Why mental disorders are just mental dysfunctions (and nothing more): some Darwinian arguments

Mental disorders are often thought to be harmful dysfunctions. Jerome Wakefield has argued that such dysfunctions should be understood as failures of naturally selected functions. This suggests, implicitly, that evolutionary biology and other Darwinian disciplines hold important information for anyone working on answering the philosophical question, 'what is a mental disorder?'. In this article, the author argues that Darwinian theory is not only relevant to the understanding of the disrupted functions, but it also sheds light on the disruption itself, as well as on the harm that attends the disruption. The arguments advanced here are partially based on the view that a core feature of Darwinism is that it stresses the environmental relativity of functions and dysfunctions. These arguments show a very close empirical connection between social judgments (values) and dysfunctions (psychopathology), which is of interest for psychiatric theory. Philosophically, they lead to the conclusion that the concept of mental disorder is identical to the concept of mental dysfunction. Consequently, it is both misleading and redundant to conceptualize mental disorders as 'harmful dysfunctions', and not simply as 'mental dysfunctions'.     

The interrelationship of tropical disease and mental disorder: conceptual framework and literature review (part I — malaria)

Substantial interactions between tropical diseases and psychiatric illness have long been recognized, but the impact of biological factors in the field of cross-cultural psychiatry has been less well studied than psychosocial factors. In reviewing the literature at the intersection of tropical medicine and psychiatry in order to summarize the existing data base in this field, a generalized interactive model informed by the theoretical contributions of George Engel, the WHO Scientific Working Group on Social and Economic Research, Arthur Kleinman, P. M. Yap, Edward Sapir and others has been developed to serve as a conceptual framework for this analysis of the literature and to guide further research. The clinical literature of tropical medicine and psychiatry which recognizes the significance of concurrent tropical disease and mental disorders is reviewed along with the more specific literature on malaria and concomitant psychiatric illness. Many authors have focused on the role of organic mental disorders, especially in connection with cerebral malaria, but several have also addressed psychosocial parameters through which the interrelationship between malaria and a full range of mental disorders is also mediated. The effects of malaria may serve as biological, psychological or social stressors operating in a cultural context which precipitate or shape features of psychiatric symptomatology. Psychiatric illness may likewise precipitate an episode of malaria with typical symptoms in a patient with a previously subclinical infection. Implications of the literature and this generalized interactive model are considered as they apply to clinical practice, public health and the application of social science theory in medicine.[/p]     

Biomarkers and clinical staging in psychiatry

Personalized medicine is rapidly becoming a reality in today's physical medicine. However, as yet this is largely an aspirational goal in psychiatry, despite significant advances in our understanding of the biochemical, genetic and neurobiological processes underlying major mental disorders. Preventive medicine relies on the availability of predictive tools; in psychiatry we still largely lack these. Furthermore, our current diagnostic systems, with their focus on well‐established, largely chronic illness, do not support a pre‐emptive, let alone a preventive, approach, since it is during the early stages of a disorder that interventions have the potential to offer the greatest benefit. Here, we present a clinical staging model for severe mental disorders and discuss examples of biological markers that have already undergone some systematic evaluation and that could be integrated into such a framework. The advantage of this model is that it explicitly considers the evolution of psychopathology during the development of a mental illness and emphasizes that progression of illness is by no means inevitable, but can be altered by providing appropriate interventions that target individual modifiable risk and protective factors. The specific goals of therapeutic intervention are therefore broadened to include the prevention of illness onset or progression, and to minimize the risk of harm associated with more complex treatment regimens. The staging model also facilitates the integration of new data on the biological, social and environmental factors that influence mental illness into our clinical and diagnostic infrastructure, which will provide a major step forward in the development of a truly pre‐emptive psychiatry.     

The rise of counselling and the return of alienism.

Current services for those with mental disorders show two trends. Psychiatric services are becoming concentrated on the care of those with "severe mental illness," largely (but unjustifiably) synonymous with chronic psychosis. The retreat of psychiatry from the care of those with non-psychotic mental disorders has helped the growth of counselling services for these patients. However, there is no evidence that non-directive counselling is effective for such disorders, in contrast to the evidence for the effectiveness of other treatments that are usually delivered by psychologists or community psychiatric nurses. By retreating from the concerns of general practice and general medicine, psychiatry is returning to the days of alienism: in Victorian terms, the care of "the mad." Possible consequences include increasing expectations of psychiatric services that cannot be met, a loss of skills within psychiatry, and increased demoralisation in the mental health services.     

Evolutionary psychiatry: foundations,progress and challenges

Evolutionary biology provides a crucial foundation for medicine and behavioral science that has been missing from psychiatry. Its absence helps to explain slow progress; its advent promises major advances. Instead of offering a new kind of treatment, evolutionary psychiatry provides a scientific foundation useful for all kinds of treatment. It expands the search for causes from mechanistic explanations for disease in some individuals to evolutionary explanations for traits that make all members of a species vulnerable to disease. For instance, capacities for symptoms such as pain, cough, anxiety and low mood are universal because they are useful in certain situations. Failing to recognize the utility of anxiety and low mood is at the root of many problems in psychiatry. Determining if an emotion is normal and if it is useful requires understanding an individual's life situation. Conducting a review of social systems, parallel to the review of systems in the rest of medicine, can help achieve that understanding. Coping with substance abuse is advanced by acknowledging how substances available in modern environments hijack chemically mediated learning mechanisms. Understanding why eating spirals out of control in modern environments is aided by recognizing the motivations for caloric restriction and how it arouses famine protection mechanisms that induce binge eating. Finally, explaining the persistence of alleles that cause serious mental disorders requires evolutionary explanations of why some systems are intrinsically vulnerable to failure. The thrill of finding functions for apparent diseases is evolutionary psychiatry's greatest strength and weakness. Recognizing bad feelings as evolved adaptations corrects psychiatry's pervasive mistake of viewing all symptoms as if they were disease manifestations. However, viewing diseases such as panic disorder, melancholia and schizophrenia as if they are adaptations is an equally serious mistake in evolutionary psychiatry. Progress will come from framing and testing specific hypotheses about why natural selection left us vulnerable to mental disorders. The efforts of many people over many years will be needed before we will know if evolutionary biology can provide a new paradigm for understanding and treating mental disorders.     

The revolution in psychiatric diagnosis: problems at the foundations

The third edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III; 1974) not only revolutionized psychiatric diagnosis, it transformed and dominated American psychiatry. The nosology of psychiatry had been conceptually confusing, difficult to apply, and bound to widely questioned theories. Psychiatry and clinical psychology had been struggling with their scientific status. DSM attempted to solve psychiatry's problems by making psychiatry more like its authors' perception of general medicine. It tried to avoid theory, especially psychoanalytic theories, by discussing only observable manifestations of disorders. But DSM is actually highly theory-bound. It implicitly and powerfully includes an exclusively "medical" model of psychological disturbance, while excluding other psychiatric ideas. Its authors tried to meet what they saw as "scientific standards." To a surprising extent, DSM reflects its creators' personal distaste for psychoanalysis. The result is that DSM rests on a narrow philosophical perspective. The consequences of its adoption are widespread: it has profoundly affected drug development and other therapeutic studies, psychiatric education, attitudes toward patients, the public perception of psychiatry, and administrative and legal decisions. This article explores how DSM's most problematic features arise from its history in psychiatric controversies of the 1960s and its underlying positivistic philosophy.     

Folles histoires: de l’utilité et des inconvénients de la psychiatrie évolutionniste

Ever since Darwin, both psychiatrists and evolutionary biologists have wondered why some of our mental and emotional capacities are rather badly designed, given that natural selection has produced such ingenious solutions to so many other traits. Over the last 50 years, evolutionary psychiatrists have set out to answer this question by means of a number of explanatory models. Thus they have argued, for example, that mental disorders should be considered as mismatches or even adaptations, rather than diseases. These models are truly fascinating, yet most of them rely on disputable assumptions. For example: evolutionary psychiatrists commonly claim that schizophrenia is at least a-hundred thousand year old, while there are in fact no good reasons to believe so. On the plus side, however, evolutionary psychiatry certainly invites us to think about possible evolutionary alternatives for the contemporary role of psychiatric patient.     

New insights from the last decade of research in psychiatric genetics: discoveries,challenges and clinical implications

Psychiatric genetics has made substantial progress in the last decade, providing new insights into the genetic etiology of psychiatric disorders, and paving the way for precision psychiatry, in which individual genetic profiles may be used to personalize risk assessment and inform clinical decision-making. Long recognized to be heritable, recent evidence shows that psychiatric disorders are influenced by thousands of genetic variants acting together. Most of these variants are commonly occurring, meaning that every individual has a genetic risk to each psychiatric disorder, from low to high. A series of large-scale genetic studies have discovered an increasing number of common and rare genetic variants robustly associated with major psychiatric disorders. The most convincing biological interpretation of the genetic findings implicates altered synaptic function in autism spectrum disorder and schizophrenia. However, the mechanistic understanding is still incomplete. In line with their extensive clinical and epidemiological overlap, psychiatric disorders appear to exist on genetic continua and share a large degree of genetic risk with one another. This provides further support to the notion that current psychiatric diagnoses do not represent distinct pathogenic entities, which may inform ongoing attempts to reconceptualize psychiatric nosology. Psychiatric disorders also share genetic influences with a range of behavioral and somatic traits and diseases, including brain structures, cognitive function, immunological phenotypes and cardiovascular disease, suggesting shared genetic etiology of potential clinical importance. Current polygenic risk score tools, which predict individual genetic susceptibility to illness, do not yet provide clinically actionable information. However, their precision is likely to improve in the coming years, and they may eventually become part of clinical practice, stressing the need to educate clinicians and patients about their potential use and misuse. This review discusses key recent insights from psychiatric genetics and their possible clinical applications, and suggests future directions.     

Charcot–Marie–Tooth disease,psychiatric indicators and quality of life: a systematic review

This study is aimed to conduct a systematic literature review regarding the associations between psychiatric symptoms, functional impairments, and quality of life in patients with CMT (Charcot–Marie–Tooth). The PUBMED, PsycInfo, SCIELO, and LILACS electronic databases were used, and the following search terms were employed: CMT, HMSN (hereditary motor and sensory neuropathy), mental disorder, quality of life, psychiatry, psychiatric, and psychological without the use of time-limit filters. According to the adopted inclusion criteria, 20 studies were included and appraised. These studies indicated that patients with CMT exhibited an increased trend toward depressive symptoms compared with the general population. In addition, CMT patients were exposed to a higher risk of reduced quality of life and significant sleep impairment. Considering the comorbidity of CMT with other psychiatric disorders, the heterogeneity of the instruments used to evaluate the psychiatric symptoms compromised the ability to compare the studies examined. Our results indicate a need for a systematic evaluation of these conditions to minimize the impairments and decreased quality of life caused by CMT.     

Excavating the Psyche: A Social History of Soviet Psychiatry in Bulgaria

This article investigates how an imported Soviet psychiatric model affected Bulgarians who experienced psychological crisis by examining therapeutic possibilities that were available and foreclosed in the People’s Republic of Bulgaria. Bulgarians struggling with psychological disorders in the present day experience polar forms of marginalization: non-recognition on one extreme, and chronic medicalization on the other. Both tendencies can be traced to the Communist-period remodeling of mental healthcare, which outlawed private practice and individual-centered therapy, which reified empirically observable, physiological underpinnings of pathology while suppressing therapies that engaged with the existential context of mental illness. I argue that the reproduction of a Soviet psychiatric model instigated a modernization process but failed to anticipate the idiosyncrasy of economic and social conditions within the country. Furthermore, that this model rejected a therapeutic focus on the individual but developed no effective alternative for identifying and treating subjective characteristics of mental illness. Bulgaria’s history of psychiatry has received little scholarly attention beyond Bulgarian psychiatrists who documented the development of their field. This article presents archival, literary and oral history footholds towards the development of a social history of Bulgarian psychiatry—a perspective that is especially and problematically missing.     

精神障碍的神经电生理循证医学证据

寻找客观标记物是精神医学研究最重要的课题之一,近期融合了循证医学的神经电生理研究为此提供了重要的途径,并取得了较为可观的研究成果,然而现有的研究结果仍然存在较多争议,难以取得一致共识.本文全面总结和归纳了结合以元分析(meta-analysis)为代表的循证医学方法和以脑电图(electroencephalography)为代表的神经电生理技术的精神障碍相关脑电研究成果,将事件相关电位划分为早期和晚期成分,并结合定量EEG分析,从感知加工、认知控制、情绪反应和社会认知等不同认知过程出发,系统分析和评述了精神障碍患者及高危人群的神经认知功能异常情况.我们发现:精神分裂症患者存在从早期到晚期的各种感知、情感和社会认知方面的缺陷,注意缺陷/多动障碍(ADHD)患者存在从早期到晚期的认知控制缺陷,焦虑和强迫障碍患者则存在早期的认知控制缺陷,而孤独症谱系障碍(ASD)患者则存在早期的感知加工和社会认知缺陷.此外,反映注意资源分配和认知加工速度的P300异常特征跨越了多个诊断类型,这表明该脑电成分可能反映了精神障碍的一般性认知缺陷.未来研究可利用多中心大样本数据库探寻精神疾病的神经电生理客观标记物...     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Developing a Curriculum for Evolutionary Medicine: Case Studies of Scurvy and Female Reproductive Tract Cancers

Most early evolutionary thinkers came from medicine, yet evolution has had a checkered history in medical education. It is only in the last few decades that serious efforts have begun to be made to integrate evolutionary biology into the medical curriculum. However, it is not clear when, where (independently or as part of preclinical or clinical teaching courses) and, most importantly, how should medical students learn the basic principles of evolutionary biology applied to medicine, known today as evolutionary or Darwinian medicine. Most clinicians are ill-prepared to teach evolutionary biology and most evolutionary biologists ill-equipped to formulate clinical examples. Yet, if evolutionary science is to have impact on clinical thought, then teaching material that embeds evolution within the clinical framework must be developed. In this paper, we use two clinical case studies to demonstrate how such may be used to teach evolutionary medicine to medical students in a way that is approachable as well as informative and relevant.     

Evolution in health and disease: work in progress.

This article surveys progress in Darwinian medicine since 1991. Evolutionary thinking has been providing an increasing flow of fresh ideas into medical science, ideas that would not be suggested by other perspectives. Recent contributions have shed new light on the evolution of virulence, of antibiotic resistance, of oocytic atresia, of menopause, of the timing of the expression of genetic disease, of links between mate choice and disease resistance, and of genomic conflict between mother and fetus over resource provisioning. An important consequence of changes from the environment of evolutionary adaptedness concerns reproductive cancers; the incidence of reproductive cancers may be linked to changes in the frequency of menstruation in postindustrial societies. Other intriguing developments include some unanticipated and undesirable consequences of good hygiene, hope from an unexpected quarter for progress on nerve and muscle regeneration, evolutionary interpretations of mental disease, and insights from functional genomics into the nature of tradeoffs. The application of evolutionary thinking to problems in medical research and practice has thus yielded an abundant and growing harvest of insights. Some are well founded, others remain speculative. The field is moving from an initial phase dominated by speculation and hypothesis formation into a more rigorous phase of experimental testing of explicit alternatives. Currently the most promising areas, those in which experimental rigor can be applied efficiently, include experimental evolution and functional genomics. The pioneers can be proud of what they have set in motion.     

Mental illness from the perspective of theoretical neuroscience

Theoretical neuroscience, which characterizes neural mechanisms using mathematical and computational models, is highly relevant to central problems in the philosophy of psychiatry. These models can help to solve the explanation problem of causally connecting neural processes with the behaviors and experiences found in mental illnesses. Such explanations will also be useful for generating better classifications and treatments of psychiatric disorders. The result should help to eliminate concerns that mental illnesses such as depression and schizophrenia are not objectively real. A philosophical approach to mental illness based on neuroscience need not neglect the inherently social and historical nature of mental phenomena.     

Neuroimaging techniques in modern forensic psychiatry

Applied neuroscientific knowledge such as brain neuroimaging has widespread application in the medical diagnostic and treatment areas. Neuroscientific progress such as cognitive neuroscience has strong implications in specific medical fields such as forensic psychiatry. Significant progress in forensic psychiatry has affected the practice of law, in which an understanding of the complex relationship among mind, brain, and behavior is becoming necessary. Forensic psychiatry is concerned with the relationship between psychiatric abnormalities and legal violations and crimes. Due to the lack of available biological criteria, assessment, evaluation and therapy in forensic psychiatry have so far been restricted to psychosocial and mental criteria of offender personality. Recent advances in nuclear radiology such as brain imaging techniques (fMRI, DT-MRI, PET SPECT) allow a closer approach to the neural correlates of personality, moral judgments and decision-making. Introduction of neurobiological criteria (based on advanced neuroimaging techniques) in the field of forensic psychiatry and establishing the rules to what extent such biological criteria will be more reliable choice in evaluating mentally ill offenders would be of fundamental value in the modern forensic psychiatry. Psychosocial and subjective criteria in forensic evaluation will be more accomplished by biopsychosocial and objective criteria. Advances in the neuroimaging techniques bring specificity to the problems underlying the application of neuroscience to criminal law.     

Psychiatric investigations among American Indians and Alaska natives: A critical review

This review of psychiatric investigations among Native Americans opens with a discussion of the dominant theoretical perspectives in psychiatric anthropology in order to provide an analytic framework with which to assess the substantive findings of researchers in the field. Studies of culture-specific disorders, service utilization and patient population studies, psychiatric epidemiological studies, and studies designed to test the validity of certain diagnostic instruments are scrutinized for evidence of the nature of the role of indigenous cultures in the manifestations of psychiatric disorders among these populations. The review reveals that a universalist theoretical perspective, which tends to obscure the role of local interpretations in the phenomenology of psychiatric illness, dominates this field of inquiry. Nonetheless, evidence has accumulated which indicates the importance of native understandings for a more reliable and valid explanation of the nature of mental disorder among these peoples. The inadequacies of our current knowledge are examined and suggestions for directions in future work are presented in the concluding section. Recommendations include the direct investigation of the local meanings of the signs, symptoms, and syndromes of Western psychiatry; the concentrated search for potentially unique and powerful local signs of distress; and the study of the culturally-constituted social processes of illness.     

The Cultural Construction of Mental Illness in Prison: A Perfect Storm of Pathology

Large numbers of individuals in U.S. prisons meet DSM criteria for severe psychiatric disorder. These individuals also have co-occurring personality and substance abuse disorders, medical conditions, and histories of exposure to social pathologies. Based on nine months of ethnographic fieldwork in a U.S. prison, focusing on staff narratives, I utilize interpretivist and constructivist perspectives to analyze how mental health clinicians construct psychiatric disorder among inmates. Discrete categorization of disorders may be confounded by the clinical co-morbidities of inmates and the prison context. Incarcerated individuals’ responses to the institutional context substantially inform mental health staffs’ illness construction and the prison itself is identified as an etiological agent for disordered behaviors. In addition, diagnostic processes are found to be indeterminate, contested, and shaped by interactions with staff. Analysis of illness construction reveals that what is at stake for clinicians is not only provision of appropriate treatment, but also mandates for the safety and security of the institution. Enmeshed in these mandates, prison mental health becomes a particular local form of psychiatric knowledge. This paper contributes to anthropological approaches to mental disorder by demonstrating how local contexts mediate psychiatric knowledge and contribute to the limited ethnographic record of prisons.