The Spectrum Collaborative Project

was established to develop a research agenda based upon Giovanni Cassano’s observation that there is a range of common clinical features that accompany each disorder classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and that these features have clinical and research implications. A major focus of the project is to develop and test assessment instruments for assessment of the spectrum of clinical features associated with the current version of the DSM psychiatric disorders. The spectrum model we propose highlights the significance of isolated symptoms and subthreshold symptom clusters which precede, follow, or are manifested in concurrence with the main disorder. In our experience, such symptomatology may have important implications for the course of illness, for adherence and response to treatment, and for comorbidity with other conditions.

What is the background and history of the spectrum model?

There has been great interest in classification of mental disorders over the last three decades. During this period, operationalized criteria for classifying the disorders have been adopted, as described in the official international systems of classification used today (Diagnostic and Statistical Manual, in its current DSM-IV-TR version; and Research Diagnostic Criteria, ICD-10). This important change has produced remarkable progress in diagnostic reliability. However this system does not always succeed in capturing the complexities of clinical reality which emerges when comorbidity is considered or when symptoms are examined using a dimensional approach. The options furnished by the official classifications (DSM and ICD-10) may not optimally reflect clinical reality of psychopathological conditions among the general population or in clinical settings.  The official nomenclature provides a useful but incomplete characterization of psychopathology. Impairment in work, family, and social functioning is often inadequately explained by symptoms of threshold-level disorders.  Some individuals experience substantial impairment from certain isolated symptoms or subthreshold  symptom clusters. The current system of categorization does not take into account the continuum between the criterion symptoms of a disorder and clinically significant  prodromic, residual, atypical, and subclinical characteristics. With this in mind, Professor Giovanni B. Cassano and colleagues in Italy and U.S.A. have proposed the "spectrum" model which has advantages for better understanding of the etiology of mental disorders and for clinical assessment and treatment including subclinical and atypical symptomatology, the importance of which is often underestimated.

What is the relationship between spectrum and the current version of the DSM?

DSM-IV is the current version of the DSM and the official nomenclature used to guide psychiatric practitioners in assessment and diagnosis. This categorical diagnostic system is clear and easy to use and has many advantages. However, DSM-IV also has some important limitations. While DSM-IV criteria reliably identify categories of illness, Cassano and colleagues observed that the DSM approach does not provide an adequate description of the patients who meet these criteria. Spectrum is a complementary way of describing and assessing psychopathology. How is spectrum psychopathology assessed?

• Spectrum assessment is based upon a concept that uses individual DSM criterion symptoms as a starting point, and extends the DSM description to encompass the halo of surrounding clinical phenomena. These include associated features described in the DSM as well as symptoms, maladaptive behavioral traits and temperamental features that do not appear in the DSM.

• Spectrum assessment generates a dimensional profile as opposed to a categorical diagnosis, obviating the need for threshold-based definition of caseness.

Who are the investigators?

The Spectrum Collaborative Project is an international project that has involved clinicians and researchers from the University of Pisa (Italy) and the University of Pittsburgh, Columbia University, and University of California, San Diego (USA). Participants in the project include (in alphabetical order):

• Susanna Banti, M.D. Psychiatrist, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa. Dr. Banti is a collaborator of Dr. Cassano’s both in research and patient care. She has been part of the Spectrum Collaborative Project from its inception and has contributed substantially to design, implementation, and coordination of most of the Italian studies on spectrum interviews, especially in the multicenter panic-agoraphobic spectrum study and the Pisa-Pittsburgh Cross-Cultural Collaborative Study.
• Antonella Benvenuti, M.D., Ph.D. Psychiatrist, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa. Dr. Benvenuti is a collaborator of Dr. Cassano's both in research and patient care. He has been involved in the Spectrum Collaborative Project from its inception, and has contributed substantially to the design, implementation, and coordination of most of the Italian studies on spectrum interviews. Dr. Benvenuti has been especially interested in the study of eating disorders spectrum and psychotic spectrum symptoms. More recently her interest has focused on mood spectrum symptoms, residual symptoms of depression and manic switches during the treatment of depressive episodes.
• Giovanni B. Cassano, M.D. Professor Emeritus, Department of Psychiatry, Neurobiology, Pharmacology, and Biotechnology, University of Pisa. Dr. Cassano has an international reputation as a treatment outcome researcher and descriptive psychopathologist. Among the very first clinicians to bring modern psychopharmacology to Italy, he has a nearly forty-year track record of empirical investigation of mood disorders. He has also had a long-standing interest in the description on clinical conditions in a more subtle and clinically useful manner. Most recently, he has devoted intense effort to the codification of these ideas in structured clinical interviews and in the self-report assessments developed on this project.
• Liliana Dell’Osso, M.D. Professor and Chief of Psychiatry, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa. For more than 20 years, Dr. Dell’Osso has worked on problems of mood disorder treatment and description of mood and anxiety psychopathology. She has been involved in the Spectrum Collaborative Project from its inception and has contributed substantially to the development and validation of these instruments.
• Jean Endicott, Ph.D. Professor of Clinical Psychology, Department of Psychiatry, College of Physicians and Surgeons, Columbia University and Chief, Department of Research Assessment and Training and Director, Division of Clinical Phenomenology New York State Psychiatric Institute. Dr. Endicott contributes expertise in psychometrics and the evaluation of impairment and quality of life.
• Andrea Fagiolini, M.D. Associate Professor of Psychiatry, University of Siena. Dr. Fagiolini is presently chairman and residency training director at the Department of Mental Health of the University of Siena and at the Siena Medical Center. He has extensive experience in the treatment and study of mood disorders.
• Ellen Frank, Ph.D. Distinguished Professor of Psychiatry and Professor of Psychology, University of Pittsburgh Clinical Program. Dr. Frank is an internationally recognized expert on the evaluation and treatment of mood and anxiety disorders. In the context of her 35-year career in this area, she and her colleagues have developed new interventions or modified existing interventions for post-rape trauma, recurrent unipolar depression, and bipolar disorder. Dr. Frank has been responsible for important innovations in both the psychotherapy and the pharmacotherapy of mood disorders. Recently, and directly as a result of her collaboration with Dr. Cassano in the development and testing of the spectrum assessments, she has turned her attention to co-occurring mood and anxiety and its treatment as well as the search for treatment-relevant phenotypes using the spectrum instruments.
• Victoria J. Grochocinski, Ph.D. Research Data Administrator, University of Pittsburgh Medical Center. Dr. Grochocinski has played an active role in the development of the spectrum instruments in the Spectrum Collaborative Project. She is responsible for maintaining the English versions of the instruments and for maintaining the content of the website. Dr. Grochocinski has acted as database administrator for numerous NIMH-sponsored research projects and programs conducted in the Department of Psychiatry at the University of Pittsburgh.
• Jack D. Maser, Ph.D. Professor, Department of Psychiatry, University of California, San Diego. Dr. Maser is an internationally recognized expert in mood, anxiety and personality disorders, and worked for 24 years at the NIMH in these areas. He is especially interested in research related to comorbidity and subsyndromal conditions. He has participated in the Spectrum Collaborative Project since its inception. Dr. Maser has retired and living in California.
• Mauro Mauri, M.D. Associate Professor of Psychiatry, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa. Dr. Mauri is a long-standing collaborator of Dr. Cassano’s in his empirical and descriptive work. He has been involved in the Spectrum Collaborative Project from its inception and has contributed substantially to the development and validation of these instruments.
• Mario Miniati, M.D. Psychiatrist, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa. Dr. Miniati is a collaborator of Dr. Cassano’s both in research and patient care. He has been involved in the Spectrum Collaborative Project from its inception, and has contributed substantially to the design, implementation, and coordination of most of the Italian studies on spectrum interviews. Dr. Miniati has been especially interested in the study of panic-agoraphobic spectrum symptoms in patients with cardiovascular diseases and in the study of mood spectrum signs and symptoms in patients with Depression, followed-up with the Interpersonal Psychotherapy (IPT).
• Paola Rucci, Statistician and Assistant Professor of Psychiatry, University of Pittsburgh. Dr. Rucci, who also has a fellowship at the University of Bologna, is a biostatistician highly experienced in the design management and analysis of treatment outcome and health services studies. Her main activity consists in testing the validity and reliability of clinical interviews and self-report assessments developed on this Project.
• Alfredo Sbrana, M.D. Psychiatrist, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa. Dr. Sbrana is a collaborator of Dr. Cassano’s both in research and patient care. He has involved in the Spectrum Collaborative Project and has contributed substantially in the development and validation of substance use spectrum and psychosis spectrum.
• M. Katherine Shear, M.D. Marion Kenworthy Professor of Psychiatry, Columbia University School of Social Work and Columbia University College of Physicians and Surgeons, and Adjunct Professor of Psychiatry University of Pittsburgh. Dr. Shear is an internationally recognized expert and innovator in the assessment and treatment of anxiety disorders. Dr. Shear has made major contributions to the development and testing of diagnostic criteria and treatment approaches for complicated grief , and for depression with co-occurring panic symptomatology. Dr. Shear has been involved since the inception the Spectrum Collaborative Project in the development and testing of these instruments and is intimately familiar with the performance of these scales in clinical populations.