Diagnostic operationalization and phenomenological heterogeneity in psychiatry: the case of attention deficit hyperactivity disorder

Giovanni Abrahão Salum, Ary Gadelha, Guilherme Vanoni Polanczyk, Eurípedes Constantino Miguel, Luis Augusto Rohde

DOI: https://doi.org/10.17711/SM.0185-3325.2018.037

Abstract


Introduction. We assessed the impact of polythetic conceptualizations of mental disorders on the validity and reliability of psychiatric diagnosis, with a specific focus on two levels of heterogeneity: phenomenological and pathophysiological.

Objective. We investigated this issue using attention deficit hyperactivity disorder (ADHD) as an example.

Method. We examined individuals from two samples enriched for psychopathology (n = 1 255 children in Porto Alegre and 1 257 children in São Paulo, Brazil). We conducted a series of data analyses to investigate phenomenological heterogeneity, including confirmatory factor analysis. We also investigated pathophysiological heterogeneity using symptom-level regressions between ADHD symptoms and four neurocognitive processes consistently linked to ADHD (working memory, inhibitory control, intra-subject variability in reaction times, and temporal processing). Lastly, we assessed the performance of polythetic systems for reliability testing inter-rater and test-rest reliability of two well-known symptomatic scales.

Results. Among the 116 200 possible combinations of symptoms to achieve DSM symptomatic threshold for categorical ADHD diagnosis, we found 173 combinations in the two independent samples, and only four were replicated in both samples (2.3%). We also found that the number of ADHD symptoms is a poor indicator of variation in the general ADHD latent trait. Overall, symptoms did not have specific profiles of associations with any of the neurocognitive processes. Reliability analyses revealed that increasing the number of items augments overall reliability of measurements.

Discussion and conclusion. Our findings illustrate both potential benefits and problems inherent to the polythetic system for ADHD. Implications for the search of mechanisms underlying psychiatric disorders are discussed.


Keywords


Attention; psychiatry; diagnosis

Full Text:

HTML Pdf ePub Xml

References


Achenbach, T. M. & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms and profiles. Burlington: University of Vermont.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders-Text Revision(4 ed.). Washington: American Psychiatric Association.

Anselmi, L., Fleitlich-Bilyk, B., Menezes, A. M., Araujo, C. L., & Rohde, L. A. (2010). Prevalence of psychiatric disorders in a Brazilian birth cohort of 11-year-olds. Social Psychiatry and Psychiatric Epidemiology, 45(1), 135-142. doi: 10.1007/s00127-009-0052-2

Bitsakou, P., Psychogiou, L., Thompson, M., & Sonuga-Barke, E. J. (2008). Inhibitory deficits in attention-deficit/hyperactivity disorder are independent of basic processing efficiency and IQ. J Neural Transm, 115(2), 261-268. doi: 10.1007/s00702-007-0828-z

Brunner, M., Nagy, G., & Wilhelm, O. (2012). A tutorial on hierarchically structured constructs. Journal of Personality, 80(4), 796-846. doi: 10.1111/j.1467-6494.2011.00749.x

Castellanos, F. X., Sonuga-Barke, E. J., Scheres, A., Di Martino, A., Hyde, C., & Walters, J. R. (2005). Varieties of attention-deficit/hyperactivity disorder-related intra-individual variability. Biological Psychiatry, 57(11), 1416-1423. doi: 10.1016/j.biopsych.2004.12.005

Coghill, D. & Sonuga-Barke, E. J. (2012). Annual research review: Categories versus dimensions in the classification and conceptualisation of child and adolescent mental disorders-implications of recent empirical study. Journal of Child Psychology and Psychiatry, 53(5), 469-489. doi: 10.1111/j.1469-7610.2011.02511.x

Cooper, L. D. & Balsis, S. (2009). When less is more: How fewer diagnostic criteria can indicate greater severity. Psychological Assessment, 21(3), 285-293. doi: 10.1037/a0016698

Cooper, L. D., Balsis, S., & Zimmerman, M. (2010). Challenges associated with a polythetic diagnostic system: criteria combinations in the personality disorders. Journal of Abnormal Psychology, 119(4), 886-895. doi: 10.1037/a0021078

Costello, E. J., Compton, S. N., Keeler, G., & Angold, A. (2003). Relationships between poverty and psychopathology: A natural experiment. JAMA, 290(15), 2023-2029. doi: 10.1001/jama.290.15.2023

Dumenci, L., McConaughy, S. H., & Achenbach, T. M. (2004). A Hierarchical Three-Factor Model of Inattention-Hyperactivity-Impulsivity Derived From the AttentionProblems Syndrome of the Teacher’s Report Form. School Psychology Review, 33(2), 287-301.

Faraone, S. V., Kunwar, A., Adamson, J., & Biederman, J. (2009). Personality traits among ADHD adults: implications of late-onset and subthreshold diagnoses. Psychol Medicine, 39(4), 685-693. doi: 10.1017/S0033291708003917

Fleitlich-Bilyk, B. & Goodman, R. (2004). Prevalence of child and adolescent psychiatric disorders in southeast Brazil. Journal of the American Academy of Child & Adolescent Psychiatry, 43(6), 727-734. doi: 10.1097/01.chi.0000120021.14101.ca

Gibbins, C., Toplak, M. E., Flora, D. B., Weiss, M. D., & Tannock, R. (2011). Evidence for a General Factor Model of ADHD in Adults. Journal of Attention Disorders, 16(8), 635-644.

Glaser, P. E., Thomas, T. C., Joyce, B. M., Castellanos, F. X., & Gerhardt, G. A. (2005). Differential effects of amphetamine isomers on dopamine release in the rat striatum and nucleus accumbens core. Psychopharmacology, 178(2-3), 250-258. doi: 10.1007/s00213-004-2012-6

Goodman, R., Ford, T., Richards, H., Gatward, R., & Meltzer, H. (2000). The Development and Well-Being Assessment: Description and initial validation of an integrated assessment of child and adolescent psychopathology. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 41(5), 645-655.

Goodman, R., Ford, T., Simmons, H., Gatward, R., & Meltzer, H. (2000). Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. The British Journal of Psychiatry, 177, 534-539.

Hidalgo, R. B., Tupler, L. A., & Davidson, J. R. (2007). An effect-size analysis of pharmacologic treatments for generalized anxiety disorder. Journal of Psychopharmacology, 21(8), 864-872. doi: 10.1177/0269881107076996

Hofmann, S. G. & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. The Journal of clinical psychiatry, 69(4), 621-632.

Hogan, A. M., Vargha-Khadem, F., Kirkham, F. J., & Baldeweg, T. (2005). Maturation of action monitoring from adolescence to adulthood: an ERP study. Developmental Science, 8(6), 525-534. doi: 10.1111/j.1467-7687.2005.00444.x

Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural equation modeling: a multidisciplinary journal, 6(1), 1-55.

Hyman, S. E. (2007). Can neuroscience be integrated into the DSM-V? Nature Reviews Neuroscience, 8(9), 725-732. doi: 10.1038/nrn2218

Kapur, S., Phillips, A. G., & Insel, T. R. (2012). Why has it taken so long for biological psychiatry to develop clinical tests and what to do about it? Molecular psychiatry, 17(12), 1174-1179. doi: 10.1038/mp.2012.105

Kendler, K. S. (2008). Explanatory models for psychiatric illness. American Journal of Psychiatry, 165(6), 695-702. doi: 10.1176/appi.ajp.2008.07071061

Kraemer, H. C. & Thiemann, S. (1987). How Many Subjects? Statistical Power Analysis in Research. Newbury Park: Sage Publications.

Kraemer, H. C. (2007). DSM categories and dimensions in clinical and research contexts. International Journal of Methods in Psychiatric Research, 16(1), S8-S15. doi: 10.1002/mpr.211

Kraemer, H. C., & Thiemann, S. (1989). A strategy to use soft data effectively in randomized controlled clinical trials. Journal of Consulting and Clinical Psychology, 57(1), 148-154.

Krueger, R. F., Hicks, B. M., Patrick, C. J., Carlson, S. R., Iacono, W. G., & McGue, M. (2002). Etiologic connections among substance dependence, antisocial behavior, and personality: modeling the externalizing spectrum. Journal of abnormal psychology, 111(3), 411-424.

Marco, R., Miranda, A., Schlotz, W., Melia, A., Mulligan, A., Muller, U., ... Sonuga-Barke, E. J. (2009). Delay and reward choice in ADHD: An experimental test of the role of delay aversion. Neuropsychology, 23(3), 367-380. doi: 10.1037/a0014914

Martel, M. M., Roberts, B., Gremillion, M., Von Eye, A., & Nigg, J. T. (2011). External validation of bifactor model of ADHD: Explaining heterogeneity in psychiatric comorbidity, cognitive control, and personality trait profiles within DSM-IV ADHD. Journal of abnormal child psychology, 39(8), 1111-1123. doi: 10.1007/s10802-011-9538-y

Martel, M. M., Von Eye, A., & Nigg, J. T. (2010). Revisiting the latent structure of ADHD: is there a ‘g’ factor? Journal of child psychology and psychiatry and allied disciplines, 51(8), 905-914.

McLaughlin, K. A., & Nolen-Hoeksema, S. (2011). Rumination as a transdiagnostic factor in depression and anxiety. Behaviour research and therapy, 49(3), 186-193. doi: 10.1016/j.brat.2010.12.006

McLoughlin, G., Albrecht, B., Banaschewski, T., Rothenberger, A., Brandeis, D., Asherson, P., & Kuntsi, J. (2009). Performance monitoring is altered in adult ADHD: a familial event-related potential investigation. Neuropsychologia, 47(14), 3134-3142. doi: 10.1016/j.neuropsychologia.2009.07.013

Merport, A. & Recklitis, C. J. (2012). Does the brief symptom inventory-18 case rule apply in adult survivors of childhood cancer?: comparison with the symptom checklist-90. Journal of pediatric psychology, 37(6), 650-659. doi: 10.1093/jpepsy/jss050

Merport, A., Bober, S. L., Grose, A., & Recklitis, C. J. (2012). Can the distress thermometer (DT) identify significant psychological distress in long-term cancer survivors? A comparison with the Brief Symptom Inventory-18 (BSI-18). Support Care in Cancer, 20(1), 195-198. doi: 10.1007/s00520-011-1269-7

Muthén, L. K., & Muthén, B. O. (2012). Mplus User’s Guide. Los Angeles: Muthén & Muthén.

Nigg, J. T., Willcutt, E. G., Doyle, A. E., & Sonuga-Barke, E. J. (2005). Causal heterogeneity in attention-deficit/hyperactivity disorder: do we need neuropsychologically impaired subtypes? Biological Psychiatry, 57(11), 1224-1230. doi: 10.1016/j.biopsych.2004.08.025

Nolen-Hoeksema, S. & Watkins, E. R. (2011). A Heuristic for Developing Transdiagnostic Models of Psychopathology Explaining Multifinality and Divergent Trajectories. Perspectives on Psychological Science, 6(6), 589-609. doi: 10.1177/1745691611419672

Olbert, C.M., Gala, G.J., & Tupler, L.A. (2014). Quantifying heterogeneity attributable to polythetic diagnostic criteria: theoretical framework and empirical application. Journal of Abnormal Psychology, 123(2), 452-62.

Penninx, B. W., Nolen, W. A., Lamers, F., Zitman, F. G., Smit, J. H., Spinhoven, P., … Beekman, A. T. (2011). Two-year course of depressive and anxiety disorders: results from the Netherlands Study of Depression and Anxiety (NESDA). Journal of Affective Disorders, 133(1-2), 76-85. doi: 10.1016/j.jad.2011.03.027

Rescorla, L., Ivanova, M. Y., Achenbach, T. M., Begovac, I., Chahed, M., Drugli, M. B., ... Zhang, E. Y. (2012). International epidemiology of child and adolescent psychopathology ii: integration and applications of dimensional findings from 44 societies. Journal of the American Academy of Child & Adolescent Psychiatry, 51(12), 1273-1283 e1278. doi: 10.1016/j.jaac.2012.09.012

Salum, G., Gadelha, A., Pan, P. M., Moriyama, T. S., Graeff-Martins, A. S., Tamanaha, A. C., ... Rohde, L. A. (2015). High risk cohort study for psychiatric disorders in childhood: rationale, design, methods and preliminary results. International Journal of Methods in Psychiatric Research, 24(1), 58-73. doi: 10.1002/mpr.1459

Salum, G., Sergeant, J., Sonuga-Barke, E., Vandekerckhove, J., Gadelha, A., Pan, P., ... Rohde, L. A. (2012). Specificity of Basic Information Processing and Inhibitory Control in Attention Deficit/Hyperactivity Disorder (ADHD). Psychological Medicine, 44(3), 617-631.

Sanislow, C. A., Pine, D. S., Quinn, K. J., Kozak, M. J., Garvey, M. A., Heinssen, R. K., ... Cuthbert, B. N. (2010). Developing constructs for psychopathology research: research domain criteria. Journal of abnormal psychology, 119(4), 631-639. doi: 10.1037/a0020909

Sonuga-Barke, E. (2013). The challenge of mapping diagnostic categories onto developmental pathophysiology: DSM-6 anyone?. Journal of Child Psychology and Psychiatry, 54(6), 601-602. doi: 10.1111/jcpp.12096

Sonuga-Barke, E. J. (2005). Causal models of attention-deficit/hyperactivity disorder: from common simple deficits to multiple developmental pathways. Biological Psychiatry, 57(11), 1231-1238. doi: 10.1016/j.biopsych.2004.09.008

Sonuga-Barke, E. J. (2010). Disambiguating inhibitory dysfunction in attention-deficit/hyperactivity disorder: toward the decomposition of developmental brain phenotypes. Biological Psychiatry, 67(7), 599-601. doi: 10.1016/j.biopsych.2010.01.017

Telzer, E. H., Mogg, K., Bradley, B. P., Mai, X., Ernst, M., Pine, D. S., & Monk, C. S. (2008). Relationship between trait anxiety, prefrontal cortex, and attention bias to angry faces in children and adolescents. Biological Psychology, 79(2), 216-222. doi: 10.1016/j.biopsycho.2008.05.004

Toplak, M. E. & Tannock, R. (2005). Tapping and anticipation performance in attention deficit hyperactivity disorder. Perceptual and Motor Skills, 100(3), 659-675.

Toplak, M. E., Pitch, A., Flora, D. B., Iwenofu, L., Ghelani, K., Jain, U., & Tannock, R. (2009). The unity and diversity of inattention and hyperactivity/impulsivity in ADHD: Evidence for a general factor with separable dimensions. Journal of Abnormal Child Psychology, 37(8), 1137-1150.

Toplak, M. E., Rucklidge, J. J., Hetherington, R., John, S. C., & Tannock, R. (2003). Time perception deficits in attention-deficit/ hyperactivity disorder and comorbid reading difficulties in child and adolescent samples. Journal of Child Psychology and Psychiatry, 44(6), 888-903.

Vandierendonck, A., Kemps, E., Fastame, M. C., & Szmalec, A. (2004). Working memory components of the Corsi blocks task. British journal of psychology, 95(1), 57-79. doi: 10.1348/000712604322779460

Ward, A. J. (1974). Childhood psychopathology. A natural experiment in etiology. Journal of the American Academy of Child & Adolescent Psychiatry, 13(1), 153-165.

Wechsler, D. (2002). WISC-III: Escala de Inteligência Wechsler para Crianças: Manual. Sao Paulo: Casa do Psicólogo.

Woerner, W., Fleitlich-Bilyk, B., Martinussen, R., Fletcher, J., Cucchiaro, G., Dalgalarrondo, P., ... Tannock, R. (2004). The Strengths and Difficulties Questionnaire overseas: evaluations and applications of the SDQ beyond Europe. European child & adolescent psychiatry, 13(2), ii47-ii54. doi: 10.1007/s00787-004-2008-0