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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