Every child psychiatrist regularly sees orphans. No, not kids without
parents but diagnostic orphans, troubled children with psychiatric symptoms
that don't add up to a DSM-IV diagnosis for a specific disorder.
"Children come in with a little bit of a lot of things, especially
rages, and they are significantly handicapped, even without a diagnosis, but
they still need help," said Gabrielle Carlson, M.D. She was commenting
on a discussion of subthreshold psychopathologies and their meaning at the
annual meeting of the American Academy of Child and Adolescent Psychiatry in
Chicago in October.
Gabrielle Carlson, M.D.: "How do you trade off what is in front of
you with what is down the road?"
Credit: Aaron Levin
"We created diagnostic criteria in order to have a common language in
psychiatry, and we had to simplify the terms in order to keep them
useful," she said. "But things are just more complicated than we
wish that they were."
Presenters at the symposium examined whether these subthreshold symptoms
represented subsyndromal "noncases" or were precursors to full
syndromes. The discussion, which included examples based on several disorders,
also reflected the continuing dialogue between categorical and dimensional
approaches to classifying illness.
William Copeland, Ph.D., of Duke University Medical Center began by citing
data from the Great Smoky Mountains Study, covering 8,806 assessments of 1,420
participants who were followed from ages 9 to 13 until they turned 21.
He noted that at 473 assessment points, subjects recorded symptoms for
oppositional defiant disorder (ODD), while also meeting duration criteria for
the disorder at 470 of those points, making duration redundant.
Copeland also compared the ICD-10 and DSM-IV criteria for
ODD, noting that DSM lists separate criteria for ODD and conduct
"Under the DSM, a child can have three ODD symptoms and two
conduct disorder symptoms and would still not meet diagnostic criteria,"
he said. "Almost one-third of ICD-10 disruptive behavior
disorders [DBD] don't meet DBD criteria under DSM-IV, yet both groups
are equally sick, judging by impairment or use of
Investigators also looked at impairment as a predictive factor in the
study. They found that subsyndromal CD with impairment does predict antisocial
personality disorder later in adult life, but there was not much predictive
difference between subthreshold ODD with and without impairment.
Looking at alcohol-related disorders, Christopher Martin, Ph.D., an
associate professor of psychiatry and psychology at the University of
Pittsburgh School of Medicine and the Pittsburgh Adolescent Alcohol Research
Center, said, "The choice is not whether diagnostic criteria should be
categorical or dimensional, but how to integrate both into our
The presence of at least three out of seven diagnostic symptoms is needed
for a diagnosis of alcohol dependence, and at least one out of four symptoms
is needed for a diagnosis of alcohol abuse, according to DSM-IV. DSM
also says that abuse and dependence are mutually exclusive and dependence
precludes a diagnosis of abuse.
"People with one or two symptoms may fall through the cracks, but
they are more likely to have full-blown clinical symptoms one year later than
if symptoms are absent," Martin said. These subclinical symptom ratings
are therefore helpful in identifying persons at risk for future impairment or
disorder, he said.
Reporting on material gathered as part of the Oregon Adolescent Depression
Project, Stewart Shankman, Ph.D., an assistant professor of psychology at the
University of Illinois, Chicago, said that comorbid disorders are too often
ignored in research studies. More attention to them might elucidate whether
homotypic symptoms—ones associated with the corresponding full
syndrome—predict escalation to those disorders.
The longitudinal study of 739 youths at ages 16, 17, 24, and 30 found that
subthreshold psychiatric symptoms observed at age 16 were initially associated
at age 24 with anxiety, alcohol, and conduct disorder, but once adjusted for
comorbidities, they were associated only with alcohol use and conduct
"It is important to understand why comorbidities exist and not just
consider them nuisance variables," he said.
A second analysis from the same study found that subthreshold symptoms of
major depressive disorder, bipolar disorder, anxiety, substance abuse, and
conduct disorder were associated with familial risk and/or future development
of the full syndrome disorders.
These subthreshold symptoms cannot be ignored, said Carlson, a professor of
psychiatry and behavioral science at Stony Brook University School of Medicine
in Stony Brook, N.Y., in her discussion of the panelists' talks.
She noted the relevance of subthreshold symptoms to the controversy over
diagnosing pediatric bipolar disorder. Despite that issue, she said, there is
broad agreement on treating these children to improve their emotional
regulation, create structure in their lives, and help with anger control.
"These approaches are good for most psychiatric disorders and will
help produce better outcomes for kids with these problems," she
Children with subthreshold bipolar symptoms may not develop bipolar
disorder but do have problems with mood dysregulation, expressed as depression
and anxiety disorders, she said. However, many psychiatrists fear that
treating these children for depression will raise the risk of triggering manic
"How do you trade off what is in front of you with what is down the
road?" she said. "I've seen as many kids get an SSRI and do OK as
become manic. And is having a manic episode the worst thing that can happen?
We have treatments for manic episodes but not for major depression in bipolar