Van Stoornis naar Syndroom: Geeft Ruimte voor Persoonlijke Benadering

Jim van Os

Lumpers and Splitters

Clinical

Research

What is Personalized Medicine?

Stratifier Unicity(Research) (Clinical)

The Fruits of Specialisation

DBS in Parkinson’s Disease

Gene therapy SMA

Epilepsy surgery

Intra-arterial trombectomy CVA

Monoclonal anibodies MS

Psychiatrie: Personalised?

Super-specialisatie

Personalised psychiatry

High-risk approach prevention

Belofte big data

Value-based health care

“Personalized” in the medical sense

Seven Questions for Personalized Medicine

❖Does Human Genome Contribute to Risk Prediction?

❖Will Gene-Based Drug Development Fulfill Its Promise?

❖What Will EMRs Contribute?

❖What Kinds of Studies for Personalized Medicine?

❖How Should Institutional Conflicts of Interest Be Managed?

❖How Will Personalized Medicine Affect Costs?

❖Where Is the Public Health Benefit?

Evidence-based practice: concept in crisis?

JAMA, 2010

Wake up call

Alle behandelingen hebben zelfde zwakke effect

Is Clozapine Superior?

Insufficient evidence exists on which antipsychotic is more efficacious for patients

with treatment-resistant schizophrenia, and blinded RCTs-in contrast to

unblinded, randomized effectiveness studies-provide little evidence of the

superiority of clozapinecompared with other second-generation antipsychotics.

Wat werkt: Relaties onder de behandeling

JAMA, 2010

Clinician “Random Effect”

10%

5%

% variance BDI

antidepressant% variance BDI

psychiatrist

McKay et al, 2006

Re-analysis NIMH

Treatment of

Depression

Collaborative

Research Program

Heterogeneity: Stratifiers?

IPTEMDR MFN

OLANCLOZ HALO

Heterogeneity: Stratifiers?

Stratifiers in Psychiatry?

Stratifier

Prediction

Personalised Psychiatry: Wat voor soort wetmatigheden onder de GGZ?

LR for a positive test result

LR=1.5LR=10

Most promising test in psychiatry?

The most promising finding was that the

HLA-DQB1 6672G>C polymorphism was

associated with clozapine-induced

agranulocytosis, with an odds ratio of 16.9.

A pharmacogenetic test based on this

polymorphism has been marketed, but

owing to low sensitivity (21.5%), it failed to

be a commercial or clinical success.

DSM5: Diagnostic Stratification

>150 Diagnoses

Multidisciplinaire richtlijnen

Low likelihood ratio’s under Mental Health Practice

Diagnosis Treatment PrognosisCare Need

Anxiety

Fear

Panic

Worry

Rumina-

tionParanoia

Selfre-

ference

Influence

Voices

Hyper-

TOM

Hypo-

TOM

Intru-

sions

Avoidan-

ce

CravingLow

mood

Anergia

Anhedo-

nia

Hopeless-

ness

Suicida-

lity

Insomnia

Worth-

less

Dereali-

sation

Deperso-

nalisation

AmnesiaInatten-

tion

Demora-

lisation

Obses-

sions

Compul-

sionsPain

Lack of

appetite

Guilt

Impulsi-

vityHypo-

mania

Hyper-

activity

Hyper-

ergiaTransdiagnostische

symptomen

Anxiety

Fear

Panic

Worry

Rumina-

tionParanoia

Selfre-

ference

Influence

Voices

Hyper-

TOM

Hypo-

TOM

Intru-

sions

Avoidan-

ce

CravingLow

mood

Anergia

Anhedo-

nia

Hopeless-

ness

Suicida-

lity

Insomnia

Worth-

less

Dereali-

sation

Deperso-

nalisation

AmnesiaInatten-

tion

Demora-

lisation

Obses-

sions

Compul-

sionsPain

Lack of

appetite

Guilt

Impulsi-

vityHypo-

mania

Hyper-

activity

Hyper-

ergia

Anxiety

Fear

Panic

Worry

Rumina-

tionParanoia

Selfre-

ference

Influence

Voices

Hyper-

TOM

Hypo-

TOM

Intru-

sions

Avoidan-

ce

CravingLow

mood

Anergia

Anhedo-

nia

Hopeless-

ness

Suicida-

lity

Insomnia

Worth-

less

Dereali-

sation

Deperso-

nalisation

AmnesiaInatten-

tion

Demora-

lisation

Obses-

sions

Compul-

sionsPain

Lack of

appetite

Guilt

Impulsi-

vityHypo-

mania

Hyper-

activity

Hyper-

ergia

Anxiety

Fear

Panic

Worry

Rumina-

tionParanoia

Selfre-

ference

Influence

Voices

Hyper-

TOM

Hypo-

TOM

Intru-

sions

Avoidan-

ce

CravingLow

mood

Anergia

Anhedo-

nia

Hopeless-

ness

Suicida-

lity

Insomnia

Worth-

less

Dereali-

sation

Deperso-

nalisation

AmnesiaInatten-

tion

Demora-

lisation

Obses-

sions

Compul-

sionsPain

Lack of

appetite

Guilt

Impulsi-

vityHypo-

mania

Hyper-

activity

Hyper-

ergia

Anxiety

Fear

Panic

Worry

Rumina-

tionParanoia

Selfre-

ference

Influence

Voices

Hyper-

TOM

Hypo-

TOM

Intru-

sions

Avoidan-

ce

CravingLow

mood

Anergia

Anhedo-

nia

Hopeless-

ness

Suicida-

lity

Insomnia

Worth-

less

Dereali-

sation

Deperso-

nalisation

AmnesiaInatten-

tion

Demora-

lisation

Obses-

sions

Compul-

sionsPain

Lack of

appetite

Guilt

Impulsi-

vityHypo-

mania

Hyper-

activity

Hyper-

ergia

Broad Syndrome?

METABOLIC SYNDROME

Visceral obesity

Inflammation

Insulineresistance

Hypertension

Low HDL cholesterol

High Triglycerides

DSM5: Diagnostic De-specialization

❖ Autism spectrum

❖ Addiction spectrum

10-15 Hoofdsyndromen

o Psychotisch syndroom

o Bipolair syndroom

o Depressief syndroom

o Angstsyndroom

o Dwangsyndroom

o Trauma syndroom

o Dissociatie syndroom

o Verslavingssyndroom

o Eetsyndroom

o Impulscontrole syndroom

o Neurocognitief syndroom

How Many Syndromes?

>150 Diagnosen

DIAG1 DIAG4 DIAG5DIAG3DIAG2

Needs

Symptoms

Resilience

Personalizing: Transdiagnostic Dimensions

Clinical and Recovery-Based Diagnosis: Biopsychosocio-existentiële Model

WHO, 1948

Symptoombe-

strijding

Huber, 2011

‘Je ding kunnen

doen’

Recivery-Based: CHIME principles

……..point to the need for a greater emphasis on

assessment of strengths and support for self-narrative

development, promoting the role of mental health

systems in developing inclusive communities enabling

access to peer support as well as providing retreats,

and clinical interaction styles which promote

empowerment and self-management.

CONNECTEDNESS; HOPE AND OPTIMISM;

IDENTITY; MEANING IN LIFE; EMPOWERMENT

Leamey et al, 2011

Differential Course Clinical and Personal Recovery

Clinical

Recovery

Personal

Recovery

Macpherson et al, Schiz Res, 2016

1 year

Syndromale Persoonlijke Diagnose

Breed

syndroom Verhaal

Symptoms/Resilience

Sense of purpose

Zorgbehoeften

Klinische Diagnose Hersteldiagnose

symptomenproblemenoplossingenbehandelaarprofessionele distantiefeitenbeschrijvingkennisverklaren oorzakelijke verbandeninterventiebehandeldoelfocus op genezingbeter wordenevidence-basedpatiëntdoen

signalendilemma’skeuzes en zingevinggesprekspartnerprofessionele nabijheidverhalen, overtuigingenervaringlevenskunst en wijsheidbegrijpen van betekenissenpresentieopen procesfocus op veerkrachtregie kunnen voerenlexperience-basedpersoonzijn

What is Personalized Medicine?

Stratifier Unicity(Research) (Clinical)

Workshop: Psychosis Spectrum Syndroom

Fin