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.     

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.     

AUTHORIZING PSYCHIATRIC RESEARCH: PRINCIPLES,PRACTICES AND PROBLEMS

Psychiatric research is advancing rapidly, with studies revealing new investigative tools and technologies that are aimed at improving the treatment and care of patients with psychiatric disorders. However, the ethical framework in which such research is conducted is not as well developed as we might expect. In this paper we argue that more thought needs to be given to the principles that underpin research in psychiatry and to the problems associated with putting those principles into practice. In particular, we comment on some of the difficulties posed by the twin imperatives of ensuring that we respect the autonomy and interests of the research subject and, at the same time, enable potentially beneficial psychiatric research to flourish. We do not purport to offer a blueprint for the future; we do, however, seek to advance the debate by identifying some of the key questions to which better answers are required.     

Genetics in psychiatry

Today, psychiatrists are focusing on genetics aspects of various psychiatric disorders not only for a future classification of psychiatric disorders but also a notion that genetics would aid in the development of new medications to treat these disabling illnesses. This review therefore emphasizes on the basics of genetics in psychiatry as well as focuses on the emerging picture of genetics in psychiatry and their future implications.     

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]     

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.     

The clinical psychologist; his role in private medical practice

The independent diagnosis and treatment of mental and nervous disorders according to California law constitutes practicing medicine. By this yardstick, an increasing number of clinical psychologists are entering the private practice of medicine. The medical profession has not provided through its leadership the opportunity for clinical psychologists to utilize their skills in a legitimate and supervised way in the treatment of private patients, nor has the medical profession taken sufficient interest in modern methods of treating patients with psychogenic disorders. If the psychiatric team is a feasible and practical approach to spreading the base of psychiatric treatment in hospitals and clinics, it should be applicable to private practice settings too. In the team setting, the psychologist can render great assistance to the physician in the diagnosis and treatment of patients with psychogenic disorders without compromising the principle that the primary responsibility for the patient is the physician's. By virtue of his training and experience, it is the psychiatrist who is best qualified to supervise the work of the psychologist; and until such time as the medical profession is better acquainted with psychotherapeutic techniques, the employment of psychologist assistants should be (according to good medical practice) left to the psychiatrist. The need for some regulation of the use of the title "psychologist" is increasing in order to protect the public from quacks who pose as psychologists. However, any law which is directed toward elimination of the quack should specifically define psychotherapy and contain provisions for its use under adequate medical supervision. The medical profession is obligated to take its traditional role in providing the best possible treatment for patients who are in need of it, and psychotherapy is an inherent part of treatment.     

Psychosoziale Belastungen, familiäre Konflikte und Therapieverantwortung bei Diabetes im Kindes- und Jugendalter

Children and youth with type 1 diabetes show an enhanced prevalence of psychiatric disorders, especially depression and eating disorders. Their parents suffer from constant vigilance, fear of hypoglycaemia and worries about their child’s future. Children’s quality of life corresponds largely to the quality of life of healthy peers, but is influenced by glycemic control and family conflicts. Illness related family conflicts increase in adolescence, when parental supervision of diabetes therapy run contrary to adolescents’ needs of autonomy. A stepwise transfer of treatment responsibility, which is adjusted to the child’s developmental status, should begin in adolescence at the earliest. The psychosocial care of patient families from diagnosis on should be an integral part of treatment and include patient education programs as well as psychological single case and group intervention.     

Preventive Psychiatry: The Psychiatric Team as Consultant to the Public Health Nurse

Various forms of collaboration between the disciplines of public health and psychiatry are briefly reviewed and the 25-year-old mental health program of the Vancouver Health Department is described. The public health nurse has prime responsibility in all children with emotional disorders. She is supported by a psychiatric team which provides active treatment and educational and consultative help for the nurse and the school. During the year 1963, six social workers had 2357 contacts with nurses and school personnel but only 1049 treatment interviews. Of 401 children referred to the psychiatric team, 138 received active clinic treatment, 141 remained under supervision by the public health nurse, and 122 were referred elsewhere. In addition, 1330 children were identified as “mental hygiene cases” in the caseload of the 170 public health nurses in the community. By close co-ordination, the public health nurse and the psychiatric team can enhance each other''s contributions to community mental health.     

Understanding the Impact of Brain Disorders: Towards a ‘Horizontal Epidemiology’ of Psychosocial Difficulties and Their Determinants

Objective

To test the hypothesis of ‘horizontal epidemiology’, i.e. that psychosocial difficulties (PSDs), such as sleep disturbances, emotional instability and difficulties in personal interactions, and their environmental determinants are experienced in common across neurological and psychiatric disorders, together called brain disorders.

Study Design

A multi-method study involving systematic literature reviews, content analysis of patient-reported outcomes and outcome instruments, clinical input and a qualitative study was carried out to generate a pool of PSD and environmental determinants relevant for nine different brain disorders, namely epilepsy, migraine, multiple sclerosis, Parkinson’s disease, stroke, dementia, depression, schizophrenia and substance dependency. Information from these sources was harmonized and compiled, and after feedback from external experts, a data collection protocol including PSD and determinants common across these nine disorders was developed. This protocol was implemented as an interview in a cross-sectional study including a convenience sample of persons with one of the nine brain disorders. PSDs endorsed by at least 25% of patients with a brain disorder were considered associated with the disorder. PSD were considered common across disorders if associated to 5 out of the 9 brain disorders and if among the 5 both neurological and psychiatric conditions were represented.

Setting

The data collection protocol with 64 PSDs and 20 determinants was used to collect data from a convenience sample of 722 persons in four specialized health care facilities in Europe.

Results

57 of the PSDs and 16 of the determinants included in the protocol were found to be experienced across brain disorders.

Conclusion

This is the first evidence that supports the hypothesis of horizontal epidemiology in brain disorders. This result challenges the brain disorder-specific or vertical approach in which clinical and epidemiological research about psychosocial difficulties experienced in daily life is commonly carried in neurology and psychiatry and the way in which the corresponding health care delivery is practiced in many countries of the world.     

Darwinian psychiatry and the concept of mental disorder

In this paper, we discuss the concept of mental disorder from the perspective of Darwinian psychiatry. Using this perspective does not resolve all of the quandaries which philosophers of medicine face when trying to provide a general definition of disease. However, it does take an important step toward clarifying why current methods of psychiatric diagnosis are criticizable and how clinicians can improve the identification of true mental disorders. According to Darwinian psychiatry, the validity of the conventional criteria of psychiatric morbidity is dependent on their association with functional impairment. Suffering, statistical deviance, and physical lesion are frequent correlates of mental disorders but, in absence of dysfunctional consequences, none of these criteria is sufficient for considering a psychological or behavioral condition as a psychiatric disorder. The Darwinian concept of mental disorder builds from two basic ideas: (1) the capacity to achieve biological goals is the best single attribute that characterizes mental health; and (2), the assessment of functional capacities cannot be properly made without consideration of the environment in which the individual lives. These two ideas reflect a concept of mental disorder that is both functional and ecological. A correct application of evolutionary knowledge should not necessarily lead to the conclusion that therapeutic intervention should be limited to conditions that jeopardize biological adaptation. Because one of the basic aims of medicine is to alleviate human suffering, an understanding of the evolutionary foundations of the concept of mental disorder should translate into more effective ways for promoting individual and social well-being, not into the search for natural laws determining what is therapeutically right or wrong.     

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.     

Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: a systematic review and meta‐analysis of population surveys

Public attitudes towards psychiatry are crucial determinants of help‐seeking for mental illness. It has been argued that psychiatry as a discipline enjoys low esteem among the public, and a “crisis” of psychiatry has been noted. We conducted a systematic review and meta‐analysis of population studies examining public attitudes towards various aspects of psychiatric care. Our search in PubMed, Web of Science, PsychINFO and bibliographies yielded 162 papers based on population surveys conducted since 2000 and published no later than 2015. We found that professional help for mental disorders generally enjoys high esteem. While general practitioners are the preferred source of help for depression, mental health professionals are the most trusted helpers for schizophrenia. If respondents have to rank sources of help, they tend to favor mental health professionals, while open questions yield results more favorable to general practitioners. Psychiatrists and psychologists/psychotherapists are equally recommended for the treatment of schizophrenia, while for depression psychologists/psychotherapists are more recommended, at least in Europe and America. Psychotherapy is consistently preferred over medication. Attitudes towards seeking help from psychiatrists or psychologists/psychotherapists as well as towards medication and psychotherapy have markedly improved over the last twenty‐five years. Biological concepts of mental illness are associated with stronger approval of psychiatric help, particularly medication. Self‐stigma and negative attitudes towards persons with mental illness decrease the likelihood of personally considering psychiatric help. In conclusion, the public readily recommends psychiatric help for the treatment of mental disorders. Psychotherapy is the most popular method of psychiatric treatment. A useful strategy to further improve the public image of psychiatry could be to stress that listening and understanding are at the core of psychiatric care.     

Prevention of Mental Disorder—The Role of the General Practitioner

As prevention in psychiatry really refers to early detection and consequent prevention of complications and chronicity, the general practitioner is the most important person in the medical community in preventing mental disorders. As more postgraduate courses in psychiatry become available to practicing family physicians, the majority of patients with psychiatric disorders will be effectively managed by the general medical practitioner.The family physician is already doing this, although not as well as he could. In some instances, he may be unaware of the extent to which the disease with which he deals is psychic disease. As the number of community health centers increases, family physicians will play a vital role in their function. With the necessary knowledge to detect psychic disturbance and to treat emotional disorders effectively, the family physician will prevent many of the instances of progression to chronic psychiatric illness with which we are now plagued. The psychiatrist of the future will act as consultant, treating only patients with the more complicated mental disorders.     

Role of proteomics in biomarker discovery and psychiatric disorders: current status,potentials, limitations and future challenges

Proteomic approaches have advanced clinical research towards more reliable, sensitive and specific biological diagnostic markers for diseases. Mood disorders are most difficult to diagnose and very much prevalent in society; hence, their proper diagnosis becomes essential. Despite tremendous research efforts to dissect the neurobiological basis of psychiatric disorders, the diagnosis and evaluation for such diseases is still poor. Biomarker discovery in psychiatry research has been accelerated by proteomic technologies, accepting the challenges in order to meet disease state-related investigations. Proteomics-based research for disease-specific protein signatures is expected to give a new direction in psychiatry research. Therefore, this may become a more powerful tool to predict the development, course and outcome of the disease towards personalized psychiatric ailments. The review discusses the role of proteomics in elucidating mechanisms of psychiatric disorders, current status, prospects, limitations and new possibilities towards a strong diagnostic tool in the clinical laboratory.     

Family Life and Social Medicine: Discourses and Discontents Surrounding Puebla’s Psychiatric Care

Drawing on clinical data from 15 months of on-site participant observation in the only public psychiatric hospital in the state of Puebla, Mexico, this article advances our understanding of globalization in relation to psychiatry. I challenge the construction of psychiatry as only treating the individual patient and provide grounded doctor-patient-family member interaction in a Mexican psychiatric clinic in order to review what happens when doctors cannot interact with patients as atomized individuals even though in theory they are trained to think of patients that way. Challenged by severe structural constraints and bolstered by lessons from other nations’ efforts at deinstitutionalization, psychiatrists in Puebla push to keep patients out of the inpatient wards and in their respective communities. To this end, psychiatrists call upon co-present kin who are identified both as the customer and part of the caretaking system outside the clinic. This modification to the visit structure changes the dynamic and content of clinical visits while doctors seamlessly respond to unspoken beliefs and values that are central to local life, ultimately showing that efforts to define a “global psychiatry” informed by global policy will fail because it cannot exist in a uniform way—interpersonal interaction and personal experience matters.     

ETHICAL ISSUES IN FORENSIC PSYCHIATRIC RESEARCH ON MENTALLY DISORDERED OFFENDERS

This paper analyses ethical issues in forensic psychiatric research on mentally disordered offenders, especially those detained in the psychiatric treatment system. The idea of a 'dual role' dilemma afflicting forensic psychiatry is more complicated than acknowledged. Our suggestion acknowledges the good of criminal law and crime prevention as a part that should be balanced against familiar research ethical considerations. Research aiming at improvements of criminal justice and treatment is a societal priority, and the total benefit of studies has to be balanced against the risks for research subjects inferred by almost all systematic studies. Direct substantial risks must be balanced by health benefits, and normal informed consent requirements apply. When direct risks are slight, as in register-based epidemiology, lack of consent may be counter-balanced by special measures to protect integrity and the general benefit of better understanding of susceptibility, treatment and prevention. Special requirements on consent procedures in the forensic psychiatric context are suggested, and the issue of the relation between decision competence and legal accountability is found to be in need of further study. The major ethical hazard in forensic psychiatric research connects to the role of researchers as assessors and consultants in a society entertaining strong prejudices against mentally disordered offenders.     

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.