Post-traumatic stress disorder; post-tsunami and post DSM–IV

As befits a New Year and a new design, the current issue of the Journal reflects the critical tension between research findings examining established diagnoses and those forcing their contemporary re-evaluation. One area where this is pertinent is the diagnosis of post-traumatic stress disorder (PTSD), which is an unusual disorder in having a clearly prescribed aetiology. Hollifield et al (pp. ) report the results of their 1-year follow up of people in Sri Lanka affected by the south Asian tsunami. Over 20% of adults fulfilled criteria for PTSD, with significant numbers having a diagnosis of depression and anxiety disorders. The individual criteria that showed a significant association with symptoms and impairment were ‘thinking one's life was in danger’ and ‘death or injury of a family member’. The authors highlight the need for developing and implementing intervention models for alleviating the distressing symptoms after disasters. An editorial by Rosen and colleagues (pp. ) is critical of the current conceptualisation of PTSD, expressing particular concern at the lack of specificity in aetiology, the lack of a distinct clinical syndrome – especially the overlap with depression and phobia – and the insidious expansion of the diagnostic label to include ‘cross-cultural medicalisation of normal human emotions’. The authors suggest that the review of this diagnosis within DSM–V offers the opportunity to clarify the diagnostic issues, in the light of contemporary findings.

Mental health at the ends of the age spectrum: adolescence and old age

An epidemiological study of adolescent mental health in India finds a reassuringly low rate of any disorder; anxiety, depression, behavioural disorder and attention-deficit hyperactivity disorder were all below 1%. Pillai et al (pp. ) note that over 20% of the population are adolescent, so this is an important finding and suggest that this low rate of mental disorder is contributed to by the presence of strong family support, whereas non-traditional lifestyle choices were associated with higher prevalence of disorders. In the UK, Moran and colleagues (pp. ) demonstrate the association between callous and unemotional traits in children and adolescents at a young age and the subsequent increase in conduct, emotional and hyperactivity-related symptoms at later follow-up. They consider the concept of ‘fledgling psychopaths’ and whether these traits can usefully identify vulnerable groups of young people. Towards the other end of the age spectrum, Lonie et al (pp. ) examined referrals assessed at both secondary and tertiary referral memory clinics and found that a quarter of them fulfilled a diagnosis of amnestic mild cognitive impairment. However, the individuals with a pure form, characterised by an isolated impairment of episodic memory function, were in the minority with most showing deficits in more than this one domain. The authors conclude that further definition of the neuropsychological aspects of mild cognitive impairment criteria is necessary, in order to identify relevant subtypes and clarify their prognosis. Late-life depression is often underdiagnosed and may contribute to significant morbidity. Ryan et al (pp. ) report that depressive illness in late life is also associated with a significantly higher mortality rate and that this link was stronger for men than women. Interestingly, in women the highest mortality was among those with severe depression and no treatment, whereas in men, mortality risk increased with severity of illness and was highest among those with severe depression who had been prescribed antidepressants. The authors suggest that routine screening for depressive symptoms is necessary in late life, and that inadequate treatment may reduce life expectancy, especially in men.

Affect recognition, alexithymia and autism

Patients with psychotic illness have been shown to have difficulty in identifying facial expressions. Addington et al (pp. ) examined facial affect recognition in individuals at high risk for psychosis by virtue of experiencing attenuated positive symptoms. They found that deficits in facial affect recognition were evident in these high-risk individuals at a level similar to patients with first-episode psychosis, and conclude that these deficits occur prior to the onset of full-blown illness. Karlsson and colleagues (pp. ) used positron emission tomography to show that alexithymic women activated more of their sensory and motor cortices and less anterior cingulate cortex during the viewing of emotional films. They suggest that this may represent the tendency to perceive bodily sensations instead of emotions in this group of patients. The anterior cingulate cortex was also the site of differences in activation in a functional magnetic resonance imaging study of reward processing in patients with autistic-spectrum disorder, where patients demonstrated increased activation compared with control participants. Schmitz et al (pp. ) correlated the increased activation in this region with clinical ratings of abnormalities in social interaction and suggest that abnormalities in this cortical region may underpin deficits in social interaction.

We take this opportunity to wish the readers of the Journal a very peaceful and happy New Year.