Talk:Spectrum disorder/Archive 1

Page title?
I just started this page but wonder if it could also go under a title like 'Spectrum model of mental disorder'. I've reworded it to clarify the fairly complex common & scientific usage. EverSince 10:21, 20 December 2006 (UTC)


 * I see problems: for instance the basic way you are defining a spectrum disorder is at odds with any definition I've ever seen.  Providing inline citations for the article may help you avoid original research - I'm very curious to see the source for this definition of spectrum disorder.


 * Also, have a look at WP:MOS and WP:LAYOUT - all of the section headings need to be fixed. Sandy (Talk) 23:46, 20 December 2006 (UTC)

I'm not sure what you're trying to say about the definition, or what other kind you're familar with? Perhaps you mean more of an emphasis on their being peripheral or personality extensions of DSM/ICD diagnoses, or syndromes sharing similar etiology/features? Perhaps the issue is whether the 'disorder' term in the phrase refers to each individual subtype, or to the overarching spectrum? My first comment above originally just said 'The common and scientific usage is a bit variable and complicated'. I then tried to reword the intro to capture that, please feel free to do so yourself.

What do you mean about original research? I spent a lot of time referencing and trying to convey that. I wasn't sure what to cite where in-text and ran out of time, or I would have done it. E.g. 1st article of 1st reference:

Maser & Akiskal (2002): "[the DSM & ICD] presume that the syndromes they define constitute the real maladies. Laboratory testing is rarely relevant or specific enough for a given mental disorder, however. In the absence of such tests, we might use distress and dysfunction for the validation of clinical illness. It then becomes obvious that many individuals seek help for distress and dysfunction that involve mental and behavioral problems—especially in primary care clinics—which would be subthreshold to what is described in the official manuals"

To source the actual classifications listed, I think each one would need to be sourced separately, the references are already there to do it for most of them.

I think you may have made the minor formatting changes you were referring to, I wasn't sure what you meant. I personally find the way you've formatted the references a bit unclear but hopefully will find time to in-text cite things anyway. EverSince 18:50, 21 December 2006 (UTC)

p.s. why the specific deletion of Tourette's/tic disorders as 'incorrect classification'? It's widely proposed, quick search of just abstracts:

Comprehensive Psychiatry, 2003 The findings of this comorbidity study suggest that tic disorders, hypochondriasis, BDD, and trichotillomania are perhaps part of the OC spectrum disorders.

Advances in Neurology 2005 "Finally, neurobiologic evidence points to similar anatomic and chemical substrates in the pathogenesis of TS and OCD, suggesting that these two disorders share a common pathophysiology"

Prog Neuropsychopharmacol Biol Psychiatry 2006 "Comorbidity of certain obsessive-compulsive spectrum disorders (OCSDs; such as Tourette's disorder) in obsessive-compulsive disorder (OCD) may serve to define important OCD subtypes characterized by differing phenomenology and neurobiological mechanism" EverSince 19:19, 21 December 2006 (UTC)

p.s. How's this for a definition, from a letter from a psychiatrist to a psychiatric journal, 2000

Sir,

Spectrum disorder seems to have become the acceptable, if not fashionable, way of admitting our incompetence in distinguishing between mental illness and 'normality'. Personality spectrum, schizophrenia spectrum, depressive spectrum, whatever next? We appear to be moving further and further away from the fundemental idea that there is a distinct break from normality to mental illness. This 'rainbow' approach to diagnosis may well suit interior decoration but does nothing to further our patients treatments. As an 'out-clause' for our not unusual treatment failures it may have some merit, and also protect us from worry induced insomnia, but there is surely more utility in definitive diagnosis, even if eventually modified...." EverSince 23:31, 21 December 2006 (UTC)

Hello Sandy, I am in the process of trying to source & organize this page according to your suggestions, but it's being made difficult by the fact that you have started editing & tagging it while I am in the process, there having been a gap of several days since either of us did anything. It would also be helpful to know more specifically why you seem to have issues with the concept of this page. Can we cooperate? EverSince 04:27, 25 December 2006 (UTC)


 * WP:V is an important Wikipedia policy - even if a topic is only hypothetical (and doesn't enjoy widespread consensus), statements must still be referenced to reliable sources, and cannot be original research.


 * I entirely agree about verifiability and reliability. I wonder why you are quoting this at me again. EverSince 04:54, 25 December 2006 (UTC)


 * I cleaned up the references that were here the other day: I'm wondering why you are undoing them?  Also, the definition of the concept is not verified by the source given - pls don't remove the check tag unless you can reword or provide another source (thanks).


 * I was in the process of changing most of the references to in-text links which got very complicated and I overwrote the more minor changes you'd made rather than risking losing all that work. I apologize for not doing it another way. Please could you clarify why you don't think that source supports the phrase directly next to it - that the spectrum model is about subsyndromal symptoms being associated wiht clinically significant distress/dsyfunction. EverSince 04:54, 25 December 2006 (UTC)
 * The references were done correctly in References - you only had to copy them into ref tags - there's no need to change anything, or to delete the PMIDs. Sandy (Talk) 05:03, 25 December 2006 (UTC)
 * There is no wording in the source which supports the definition given - there is no definition in the source at all. As the article stands now, a concept is defined without giving anywhere a source that supports that definition.  Sandy (Talk) 05:03, 25 December 2006 (UTC)


 * As but one example of the problems in the text (besides no definition I recognize yet), note the difference between saying that


 * 1) TS and a subset of OCD are thought to be alternative expressions of the same underlying etiology, a widely-held and accepted premise, and
 * 2) saying that TS is on a vague and hypothetically-defined (and not widely-accepted) OCD spectrum which includes diagnoses shown by a body of research not to be etiologically-linked with TS.


 * For heaven's sake would you say what definition you have in mind, as I've asked you above? Or change the one that's there, as I've suggested above? Or do you just want to judge my efforts? EverSince 04:54, 25 December 2006 (UTC)


 * I don't do original research very well :-) I can't just change your wording to my understanding of what a spectrum disorder is - it is up to the person adding the text to provide a source for the text - even more so when a basic definition is given for a hypothetical context - Wiki readers need to know whose definition this is.  You seem to have an idea of where you want the article to go - I'm waiting to see sources that back up these definitions.


 * This is but one example of why you need sources backing up specific statements. I also removed a source that was hanging in the middle of the article, referencing nothing.  If you can use a correct referencing style, and make sure that your sources actually reference the text inserted, it will help. I'll wait to edit further until you're done.  Sandy (Talk) 04:41, 25 December 2006 (UTC)


 * Yes I was in mid-flow. Thank you for waiting - I'll leave a message here when I've paused/stopped. EverSince 04:54, 25 December 2006 (UTC)


 * OK - I guess the cites hanging mid-air will eventually have associated text (and hopefully they'll get their PMIDs back as well :-) Sandy (Talk) 05:03, 25 December 2006 (UTC)

Incorrect referencing style
(edit conflict): Please review the most recent featured articles for a correct referencing style on medical articles:  Bacteria, Influenza, and Tuberculosis, for example. PMID at the end, last access date needed on any full-text web links, web links are linked to the title, not the author. Thank you, Sandy (Talk) 04:30, 25 December 2006 (UTC)

Are you talking to me? This isn't just a medical article, it's also psychological. And see for example current FA Schizophrenia. EverSince 04:40, 25 December 2006 (UTC)
 * Even schizophrenia - which is one of the medical FAs in worst shape, and passed WP:FAC years ago, when standards were lower, and has deteriorated since - mostly uses a correct referencing style. It is an old FA, would never pass WP:FAC in its current shape, and is missing PMIDs - I referred you to newer FAs, which include correct medical references, including PMIDs.  Sandy (Talk) 04:45, 25 December 2006 (UTC)

Inline citations are used to, well, cite text inline - I'm wondering why you are adding inline cites not associated with any text? Sandy (Talk) 04:48, 25 December 2006 (UTC)


 * It would also be helpful if you would stop deleting PMIDs which I took the time to look up - they are a standard source on Wikipedia. Thanks, Sandy (Talk) 04:50, 25 December 2006 (UTC)


 * Well I was going to ask for advice about this. If referencing the concept of a particular spectrum, and all or some of the conditions listed within it, the reference needs to be next to the header. But I thought they'd be objections if I included it in the header, so that there was a big number. Not sure what else to do?


 * No, we can't add refs to section headings, but what you can do is add some supporting text, which explains who/why says these spectra are defined as this article says they are (which won't be easy, because none of them are straightforward or enjoy widespread consensus). It seems to me the task would be easier, and make more sense, if this article were a true definition and discussion of what a spectrum disorder is, while adding the text, lists and references about each hypothesized spectrum to the daughter article about that spectrum - that would result in this article being less speculative.  Wikipedia needs a basic, accurate definition of a spectrum disorder, rather than a list of some "spectra" as defined by some researchers, few of them enjoying research consensus as defined here, when those could be covered in each conditions' individual article.  This article should be a basic, accurate definition and description of the term, spectrum disorder.  Any alleged OCD spectrum or bipolar spectrum or whatever spectrum as defined by a specific set of researchers could be discussed in the referenced (main) daughter articles, where they will be placed in better context of the overall medical consensus.  Hope that helps, Sandy (Talk) 05:53, 25 December 2006 (UTC)


 * I take your point about the PMIDs and apologies, but as I mentioned above I found them confusing and less easy than just clicking on part of the reference (which I accept should be the title, as you say). Please feel free to reinsert them of course or let me know if you want me to EverSince 04:59, 25 December 2006 (UTC)


 * I will fix the references later - they're saved below, only need to be copied into the ref tags. PMIDs are fairly standard throughout Wikipedia now (having a template for ease of use), but when other full-text links are added, they need a last access date. Sandy (Talk) 05:53, 25 December 2006 (UTC)

Clarity
OK I've actually run out of stream on this one. I would like to establish exactly what the issues are that need to be resolved & sourced before I work on it again. You've implied that this topic is "only hypothetical (and doesn't enjoy widespread consensus)" and that "the basic way you are defining a spectrum disorder is at odds with any definition I've ever seen" - and yet you won't say what definitions you've seen and you say you don't do original research very well. You haven't provided any sources justifying these views and consequent harsh standards being applied to this article. I disagree that this is original research. I think a non-obtuse attempt to connect the dots in the referenced texts indicates the general usage, which is a common and widespread one. I accept a more formal definition is desirable.

Pages already exist on the autistic spectrum and the bipolar spectrum etc, which provide no soruces for their definitions or virtually anything on the pages. Nevertheless, it is clear these terms are in widespread usage. It is equally clear, I hope, that there is a large high-quality peer-reviewed literature on these and other putative spectra and spectrum disorders, including special editions of the highest impact psychiatric and psychological journals. It is also the case that spectrum concepts are a key consideration in the planning of DSM-V.

This article can be a really valuable NPOV account of the range of opinion and evidence out there regarding spectrum disorders, including the different categorizations commonly proposed. I hope you can help it achieve that as well as making sure it meets the very highest Wikipedia formatting standards. Thank you for waiting. EverSince 06:42, 25 December 2006 (UTC)

I've made it a stub, please expand it if you wish of course, I'm going to leave this topic for now. EverSince 13:11, 25 December 2006 (UTC)

To be even clearer: Sandy, please could you justify your expressed views that this page is original research that doesn't enjoy widespread consensus, and apparently consequent harsh standards being applied to the page. I do not believe it is in the spirit of Wikipedia to state that you see problems with a page, then neglect to respond to several questions asking you what exactly you mean, but then to start editing and tagging again the instant someone starts trying to work on the article again. EverSince 21:51, 2 January 2007 (UTC) p.s. if you don't want to or can't clarify - and believe me I have no desire for any involved or lengthy debate - I will seek additional opinions.


 * Hi, EverSince - sorry for the delay, but when you stubbed the article, I didn't realize there was anything left to add, and it only popped up on my watchlist again (today) because you posted here.


 * First, an understanding of Wiki policies - you were writing the article, so it was up to you to cite sources for text you add. I was waiting to see where you were going with it, since the information you were including 1) didn't concur with anything I'd seen for a definition, 2) wasn't yet complete, 3) was speculative, and 3) was mostly uncited, or the text wasn't backed by the sources given.


 * I can tell you what the definitions of "spectrum disorder" that I've seen say, but I haven't located a single reliable source anywhere providing a definition of a spectrum disorder, and that's where the original research comes in, and why I hesitate to add the definitions I know. I can't/won't add *my* definition to an article without sourcing it.  The problem with the direction the article was going was three-fold:
 * It didn't define a basic spectrum disorder (that is, separate from hypothetical, specific spectra).
 * It then branched out into lists of speculative proposed spectra.
 * Those hypothesized spectra are each covered in their own articles, so the information here was redundant.


 * The concept of a basic spectrum disorder – separate and distinct from the list of hypothetical spectra according to someone's whim or definition – exists, is accepted, and should be defined. I can't locate a source I'm happy with (i.e.; PubMed), but it would read something like (paraphrasing here) ... A condition whose severity of symptoms occurs along a spectrum, from mild to severe, including symptoms that don't attain a threshhold of diagnostic severity, and with additional features and subtypes that occur in a variety of combinations.


 * ADHD is a spectrum disorder, so is OCD, TS, depression, bipolar, autism - any number of conditions are widely accepted as spectrum disorders; that basic definition wasn't given in the article - that is what the article could/should cover - the basics of what a spectrum disorder is, without speculating about some conditions lying on some other hypothetical spectrum. It is speculative, unsourced, and unfounded to attribute a given DSM condition to a given spectrum - for example, ADHD is on the biplar spectrum, TS is on the autism spectrum (yes, there are adherents to every kooky spectra one can imagine) - that is where this article was going, and that is where the problem lies.  Further, there are already articles for each condition that are covering these speculative definitions of various conditions - all these hypothetical spectra already have articles.  As a starting place, this article needs to define the accepted basics of what a spectrum disorder is - perhaps you are able to locate a reliable source that give that starting place.  Regards, Sandy Georgia  (Talk) 00:59, 3 January 2007 (UTC)


 * OK, Sandy. I still disagree with, or am unclear about, the points you are making about the definition or your characterization of the state of the page, which was being seriously sourced - more than other spectrum pages which I noticed you've edited at some point, including affective spectrum and Obsessive-Compulsive Spectrum Disorder - which both seem to be based on under-sourced and under-defined lists. However, I suppose I can agree that it would be best to get a solid sourced formal definition in place for this page on the overall concept, and the rest of it can flow from that, whenever that might be EverSince 18:29, 4 January 2007 (UTC)


 * Well, maybe you had a hard time reading my stuff above because it's load with typos - I'll go back and fix in a minute. Yes, those articles are also in *very* bad shape, as are almost all of the articles in the realm of Psychology on Wikipedia - that's no reason for *this* article to be in bad shape, because spectrum disorder *is* a common term, that should have a basic definition.  The fact that the other articles are crap is not a good reason for us to give up on an article that needs a basic, accurate definition, and then branch into the other garbage articles.  The Psychology Project doesn't seem to be overly concerned with getting the basics in place.  Sandy Georgia  (Talk) 18:44, 4 January 2007 (UTC)


 * Could read it OK. I disagree that this article was in notably bad shape, especially as a start-class that was being actively worked on and multiply sourced. I won't get in to generalizations about psych disorder pages, except to say I am concerned with improving and sourcing them (which isn't to agree that it is necessarily helpful to treat them as just medical pages, or likewise as just sociology pages) EverSince 19:00, 4 January 2007 (UTC)

Consensus
Below are numerous quotes relating to definition, from articles within Spectrum concepts in major mental disorders, an issue of Psychiatric Clinics of North America (December 2002;25:4) devoted to this topic. (There is also a special edition of the Journal of Abnormal Psychology called Toward a Dimensionally Based Taxonomy of Psychopathology (2005 Nov Vol 114(4) 491-493) covering similar ground)

Assuming that some consensus combination of these can function as a source for a (somewhat variable) definition, I think we need to establish what page name this topic should come under. Given the similar but (to some at least) significantly differing terminology of spectrum/dimension/continuum, as well as categorical schemes, I think it might be most sensible to have a page that can encompass them all. A title like "Psychiatric nosology" would be neat but exclusively medical. Something like "Classification of mental disorder" seems OK to me. If there's no objections or other suggestions I'll create this EverSince 16:18, 27 February 2007 (UTC)

-- From the summarizing article: Maser & Patterson "Spectrum and nosology: implications for DSM-V":

“For clinicians trained after the publication of DSM-III, the spectrum concept may be relatively new, but it actually has a long and distinguished history that dates back to Kraepelin and beyond.”

"the term spectrum is taken from optical physics. Not only does it have a metaphorical quality to it but also clarity is obscured because different nosologists use it in different ways. Akiskal presents the bipolar spectrum as a series of phenotypic expressions of the bipolar diathesis. For Hollander, spectrum seems to mean all DSM-IV categorical disorders that include impulsivity, compulsive behaviours, and obsessive thoughts. The Spectrum Project’s definition may be said to include all of DSM-IV’s symptoms, noncriterion symptoms, isolated symptoms and long-term traits.”

"”Spectrum”, “dimension” and “continuum” are related concepts. The authors use them interchangeably, although some might argue the fine points of difference.  To say that a condition is not a unitary disorder but rather a syndrome composed of subgroups is to suggest that a spectrum exists for that syndrome.”

“spectrum starts with the nuclear, classic DSM diagnostic criteria for an axis 1 disorder and then includes the surrounding halo of phenomenology…the spectrum includes the broad range of manifestations of a disorder that may be present during, between, or even in the absence of an episode of the full-blown disorder...temperaments or traits and “lifestyle” “behavioural patterns” and "personality characteristics”...are part of the phenomenology and useful for identifying dimensions"

“Angst et al (ref 96) have called the propensity for admitting into treatment only persons who meet the DSM threshold for a disorder “threshold psychiatry”.

“Various spectrum concepts of depression have been called the depression spectrum, the affective spectrum, and the mood spectrum”.

“no system of nosology is likely to be perfect until precise and accurate causes of mental illness are known. DSM-III changed the world for psychiatry and clinical psychology, and since its publication an enormous amount of data on mental illness has been published. Included in that data is a large literature that, in the authors’ opinion, leads to an unambiguous conclusion that [a spectrum classification] provides a better perspective on phenomenology of psychopathology than a categorical classification”

From Cassano et al. Mood spectrum article:

“The authors use the term “spectrum” to refer to psychiatric conditions that encompass various arrays of symptoms, personality traits, and behavioural features related to an established DSM-IV disorder construct. The authors are aware that the term “spectrum” has a long and varied history in psychiatry, meaning one thing when referring to schizophrenia spectrum and another when referring to bipolar or obsessive-compulsive disorder spectrum, for example.”

"This evidence suggests the potential usefulness of a thorough dimensional assessment of the psychopathological continuum that includes and gives importance to all the manifestations of a disorder, including prodromal, typical, atypical, residual and trait-like symptoms.”

From Perugi & Akiskal soft bipolar spectrum redefined:

"The concept of spectrum originally was used in physics to indicate an apparent qualitative distinction arising from a quantitative continuum (i.e. a series of colors formed when a beam of white light is dispersed by a prism so that their parts are arranged in the order of their wavelengths). In psychiatry, the concept of spectrum was first used with a slightly different connotation to identify a group of disorders that is qualitatively distinct in appearance (e.g. depression and alcoholism) but believed to be related from a pathogenic point of view. For different investigators, the hypothetical common pathogenic link has been of a different nature: [examples]”

Other investigators have used the term “spectrum” in a different meaning to refer to “broad areas of psychiatric phenomena relating to a single mental disorder”. (e.g. Cassano et al. 1997, re panic-agoraphobic spectrum). This latter kind of psychiatric spectrum should include “core, atypical and subclinical symptoms of the primary Axis I disorder; signs, isolated symptoms, symptom clusters, and behavioural patterns related to the core symptoms, that may be prodomal, … prescurors… or or sequelae of a …full-fledged disorder” The use of the term “spectrum” in this sense is superposable to that of syndromic continuum (cf Alrcon, RD & Rippertoe, PA, Walter-Ryan, WG, A spectrum is not a continuum. Am J Psychiatry, 1986; 143:678)

This article exemplifies the use of the concept of the spectrum in a much broader sense….”soft bipolar spectrum” organized around bipolar II, in which we submit that cyclothymic temperamental instability represents the common substrate underlying a “spectrum” of related clinical conditions characterized by a complex combination of ood, anxiety and impulse-control disorders. Builing on previous formulations of this “less-than-manic” spectrum…”

Schneier et al, The social anxiety spectrum: “...the emergent concept of a social anxiety spectrum needs maturation...exclusive focus on the notion of a single continuum with two extremes…is premature…alternative approach is to conceptualise multiple overlapping spectra in this area of psychopathology"

Phillips, obsessive-compulsive spectrum: “this hypothesis generally implies that spectrum members should be classified together in DSM…also underlying the spectrum concept is the hypothesis that spectrum disorders are related to one another...finally, although not always explicitly stated, the OC spectrum hyopthesiss generally implies that spectrum disorders have a shared pathogenesis”

Willemsen-Swinkels autistic spectrum: “many researchers have argued for the existence of an autistic spectrum rather than an autistic continuum. The term “continuum” suggests a simple straight line from severe to mild...The term “spectrum” is used to indicate the fact that although there is a common denominator, different types of children with a PDD present with their own pattern of symptoms. These types of children differ by nature and not merely by degree. This is reminiscent, metaphorically speaking, of the spectrum of distinct colors after refraction of light by a prism”

Cadenhead, schizphrenia spectrum: “the schizophrenia spectrum describes what is most likely a continuum of illnesses that include the more severe “Kraepeliniean” schiozphrenia, schiopzhrenia-related personality disorders, and the relatively mild and “nonclinical” phenotypic deficits observed in family members.”

Moreau & Zisook PTSD: “the authors present the case that PTSD can best be understood as existing along at least three spectra: one based on symptom severity (or diagnostic threshold), another based on the nature of the stressor, and a final one based on potential responses to trauma.”

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