.2
5.3
1.6
1.7
13.0
9.0
0.3
0.6
4.9
Interquartile
range
0.04-0.10
2.2-6.7
NA
1.0-2.8
3.6-5.7
1.1-2.2
1.7-2.7
10.7-15.9
8.4-16.0
0.16-0.56
0.4-0.8
3.6-7.2
Data from: Eaton (2001), The Sociology of Mental Disorders, 3rd ed.
Number Annual
of
incidence
studies per 1000
23
NA
6
NA
1
NA
7
0.18
7
22.0
11
1.4
6
4.0
15
17.9
15
3.0
25
0.2
9
0.3
23
6.0
6
Lifetime prevalence
Prevalence: proportion of the population with the
disorder
Ë Lifetime– proportion who have, or have ever
had, the disorder
Ë Point– proportion who have the disorder now
Ë Period– proportion who have the disorder
during a stated period of time
7
Lifetime Incidence
Incidence: rate at which new cases form
Ë 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
Ë 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
Stress-Reactive Neurosis
9
Definitions for Epistemologic Approach
Syndrome
Ë Co-occurrence of signs and symptoms
Reliability
Ë Consistency of measurement
Continued
10
Definitions for Epistemologic Approach
Syndrome
Ë Co-occurrence of signs and symptoms
Reliability
Ë Consistency of measurement
Validity
Ë Measuring what is supposed to be measured
Continued
11
Definitions for Epistemologic Approach
Syndrome
Ë Co-occurrence of signs and symptoms
Reliability
Ë Consistency of measurement
Validity
Ë Measuring what is supposed to be measured
Construct validity
Ë Agreement with theoretical predictions across a
range of theories, and across a range of
modalities of measurement
12
Epistemology and Epidemiology
Adapted from: Mc Hugh and Slavney, The Perspectives of Psychiatry, 3rd edition
13
Table
14
Prevalence of Disorder in Past Six Months
ECA Program
12 %
10.8
10
8
6
2
4.2
3.4
2.9
2.7
1.8
1.7
0.9
0.8
0.8
Ph
Al obia
co
ho
lA
Dy
/D
st
hy
Co
m
ia
gn
De
iti
pr
ve
es
Im
sio
pa
n
irm
en
t
Ob
se
Dr
ss
ug
iv
eA/
Co
D
m
pu
An
lsi
ve
tiSo
cia
Pa
lP
ni
er
c
so
n
al
Sc
ity
hi
zo
ph
re
ni
a
0
Data from: Eaton (1994), Int J Methods Psychiatr Res.,
0.7
0.3
0.1
M
So
an
m
ia
at
Sc
iza
hi
zo
tio
ph
n
re
ni
fo
rm
4
15
Prevalence of Disorder in Past Six Months
ECA Program
12 %
10.8
Untreated
10
Treated
8
6
2
4.2
3.4
2.9
2.7
1.8
1.7
0.9
0.8
0.8
Ph
Al obia
co
ho
lA
Dy
/D
st
hy
Co
m
ia
gn
De
iti
pr
ve
es
Im
sio
pa
n
irm
en
t
Ob
se
Dr
ss
ug
iv
eA/
Co
D
m
pu
An
lsi
ve
tiSo
cia
Pa
lP
ni
er
c
so
n
al
Sc
ity
hi
zo
ph
re
ni
a
0
Data from: Eaton (1994), Int J Methods Psychiatr Res.,
0.7
0.3
0.1
M
So
an
m
ia
at
Sc
iza
hi
zo
tio
ph
n
re
ni
fo
rm
4
16
Symptom Groups Related to Depressive Disorder
Lifetime Prevalence in Percent
Any occurrence
ever
Dysphoric Episode
Anhedonia
Appetite
Sleep
Slow or restless
Fatigue
Guilt
Concentration
Thoughts of Death
Episode of Depressive
Syndrome:
Symptoms in 1 or more groups
Symptoms in 2 or more groups
Symptoms in 3 or more groups
Symptoms in 4 or more groups
Symptoms in 5 or more groups
Source: Baltimore Epidemiologic Catchment Area Followup
27.9
9.3
20.7
22.1
9.8
17.1
6.3
11.7
21.0
Worst Episode of
Depression
12.0
5.6
7.0
8.4
3.7
5.0
4.2
6.9
7.1
12.0
11.8
10.6
9.6
7.6
17
Epistemology and Epidemiology
Adapted from: Mc Hugh and Slavney, The Perspectives of Psychiatry, 3rd edition
18
Section B
Onset
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, 1990.
20
Continuities: Incidence as Intensification
Adapted by Bill Eaton from Lilienfeld and Stolley (1994), Foundations of Epidemiology, 3rd ed.,
Continued
21
Continuities: Incidence as Intensification
Adapted by Bill Eaton from Lilienfeld and Stolley (1994), Foundations of Epidemiology, 3rd ed.,
22
Cross Section
Association of Depressed Mood and
Somatic Symptoms of Depression
Depressed Mood
r = 0.0
Somatic Symptoms
23
Acquisition of Symptoms
So
m
at
ic
Sy
m
pt
o
m
s
Depressed Mood
.0
=
r
5
10
15
20
25
Time (Years)
Continued
24
Acquisition of Symptoms
.2
=
r
So
m
at
ic
Sy
m
pt
o
m
s
Depressed Mood
.0
=
r
precursors
5
10
15
prodrome
20
disorder
25
Time (Years)
Continued
25
Acquisition of Symptoms
r
2
=.
r=
.3
So
m
at
ic
Sy
m
pt
o
m
s
Depressed Mood
r
0
=.
precursors
5
10
15
prodrome
20
disorder
25
Time (Years)
Continued
26
Acquisition of Symptoms
r
2
=.
r=
.3
r=
.4
So
m
at
ic
Sy
m
pt
o
m
s
Depressed Mood
r
0
=.
precursors
5
10
15
prodrome
20
disorder
25
Time (Years)
27
New Syndrome
r
2
=.
r=
.3
r=
.4
r=
.5
So
m
at
ic
Sy
m
pt
o
m
s
Depressed Mood
r
0
=.
precursors
5
10
15
prodrome
20
disorder
25
Time (Years)
28
Concepts For Describing Onset
Precursor complaint or behavior
Ë A complaint or behavior from the domain of
content of a disorder that predicts full onset, but
imperfectly
Prodromal sign or symptom
Ë A sign or symptom from the domain of content
of a disorder that predicts full onset, with
perfect certainty
29
Precursors
no
sis
Dia
g
Vis
a n i b le
d S Sig
ym ns
pto
ms
Etiologically Relevant Period
Prodrome
Time
C
se
u
a
ity
l
i
ib
s
r
e
v
e
Irr
Latency
Cl
P r i nic
es al
en
ta
tio
n
Induction Period
“Etiologically Relevant Period” (Rothman)
“Incubation” (Armenian)
30
Prodromal Period for New Cases
Epidemiologic Catchment Area Program
100
80
Onset of
Problem
60
Onset of
Disorder
40
20
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
5
10
15
0
0
Cumulative Percent with Onset
DIS/DSM-III Major Depressive Disorder
Age in Years
Adapted from Eaton, et al. (1995), Am J Psychiatry
31
Incidence as Change in Causal Structure
Causes
A
B
Natural History
Incidence
Duration
C
Prevalence
Prevalence
Recurrence
32
Section C
History
Generations in Psychiatric Epidemiology
19th Century—Jarvis Commission
Generation One
Ë Facility surveys
Ë Specific diagnoses
Ë Exemplars
• Chicago (Faris and Dunham)
• New Haven (Hollingshead and Redlich)
Continued
34
Generations in Psychiatric Epidemiology
Generation Two
Ë Household surveys
Ë Overall caseness rating
Ë Exemplars
• Midtown Manhattan
(Srole, Langner, et al.)
• Stirling County (Leighton, et al.)
Generation Three
Ë Diagnostic Surveys
Ë Exemplars
• ECA, NCS
Continued
35
Lunacy and Idiocy in Massachusetts in 1854
Report of the Jarvis Commission
Lunatics
Idiots
Total
Number
1,522
418
23,125
Prevalence/1000
65.82
18.08
Number
1,110
671
Prevalence/1000
1.01
0.61
Number
2,622
1,089
Prevalence/1000
2.33
0.97
Paupers
Independents
1,102,551
Total
1,124,676
Data from: Commission on Lunacy, 1855: Table IV, VIII, XIX, XXI, and frequencies, on page 52.
36
Urban Areas
37
Manic Depressive Rates in Chicago (1922-1931)
38
Manic-Depressive Insanity
39
Social Class and Mental Disorder in the New Haven Study
Level of Social Class
I-II
III
IV
V
Neurosis
Prevalence
3.49
2.50
1.14
0.97
Incidence
0.69
0.78
0.52
0.66
Prevalence
1.88
2.91
5.18
15.05
Incidence
0.28
0.36
0.37
0.73
Psychosis
Rates* per 1,000
* Prevalence rate is point prevalence; incidence rate is annual.
Data from: Hollingshead and Redlich, 1958, Table 16.
40
Midtown Manhattan
Social Class and Stress in Manhattan
.80
Mental
Health
Risk
Compared
to an
Average
Person
.70
Middle class
Lower class
.60
.50
Upper class
.40
.30
.20
2
4
6
8
10 12 14 16
Stress Score
Redrawn from Figure 14.2 of Langner and Michael, 1963.
41
ECA
42
DIS Probe Structure
43
ECA—Total True Prevalence
44