Article AbstractBecause this piece does not have an abstract, we have provided for your benefit the first 3 sentences of the full text.To the Editor: Olfactory reference syndrome (ORS) is a condition characterized by concerns about perceived body odor, which may lead to repetitive behaviors to diminish the odor, as well as to avoidance of social interactions. A range of other terms describing olfactory reference symptomatology has appeared in the literature; for example, based on the observation that it involves a single belief that is often delusional in intensity, ORS has been referred to as a type of monosymptomatic hypochondriacal psychosis (eg, see references). ORS is now referred to in DSM-5 as a type of "other specified obsessive-compulsive and related disorder."

Data are consistent with literature failing to confirm the three-factor structure of DSM-IV PTSD, and they support the DSM-5 inclusion of a symptom cluster addressing altered mood and cognition in PTSD. The efficacy of venlafaxine ER in reducing a range of symptom clusters in PTSD is consistent with its multiple mechanisms of action.

This chapter takes an anthropological approach to the study of global mental health among women. It explores the cultural, economic, and political determinants of women's mental health in an effort to identify directions for future research on pathways to improve women's well-being, emphasizing the role of empowerment. The chapter elaborates upon the World Health Organization (WHO) analyses, utilizing the 2009 updates on the disability-adjusted life years (DALYS) and global burden of disease to consider comparisons between women and men in the context of selected countries. It presents global trends as well as a comparison across the world's populous countries and diverse predominantly Muslim countries of high, medium, and low income, three of which have been highly affected by war. Future research on global mental health of women should be grounded in the lived experience of mental illness in an inexorably entangled nexus of relations of culture, power, gender, and meaning.

Post-traumatic stress disorder (PTSD) should be one of the most preventable mental disorders, since many people exposed to traumatic experiences (TEs) could be targeted in first response settings in the immediate aftermath of exposure for preventive intervention. However, these interventions are costly and the proportion of TE-exposed people who develop PTSD is small. To be cost-effective, risk prediction rules are needed to target high-risk people in the immediate aftermath of a TE. Although a number of studies have been carried out to examine prospective predictors of PTSD among people recently exposed to TEs, most were either small or focused on a narrow sample, making it unclear how well PTSD can be predicted in the total population of people exposed to TEs. The current report investigates this issue in a large sample based on the World Health Organization (WHO)'s World Mental Health Surveys. Retrospective reports were obtained on the predictors of PTSD associated with 47,466 TE exposures in representative community surveys carried out in 24 countries. Machine learning methods (random forests, penalized regression, super learner) were used to develop a model predicting PTSD from information about TE type, socio-demographics, and prior histories of cumulative TE exposure and DSM-IV disorders. DSM-IV PTSD prevalence was 4.0% across the 47,466 TE exposures. 95.6% of these PTSD cases were associated with the 10.0% of exposures (i.e., 4,747) classified by machine learning algorithm as having highest predicted PTSD risk. The 47,466 exposures were divided into 20 ventiles (20 groups of equal size) ranked by predicted PTSD risk. PTSD occurred after 56.3% of the TEs in the highest-risk ventile, 20.0% of the TEs in the second highest ventile, and 0.0-1.3% of the TEs in the 18 remaining ventiles. These patterns of differential risk were quite stable across demographic-geographic sub-samples. These results demonstrate that a sensitive risk algorithm can be created using data collected in the immediate aftermath of TE exposure to target people at highest risk of PTSD. However, validation of the algorithm is needed in prospective samples, and additional work is warranted to refine the algorithm both in terms of determining a minimum required predictor set and developing a practical administration and scoring protocol that can be used in routine clinical practice.

Although epigenetic regulation plays a critical role in embryonic development, few studies have examined the relationship of epigenome-wide methylation with fetal growth. Using the Infinium HumanMethylation450 BeadChip (Illumina, Inc., San Diego, California) in a substudy of 1,046 infants from the Norwegian Mother and Child Cohort Study (MoBa) enrolled between 1999 and 2008, we examined epigenome-wide cord blood DNA methylation in relation to birth weight. In multivariable-adjusted robust linear regression models, we identified differential methylation at 19 cytosine-guanine dinucleotides (CpGs) associated with either decreased (AT-rich interactive domain 5B (MRF1-like) (ARID5B), 2 CpGs) or increased (x-ray repair complementing defective repair in Chinese hamster cells 3 (XRCC3), 4 CpGs) birth weight. ARID5B knockout mice have less adipose tissue and significantly lower weight in the postnatal period. XRCC3 plays a key role in the maintenance of chromosome stability and the repair of DNA damage. Although there are fewer data on the other implicated genes, many of these genes have been shown to have roles in developmental processes. This constitutes the largest and most robust study of birth weight using an epigenome-wide methylation platform and offers potential insights into epigenetic mechanisms of fetal growth.

There are suggestions of an inverse association between folate intake and serum folate levels and the risk of oral cavity and pharyngeal cancers (OPC), but most studies are limited in sample size, with only few reporting information on the source of dietary folate. This study aims to investigate the association between folate intake and the risk of OPC within the International Head and Neck Cancer Epidemiology (INHANCE) Consortium.

Psychiatric classifications have traditionally recognized a number of conditions as representing impulse control disorders. These have included pathological gambling, intermittent explosive disorder, kleptomania, pyromania, and trichotillomania. In 1992, the World Health Organization (WHO) described habit and impulse disorders (F63) as characterized by repeated acts that have no clear rational motivation, generally harm the person's own interests and those of other people, and are associated with impulses the person experiences as uncontrollable 1. In DSM-IV-TR, the American Psychiatric Association further characterized these impulse control disorders as being preceded by a rise in tension before the behaviour or when resisting the behaviour, and followed by pleasure, gratification, or relief of tension 2. In the past two decades, the public health importance of these disorders has become increasingly apparent. For example, pathological gambling and intermittent explosive disorder are prevalent conditions (lifetime prevalence rates of 1% and 3%, respectively) that are recognized to represent a substantial burden of disease (for example, increased health concerns, family discord, and financial problems) 3, 4. Furthermore, there is a growing literature addressing the psychobiology and management of all of these impulse control disorders 5-7. Some animal models and clinical imaging studies suggest that these conditions represent “behavioural addictions”, characterized by abnormalities in reward processing 8-11. As a result, proposals have been made to include compulsive sex, compulsive buying, and compulsive Internet use under this rubric, on the grounds that they too represent a large burden of disease and deserve appropriate diagnosis and treatment 7, 12-14. The WHO's development of the ICD-11 provides an important opportunity to optimize the classification and description of impulse control disorders and to address some of the controversies surrounding these putative “behavioural addictions”. The WHO has emphasized that ICD-11 should pay particular attention to issues of clinical utility, global applicability, and scientific validity 15. The ICD-11 Working Group on Obsessive-Compulsive and Related Disorders was asked to review the scientific and other information about use, clinical utility, and experience with relevant ICD-10 diagnoses, including impulse control disorders; to review the approach of the DSM-5 to these conditions, with a focus on whether this approach might be suitable and useful for global applications; and to develop proposals for ICD-11, with a particular emphasis on improving clinical utility in a broad range of settings. The Working Group has recommended that a grouping of impulse control disorders be retained in ICD-11. These disorders should be defined by the repeated failure to resist an impulse, drive, or urge to perform an act that is rewarding to the person (at least in the short-term), despite longer-term harm either to the individual or others. Impulse control disorders would therefore include pathological gambling, intermittent explosive disorder, kleptomania, and pyromania, as well as compulsive sexual behaviour disorder. In the ICD-10, many of these behaviours are already conceptualized in this manner under the grouping of habit and impulse disorders. Trichotillomania is also listed under the same heading, but the Working Group has recommended it to be moved to the grouping of obsessive-compulsive and related disorders in ICD-11, and that skin picking (excoriation) disorder also be added to the same grouping. Compulsive sexual behaviour disorder will be new to this grouping, and would replace the ICD-10 category of excessive sexual drive. Other putative impulse control disorders such as problematic Internet use and compulsive buying do not appear at this time to have enough data to support their inclusion as independent mental health conditions. A first key controversy in the field is whether pathological gambling and related conditions should be characterized as “behavioural addictions” and thereby be subsumed under a larger category that is more closely related to substance-related disorders. While a good deal of literature supports the idea that individuals with pathological gambling have altered reward circuitry 6, they also have other brain abnormalities. For example, prefrontal cortical dysfunction appears similar between gamblers and individuals with mania 16, 17. Additionally, although there is a shared genetic vulnerability between gambling and alcohol addiction, pathological gambling also shares genetic vulnerability factors with major depressive disorder 18. Therefore, categorizing gambling behaviour as an addiction, although heuristically appealing, seems premature based on the evidence. Furthermore, the change in categorization does not have clear clinical utility, insofar as a range of treatment approaches, other than those used in the treatment of substance addictions, may be useful for pathological gambling (for example, lithium and exposure therapies) 19, 20. A second key controversy in the field is whether compulsive sexual behaviour disorder should be included in the nosology. On the one hand, it is important that the classification does not pathologize normal behaviour. On the other, it is desirable that the classification allows for appropriate diagnosis and treatment of disorders that impact public health 21. Based on the definition of impulse control disorders as characterized by the inability to control behaviour despite its negative consequences, the Working Group recommended that compulsive sexual behaviour disorder be included in that grouping. A third key controversy in the field is whether problematic Internet use is an independent disorder. The Working Group noted that this is a heterogeneous condition, and that use of the Internet may in fact constitute a delivery system for various forms of impulse control dysfunction (e.g., pathological game playing or pornography viewing). Importantly, the descriptions of pathological gambling and of compulsive sexual behaviour disorder should note that such behaviours are increasingly seen using Internet forums, either in addition to more traditional settings, or exclusively 22, 23. The DSM-5 has included Internet gaming disorder in the section “Conditions for further study”. Although potentially an important behaviour to understand, and one certainly with a high profile in some countries 12, it is questionable whether there is enough scientific evidence at this time to justify its inclusion as a disorder. Based on the limited current data, it would therefore seem premature to include it in the ICD-11. A fourth key controversy is how best to draw thresholds for these disorders so that inappropriate diagnoses are not rendered for behaviours that are either normative (for example, sex) or simply illegal (for example, stealing). The WHO has emphasized a distinction between symptoms and disability 24. Where there is a continuum between normal and pathological behaviour, associated impairment may become a key determinant of whether or not a behaviour is disordered. An additional important consideration, from a public health perspective, is whether efficacious treatments are available. As noted above, these have now been developed for all impulse control disorders, particularly pathological gambling and intermittent explosive disorder 25, 26. There are a number of important differences between the proposals for the ICD-11 and the approach taken in the DSM-5. These stem in part from the WHO's emphasis on clinical utility in a broad range of settings. In the DSM-5, the impulse control disorders grouping was dismantled, and pathological gambling was moved to the same section as substance addictions. Although evidence may indicate that pathological gambling resembles substance addictions in many ways, data also support its relationship to other impulse control disorders such as kleptomania, intermittent explosive disorder, and compulsive sexual behaviour 14. The outward clinical similarities of these disorders (that all of these behaviours are rewarding, at least initially, that they lead to feeling out of control, that the person reports urges or cravings, that no substance is taken into the body, and that there are no indications or outward signs of intoxication) further supports their unique categorization as impulse control disorders. Another difference between the proposals for ICD-11 and DSM-5 is that the DSM-5 rejected its own Sexual and Gender Identity Disorders Work Group's proposal to include “hypersexuality”. One objection to this proposal was its implicit normative reference to the “right amount” of sexuality. The ICD-11 Working Group believes that it is more clinically useful – both in terms of conceptualizing the symptomatology and of treatment strategies – to view compulsive sexual behaviour disorder as being related to other disorders that are also characterized by repeated failures to resist impulses, drives, or urges despite longer-term harm. Therefore, the Working Group has proposed replacing the ICD-10 concept of excessive sexual drive with a term that places greater emphasis on behaviour, and moving this condition to the grouping of impulse control disorders rather than placing the primary focus on the fact that the behaviour involved is sexual in nature. The ICD-11 will be used globally, in a broad range of specialist and primary care settings, often by non-specialized health workers. There has been growing emphasis on encouraging screening for substance use disorders in these settings, and one advantage of expanding the substance use category to include behavioural addictions would be the encouragement of similar assessment and treatment approaches for a range of conditions, which taken together do constitute a major health problem but are often neglected by individual practitioners as well as by health care systems. At the same time, however, much remains unknown about the underlying psychobiology and optimal management of these conditions, some of them have only been described in Western contexts, and the boundaries between disorder and normality remain contested. The Working Group therefore recommends, based on the current evidence, that there be a category of impulse control disorders and that it include pathological gambling, kleptomania, pyromania, compulsive sexual disorder, and intermittent explosive disorder. This approach differs from DSM-5, which splits these disorders across diagnostic categories. Instead, the ICD-11 proposal recommends keeping these together, so that clinicians can screen for them all. We believe that this approach is much simpler, will be easier for clinicians to use, is more continuous with the previous classification, and will be more feasible in low-resource settings than the DSM-5 approach. All proposals for the ICD-11 will be made publically available for review and comment. These recommendations therefore represent only a starting point, and set the stage for a global exchange about how best to address the nosology of these behaviours with the goal of improving its clinical utility. In addition, the proposals for ICD-11 will be field tested using two main approaches: an Internet-based approach and a clinical settings (clinic-based) approach. Internet-based field studies will be implemented primarily through the Global Clinical Practice Network, a network currently consisting of nearly 10,000 individual mental health and primary care professionals in more than 100 countries (www.globalclinicalpractice.net). Clinic-based studies will be implemented through the network of collaborating international field study centers appointed by the WHO. The timing of the review and comment processes and of field studies will be such that their results can be integrated into the ICD-11 prior to it submission to the World Health Assembly for approval. The authors of this paper are members of the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders, reporting to the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. However, the views expressed in this paper are those of the authors and, except as specifically noted, do not represent the official policies or positions of the International Advisory Group or the World Health Organization. The authors thank G. Reed for his guidance of the Working Group and inputs to this paper.

Objective Suicide and suicidal behaviours are significant public health problems and a leading cause of death worldwide and in South Africa. We examined the association between childhood adversities and suicidal behaviour over the life course. Methods A national probability sample of 4351 South African adult participants (aged 18 years and older) in the South African Stress and Health (SASH) study was interviewed as part of the World Mental Health Surveys initiative. Respondents provided sociodemographic and diagnostic information, as well as an account of suicide-related thoughts and behaviours. Suicidality or suicidal behaviour were defined as were defined as suicide attempts and suicidal ideation in the total sample, and suicide plans and attempts among ideators. Childhood adversities included physical abuse, sexual abuse, parental death, parental divorce, other parental loss, family violence, physical illness and financial adversity. The association between suicidality and childhood adversities was examined using discrete-time survival models. Results More than a third of the respondents with suicidal behaviour experienced at least one childhood adversity, with physical abuse, parental death and parental divorce being the most prevalent adversities. Physical abuse, sexual abuse and parental divorce were identified as significant risk markers for lifetime suicide attempts, while physical abuse and parental divorce were significantly correlated with suicidal ideation. Two or more childhood adversities were associated with a twofold higher risk of lifetime suicide attempts. Sexual abuse (OR 9.3), parental divorce (OR 3.1) and childhood physical abuse (OR 2.2) had the strongest associations with lifetime suicide attempts. The effect of childhood adversities on suicidal tendencies varied over the life course. For example, sexual abuse was significantly associated with suicide attempts during childhood and teen years, but not during young and later adulthood. Conclusions Childhood adversities, especially sexual abuse, physical abuse and parental divorce, are important risk factors for the onset and persistence of suicidal behaviour, with this risk being greatest in childhood and adolescence.