Iterative Generation of Diagnostic Categories Through Production and Practice: The Case of Postpartum Depression

Examining the process undertaken to name and codify psychiatric illnesses provides important insights into how everyday healthcare practices are shaped by knowledge production processes. However, studies of illness classification often rely on an overly simplified distinction between the production of diagnostic categories and the application of those categories in practice. Drawing insight from science and technology studies, I argue that psychiatric diagnostic categories are iteratively generated through production and practice, even during the development of those categories. Through a discursive analysis of interviews, archival documents, and psychiatric literature, I identify the practical politics that enabled the creation of the postpartum depression (PPD) modifier in the Diagnostic and Statistical Manual of Mental Disorders, version four (DSM-IV). In addition, I demonstrate how the overarching discourses of evidence-based decision-making and biomedicine shaped the development of the postpartum modifier, and draw together comments made by interview participants regarding the administrative value of a PPD-related category in the DSM. These remarks suggest that, in their practice, researchers and clinicians also take into consideration their own knowledge about DSM production processes, providing further support for the argument that diagnostic categories are iteratively generated.     

When love meets drugs: pharmaceuticalizing ambivalence in post-socialist China

In this article, I examine the interaction between intimacy and psychiatry to explore the ambivalences in the use of pharmaceuticals in psychiatric practice. Of particular interest is how pharmaceuticals come to constitute in multiple ways what pathology is and what form of life needs to be restored, and how psychiatric medications reconfigure the ambivalence of intimacy in post-socialist China. Following the life of Mei, a female psychiatric patient, for two years, I have made a series of discoveries related to medicine and intimacy in China. Specifically, I show that psychopharmaceuticals indicate a diseased body that threatens the intimate bond. They also highlight a socially suffering subject that is in lack of love from the intimate partner who demands the latter’s redemption. I discuss how these multiple and contradicting meanings of psychopharmaceuticals and intimacy are socio-historically situated. Thus, while previous research in medical anthropology criticizes pharmaceuticalization for reducing the socio-political life (bios) to a biological body (zoē), I argue that these life forms co-exist in a pharmaceutical “zone of indistinction” (Agamben, Homo Sacer: Sovereign Power and Bare Life. Stanford University Press, Stanford, 1998), in which they constitute and contradict each other. This discussion warns researchers against falling back into the usual orientation of either biomedicine or the social sciences.     

Diagnosis Postponed: Shenjing Shuairuo and the Transformation of Psychiatry in Post-Mao China

Building on Arthur Kleinman's seminal work in Hunan, this paper examines the social context in which shenjing shuairuo (neurasthenia), a ubiquitous psychiatric disease in China prior to 1980, is contested, marginalized, and reconstituted as the popular Western disease of depression among academic psychiatrists in urban China. It is argued that this dramatic change of diagnostic labelling is not only based on empirical evidence. Rather, it is also a product of interests and strategies that are themselves embedded in a confluence of historical, social, political, and economic forces. Specifically, China's open door policy, the hegemony of DSM discourse, the depoliticization of experience, and the transnational commercialization of suffering have all played a role in creating the new-found disease of depression. As a new social construct in China, depression may serve different social functions for different institutional groups, such as drug companies' marketing of new antidepressant therapy, and academic psychiatrists' effort to render the study of suicide more admissible to the state. Because of the government's budgetary limitations and drastic changes in health care financing, however, global diagnostic technology and markets for drugs merely reinforce people's markedly unequal access to health care, which is but one facet of the pervasive social inequity that is China nowadays.     

The Temporality of “Chronic” Mental Illness

Although multiple concepts of time can be found in psychiatric discourses and practices, the notion of time as an absolute category seems to predominate. In particular, the notion of “chronicity” implies the persistence of symptoms over the temporal course of a disease, thereby following a logic that conceptualizes time as an objective and universal measure. I argue that such a notion of time impedes the development of patients and the metrics by which to map change. This article, therefore, aims to present a different concept of time that should enable dealing with "chronic" mental illness in more flexible and creative ways. A case study of an everyday psychiatric routine is presented, followed by an in-depth analysis of its temporal implications. I conceptualize the notion of time as an extended field, being relationally and intersubjectively structured and linked to performed activities. Such a notion of time needs to be seen as a flexible and fluid matrix that possesses the character of an event-oriented and productive space. This conception favors an individualized temporality of change, suggesting concrete therapeutic procedures that can be implemented in clinical practice.     

Diagnostic differences in psychogeriatric patients in Toronto,New York and London,England.

National statistics on psychiatric illness in the elderly patient from Canada, the United States and the United Kingdom suggest great differences in morbidity in these three centres. The present study shows that these differences stem mainly from different diagnostic habits in the three countries, but also there were more alcoholics in the Canadian sample. In particular, the diagnostic bias of the New York psychiatrists towards diagnosing most elderly patients as senile was not shared by their Toronto colleagues. Some patients were psychiatrically well, in spite of receiving a psychiatric diagnosis, and could have been helped without hospitalization. In addition, some depressed patients were labelled senile. Recommendations include improvement of catchment and treatment facilities for the elderly alcoholic and the provision of psychogeriatric diagnostic centres.     

Is ‘Best Proven’ A Useless Criterion?

In this article I examine some proposals for modification of ethical documents regulating research, particularly, the problems that introducing certain economic clauses may pose. I evaluate suggestions that reject the notion of providing the 'best proven diagnostic and therapeutic method' in favor of 'the highest attainable therapeutic method' or 'the proven effective prophylactic, diagnostic and therapeutic methods'. I analyze the plausibility and problems of introducing a double standard and the consequences it may have in developing countries. Finally I highlight the impact these changes may imply for these countries.     

Culture,cultural factors and psychiatric diagnosis: review and projections

This paper aims to provide conceptual justifications for the inclusion of culture and cultural factors in psychiatric diagnosis, and logistic suggestions as to the content and use of this approach. A discussion of the scope and limitations of current diagnostic practice, criticisms from different quarters, and the role and relevance of culture in the diagnostic encounter, precede the examination of advantages and disadvantages of the approach. The cultural content of psychiatric diagnosis should include the main, well-recognized cultural variables, adequate family data, explanatory models, and strengths and weaknesses of every individual patient. The practical aspects include the acceptance of “cultural discordances” as a component of an updated definition of mental disorder, and the use of a refurbished cultural formulation. Clinical “telescoping” strategies to obtain relevant cultural data during the diagnostic interview, and areas of future research (including field trials on the cultural formulation and on “culture bound syndromes”), are outlined.     

“THAT’S NOT HIS ONLY PROBLEM...” CLINICAL TEAMWORK IN A PSYCHIATRIC EMERGENCY ROOM

This article is a qualitative study of the social organization of clinical work in a psychiatric emergency room. The research involved observation of emergency room practices and interviews with the clinical staff members. Due to responsibility of ensuring confidentiality, audio taping was not possible. Observations and interviews were recorded by hand, and thus, except in brief instances, I describe talk rather than reproduce it verbatim. Psychiatry, I argue, should not be explored as a singular profession but as the team practice of a team of occupational groups. These groups are often seen as subordinate to psychiatric physicians, but as this paper will demonstrate these groups are often able to call upon their specific claims to expert knowledge to assume clinical authority over a patient’s diagnosis and treatment. The successful pursuit of such a claim puts these clinical occupational groups in a position to challenge psychiatrists over crucial hospital resources such as beds. These groups’ claim to authority emerges from two sources. The first is their specific histories and their clinical knowledge systems that initially developed independently of cosmopolitan medicine. The second is the political economic environment of urban hospital psychiatric departments which largely treat patients with opaque symptoms of unclear origin that defy easy psychiatric classification.     

Sequence variation in the cytochrome oxidase I, internal transcribed spacer 1, and Ts14 diagnostic antigen sequences of Taenia solium isolates from South and Central America, India, and Asia

We examined the genetic variability in the pig–human tapeworm, Taenia solium, by sequencing the genes for cytochrome oxidase I, internal transcribed spacer 1, and a diagnostic antigen, Ts14, from individual cysts isolated from Peru, Colombia, Mexico, India, China, and the Philippines. For these genes, the rate of nucleotide variation was minimal. Isolates from these countries can be distinguished based on one to eight nucleotide differences in the 396 nucleotide cytochrome oxidase I (COI) sequence. However, all of the 15 isolates from within Peru had identical COI sequences. The Ts14 sequences from India and China were identical and differed from the Peru sequence by three nucleotides in 333. These data indicate that there is minimal genetic variability within the species T. solium. Minimal variability was also seen in the ITS1 sequence, but this variation was observed within the individual. Twenty-two cloned sequences from six isolates sorted into 13 unique sequences. The variability observed within the sequences from individual cysts was as great as the variability between the isolates.     

Forensic importance of jealousy

The aim of the investigation is to define as clearly as possible specific forensic psychiatric characteristics of persons who committed homicide and or attempted due to jealousy (the nature and severity of psychopathology, the level of responsibility, danger for the community, intensity and nature of aggression, the victimologic dimension, the relation of alcohol and jealousy). A retrospective method based on forensic psychiatric expertises in the period 1975-1999 was used. They encompassed 200 examinees that committed murder or attempted it. The results show the connection of psychotic jealousy with the highest degree of danger in diagnostic categories of paranoid psychosis and paranoid schizophrenia. The time span from the first manifestations of jealousy until the actual commitment of a crime is the longest in personality disorders and the shortest in schizophrenia. Exogenous provoking situations were dominant for committing homicide due to jealousy in personality disorders. Acute alcohol intoxication has a specific significance in crime due to jealousy in the same diagnostic category. Clear criteria were designed for forensic psychiatric evaluation of murder and attempts of homicide caused by jealousy, which will be of help in everyday practice in the field forensic work and treatment.     

Sequence variation in the cytochrome oxidase I, internal transcribed spacer 1, and Ts14 diagnostic antigen sequences of Taenia solium isolates from South and Central America, India, and Asia.

We examined the genetic variability in the pig–human tapeworm, Taenia solium, by sequencing the genes for cytochrome oxidase I, internal transcribed spacer 1, and a diagnostic antigen, Ts14, from individual cysts isolated from Peru, Colombia, Mexico, India, China, and the Philippines. For these genes, the rate of nucleotide variation was minimal. Isolates from these countries can be distinguished based on one to eight nucleotide differences in the 396 nucleotide cytochrome oxidase I (COI) sequence. However, all of the 15 isolates from within Peru had identical COI sequences. The Ts14 sequences from India and China were identical and differed from the Peru sequence by three nucleotides in 333. These data indicate that there is minimal genetic variability within the species T. solium. Minimal variability was also seen in the ITS1 sequence, but this variation was observed within the individual. Twenty-two cloned sequences from six isolates sorted into 13 unique sequences. The variability observed within the sequences from individual cysts was as great as the variability between the isolates.     

Issues for cross-cultural psychiatric research in South Africa

South Africa's heterogenous society offers many opportunities for cross-cultural psychiatric research, but researchers in the country are subject to a number of restraints. Apart from legally enforced segregation, there are strict censorship laws and restricted access to certain types of information. The issues surrounding categorization of cultures and factors affecting publishing research from South Africa have important implications for the type of work that is done. It is a central argument of this article that the issues affecting research in South Africa are relevant to other countries as well, and parallels between the local and international context are drawn. The South African experience suggests that analysis of the research enterprise itself is a useful part of the business of cross-cultural psychiatric research.I am grateful to Beverley Jo Dickman, Terry Dowdall, Ronith Elk, Alan Flisher, Don Foster, Jane Steere and Sally Swartz for their comments on this article. Emile Boonzaaier provided a useful critique on an earlier draft. The arguments presented in this article are, however, my responsibility alone.     

The nature of psychiatric disorders

A foundational question for the discipline of psychiatry is the nature of psychiatric disorders. What kinds of things are they? In this paper, I review and critique three major relevant theories: realism, pragmatism and constructivism. Realism assumes that the content of science is real and independent of human activities. I distinguish two “flavors” of realism: chemistry‐based, for which the paradigmatic example is elements of the periodic table, and biology‐based, for which the paradigm is species. The latter is a much better fit for psychiatry. Pragmatism articulates a sensible approach to psychiatric disorders just seeking categories that perform well in the world. But it makes no claim about the reality of those disorders. This is problematic, because we have a duty to advocate for our profession and our patients against other physicians who never doubt the reality of the disorders they treat. Constructivism has been associated with anti‐psychiatry activists, but we should admit that social forces play a role in the creation of our diagnoses, as they do in many sciences. However, truly socially constructed psychiatric disorders are rare. I then describe powerful arguments against a realist theory of psychiatric disorders. Because so many prior psychiatric diagnoses have been proposed and then abandoned, can we really claim that our current nosologies have it right? Much of our current nosology arose from a series of historical figures and events which could have gone differently. If we re‐run the tape of history over and over again, the DSM and ICD would not likely have the same categories on every iteration. Therefore, we should argue more confidently for the reality of broader constructs of psychiatric illness rather than our current diagnostic categories, which remain tentative. Finally, instead of thinking that our disorders are true because they correspond to clear entities in the world, we should consider a coherence theory of truth by which disorders become more true when they fit better into what else we know about the world. In our ongoing project to study and justify the nature of psychiatric disorders, we ought to be broadly pragmatic but not lose sight of an underlying commitment, despite the associated difficulties, to the reality of psychiatric illness.     

Indexation of psychiatric journals from low‐ and middle‐income countries: a survey and a case study

There is a marked underepresentation of low- and middle-income countries (LAMIC) in the psychiatric literature, which may reflect an overall low representation of LAMIC publications in databases of indexed journals. This paper investigates the worldwide distribution of indexed psychiatric journals. A survey in both Medline and ISI Web of Science was performed in order to identify journals in the field of psychiatry according to their country of origin. Two hundred and twenty-two indexed psychiatric journals were found. Of these, 213 originated from high-income countries and only nine (4.1%) from middle-income countries. None were found in low-income countries. We also present the experience of a LAMIC psychiatric journal, the Revista Brasileira de Psiquiatria, in its recent indexation process. This case study may serve as an example for other LAMIC journals to pursue indexation in major databases as a strategy to widen the international foundation of psychiatric research. There is an important need for the inclusion of LAMIC psychiatric publications in the major indexation databases. This process will require multiple agents to partner with journals from LAMIC to improve their quality and strengthen their chances of being indexed.     

The biomedical standardization of premenstrual syndrome

This essay traces the history of premenstrual syndrome (PMS) in French, British, and American medical literature from 1950 to 2004. Aetiological theories, treatments and diagnostic criteria have varied over time and place, reflecting local conditions and changing notions of objectivity and evidence. During the 1970s researchers in each nation utilised different research strategies to overcome variation and contradictory results characteristic of PMS research. Since the 1980s, attempts have been made to standardise research internationally through prospective daily rating questionnaires that diagnose and measure PMS. Amidst controversy, a psychiatric reformulation of the syndrome was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). While the diagnostic criteria for this psychiatric category, now called premenstrual dysphoric disorder (PMDD), are widely accepted for research purposes, efforts to transfer them to medical practice have been less successful. PMDD remains a contested disease construct.     

Hospitalization for mental illness: evaluation of admission trends from 1941 to 1971.

A study of the diagnostic composition of the inpatient population of Ontario and Canadian psychiatric facilities has shown an important change in hospital-treated illness over the period 1941-71. Patients with nonpsychotic disorders accounted for 54% of all admissions to Ontario public mental hospitals in 1971, compared with only 8% in 1941. The trend was similar for both first admissions and proportion of readmissions, and was similar for psychiatric units of general hospitals. In contrast, the overall rate of first admission for psychotic disorders to inpatient facilities remained remarkably constant over time, as did the proportion of readmissions among all admissions. The findings dispel the notion that the increasing proportion of readmissions is due largely to a rapid turnover of former long-stay psychotic patients (the "revolving-door phenomenon"). The findings could not be attributed to a changing prevalence of types of psychiatric illness, increased availability of psychiatric inpatient facilities or comprehensive medical insurance.     

Do we have any solid evidence of clinical utility about the pathophysiology of schizophrenia?

A diagnosis of schizophrenia, as in most of psychiatric practice, is made largely by eliciting symptoms with reference to subjective, albeit operationalized, criteria. This diagnosis then provides some rationale for management. Objective diagnostic and therapeutic tests are much more desirable, provided they are reliably measured and interpreted. Definite advances have been made in our understanding of schizophrenia in recent decades, but there has been little consideration of how this information could be used in clinical practice. We review here the potential utility of the strongest and best replicated risk factors for and manifestations of schizophrenia within clinical, epidemiological, cognitive, blood biomarker and neuroimaging domains. We place particular emphasis on the sensitivity, specificity and predictive power of pathophysiological indices for making a diagnosis, establishing an early diagnosis or predicting treatment response in schizophrenia. We conclude that a number of measures currently available have the potential to increase the rigour of clinical assessments in schizophrenia. We propose that the time has come to more fully evaluate these and other well replicated abnormalities as objective potential diagnostic and prognostic guides, and to steer future clinical, therapeutic and nosological research in this direction.     

Guías de práctica clínica para la valoración y tratamiento de la transexualidad. Grupo de Identidad y Diferenciación Sexual de la SEEN (GIDSEEN)*(anexo 1)

Transsexual patients can only be diagnosed and treated at functional gender identity Units with provision of high quality care, development of clinical practice guidelines, and interdisciplinary working groups. The therapeutic process has three mainstays: initial psychological diagnostic evaluation and psychotherapy, endocrinological evaluation and hormone therapy, and sex reassignment surgery. Cross-sex hormone therapy is essential for the anatomical and psychological transition process in duly selected patients. Hormones help optimize real-life sex identity, improve quality of life, and limit psychiatric co-morbidities often associated to lack of treatment. Development of this clinical practice guideline addresses the need for implementing a coordinated action protocol for comprehensive health care for transgender people in the National Health System.