Boundaries Of Psychiatry Research Articles

Expanding boundaries in psychiatry: uncertainty in the context of diagnosis-seeking and negotiation.

Psychiatric diagnosis has become pervasive in modern culture, exerting an increasing influence on notions of personhood, identity practices and forms of self‐governing. The broadening of diagnostic categories and increasing awareness regarding popular diagnostic categories has led to an increased demand for formal diagnosis within clinical encounters. However, there is continuing ‘epistemological uncertainty’ (Fox 2000) surrounding these entities, in part due to their lack of associated clinical biomarkers and their ‘fuzzy boundaries’. Meanwhile, this diagnostic expansion has encountered resistance from those concerned with the alleged ‘over‐pathologisation’ of emotional distress. Drawing upon the concepts of ‘diagnostic cultures’ (Brinkmann 2016) and the ‘looping effects of human kinds’ (Hacking 1995), this article considers some of the competing forces acting upon the contested boundaries of diagnostic categories as they play out within diagnostic interactions. The study involved ethnographic observations of diagnostic encounters within several UK‐based mental health clinics. By focusing on interactions where diagnosis is negotiated, findings illustrate the role played by different kinds of diagnostic uncertainty in shaping these negotiations. It is argued that diagnostic reification plays a key role in the moral categorisation of patients, particularly where there is uncertainty regarding individual diagnostic status.

To cross or not to cross: Clinical boundary considerations with persons who are refugees.

Recent studies suggest that culturally divergent explanatory models of illness and treatment practices, differing physician-patient goals and expectations, and mistrust and misunderstandings between refugee patients and health care professionals are associated with lower health care utilization and outcomes among refugees in Western host countries. In our experience working as psychiatrists with persons who are refugees, we have found that attention to the processes that define and redefine boundary relationships has important implications for therapeutic care, as well as for training residents and others in culturally-responsive care. This article examines the manner and micro-processes by which boundaries are established, maintained, or altered between medical provider and person who is a refugee as a key pathway in the development of working relationships that are culturally sensitive. We work from an expanded concept of boundaries in psychiatry, viewing boundaries as a way of describing interactions that play important and even critical roles in advancing, impeding, and redefining significant aspects of the therapeutic relationship between practitioner and patient. The quality of the interactions occurring minute by minute within treatment sessions provides the foundation from which relationships are defined, parameters of openness or closure of communication are conveyed, and the power structure is laid out. We offer Martin Buber's formulation of the I-Thou relationship as the philosophical grounding of flexible, culturally sensitive boundary behaviors. At its best, boundaries of mutual engagement that are respectful and cognizant of a patient's individuality and cultural history and values are conveyed to the refugee patient.

Helen Herrman: president elect of the World Psychiatric Association

Helen Herrman: president elect of the World Psychiatric Association

The interface between neurology and psychiatry: the case of multiple sclerosis

SummaryThere has been a surge in interest in the boundaries of psychiatry, both as a specialty in its own right and as a branch of medicine separate from neurology. Our article expands on this, giving examples of how recent developments in neuroimmunology can be beneficial for psychiatry, using multiple sclerosis (MS) as an example. We also provide a summary of literature on novel research in the treatment of depression using anti-inflammatory agents. Finally, we suggest approaches to the identification and management of major depressive disorder in patients with MS or other physical illnesses, and how this translates to general psychiatric practice.

The New Crisis in Confidence in Psychiatric Diagnosis

The New Crisis in Confidence in Psychiatric Diagnosis

Diagnostic and statistical manual-5: Position paper of the Indian Psychiatric Society.

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease.

Proposed College working party on psychiatry and religion

The establishing of a Royal College of Psychiatrists’ working party to consider the boundaries of psychiatry and religion, as suggested by Poole & Higgo,[1][1] is indeed a pragmatic, constructive and, in our view, long overdue proposal. It was in 1991 that our Patron, the Prince of Wales, first

Spirituality and secularity: professional boundaries in psychiatry

Spirituality is assuming increasing importance in clinical practice and in research in psychiatry. This increasing salience of spirituality raises important questions about the boundaries of good professional practice. Answers to these questions require not only careful attention to defining and understanding the nature of spirituality, but also closer attention to the nature of concepts of secularity and self than psychiatry has usually given. Far from being “neutral ground,” secularity is inherently biased against concepts of transcendence. Our secular age is preoccupied with a form of immanence that emphasises interiority, autonomy and reason, but this preoccupation has paradoxically been associated with an explosion of interest in the transcendent in new, often non-religious and non-traditional forms. This context, as well as the increasing evidence base for spiritual and religious coping as important ways of dealing with mental stress and mental disorder, requires that psychiatry gives more careful attention to the ways in which people find meaning in spirituality and religion. This in turn requires that more clinical attention be routinely given to spiritual history taking and the incorporation of spiritual considerations in treatment planning.

Spirituality and the threat to therapeutic boundaries in psychiatric practice

There is a determined campaign to make exploration of patients’ spiritual experience an intrinsic and necessary part of routine psychiatric care. This has support from the Royal College of Psychiatrists, though there has been no consultation with psychiatrists. Whilst many of the proposals are uncontroversial, some involve serious breaches of normal professional boundaries of behaviour as set out in General Medical Council guidance. The contentious proposals are that a spiritual history should be taken from all patients, even where they resist; that it is sometimes acceptable to pray with patients; and that clinicians should support “healthy” religious beliefs and challenge “unhealthy” ones. The proposals are based on a model of universal spirituality which, we argue, is culture bound and lacks neutrality. This paper explores these issues and the consequences that might flow from altering professional boundaries in psychiatry. We conclude that the changes are unnecessary and should be resisted.

Als Clinicus over de Grenzen van de Psychiatrie. De verwantschap tussen literatuur en wetenschap in het werk van de psychiater H.C. Rümke (1893-1967)

As a clincian beyond the boundaries of psychiatry. The congeniality of literature and psychiatry in the work of psychiatrist H.C. Rumke (1893-1967) One of the most important Dutch psychiatrists in the interwar period was H.C. Rumke (1893-1967). With his eclectic interest in psychiatric approaches such as both psychoanalysis and phenomenology, Rumke is most well known for his remarkable diagnostic and therapeutic skills. The life and work of Rumke has been studied in detail, most notably by the Dutch historian Jacob Van Belzen. Despite this extensive research, in this paper it is stated that a relevant aspect of Rumke’s work has been largely disregarded – namely his profound interest in and use of poetry and literature. Not only did Rumke write poems himself under the pseudonym of H. Cornelius, in his scholarly work he frequently refers to fictional literature and at the end of his career he wrote a comprehensive analysis of Frederik van Eeden’s novel Van de Koele Meeren des Doods. For the eclectic clinician Rumke literature and poetry are a source of knowledge to gain insight into the human psyche. Furthermore, according to Rumke, often literature succeeds better at expressing the human condition than the science of psychiatry can. In this article it is argued that for a coherent interpretation of the life and work of Rumke this literal and poetic aspect of his work cannot be disregarded. It is precisely Rumke’s profound interest in literature and poetry that reflects his two main theses about the science of psychiatry. These are on the one hand the centrality of clinical practice and on the other hand the boundaries of psychiatry. As a clinical practitioner Rumke’s aim was to be able to understand the suffering of the patient – literature and poetry could help him do that. Rumke’s use of literature and poetry can be understood by taking into account the context of the clinic, but the intertwinement between psychiatry, literature and poetry in Rumke’s work also reflects a broader issue. Namely that the science of psychiatry is not omnipotent and that sometimes the arts are better equipped to grasp the human condition.

Teaching Professional Boundaries to Psychiatric Residents

The authors demonstrate that the teaching of professional boundaries in psychiatry is an essential component of training to prevent harm to patients and to the profession. The authors illustrate overarching principles that apply to didactic teaching in seminars and to psychotherapy supervision. The teaching of boundaries must be based in sound clinical theory and technique so that transference, countertransference, and frame theory are seen as interwoven with the concept of boundaries and must use case-based learning so that a "one-size-fits-all" approach is avoided. The emphasis in teaching should be on both the clinician's temptations and the management of the patient's wish to transgress therapeutic boundaries.

Spirituality and boundaries in psychiatry

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History of psychiatric patients and symptoms

Purpose of review: The article reviews publications on the history of psychiatric patients and symptoms between April 2002 and May 2003. Recent findings: Findings are grouped under the following headings: concepts and general themes; countries and institutions; nursing; clinicians and therapies; and technology. Summary: The history of psychiatry is a rapidly expanding field of investigation. This is reflected by the rich diversity of subjects, methodologies and academic background of researchers in this field. This review highlights some of the newer themes and the ways in which interdisciplinary research leads to new approaches. Several of the most important publications in the period under discussion are focused on the nature and boundaries of psychiatry and on the identity of the psychiatrist as a professional. More than in previous periods the moral and politicial dimensions of this issue were the subject of discussion.

Delirium: la confusión de los clínicos

Delirium or acute confusional state is a condition that lies within the boundaries of psychiatry and other medical specialties. It is defined as a syndrome characterized by a fluctuating cognitive impairment of acute onset. The pathogenesis is multifactorial and it frequently appears in elderly patients admitted to general hospitals. Delirium carries a high mortality and it prolongs hospital stay. Its diagnosis if often overlooked and the treatment is inadequate or belated. This article discusses the most efficient procedures to diagnose and treat delirium. The review was based on a systematic search in the literature using the key words delirium, acute mental syndrome, acute confusional state and organic mental syndrome. Articles were selected according to their relevance and methodological accuracy.

Labelling and the Boundaries of Psychiatry

Objective: An attempt to discover the meaning of “disease” in general medicine and “disorder” in psychiatry. Conclusions: There is no satisfactory definition: the terms are social constructs.

Rights and responsibilities of thepsychiatric profession

Psychiatry as a medical discipline relies on the authority of medicine that is associated with the help to a suffering and deserving individual. If this source of authority is obscured, the discipline will be blamed for serving as a social tool for controlling undesirable phenomena and practices. Psychiatry as a medical science accumulates knowledge on the relationship of biology and psychopathology. It can provide an explanation of the extent to which mental illness participates in socially undesirable behaviour and phenomena. But it cannot explain undesirable social phenomena as a mental illness of sorts, let alone offer an effective treatment for them. We should carefully guard the boundaries of psychiatry to prevent its abuse in the future.

Changing boundaries in psychiatry

M any psychiatrists wonder if psychiatry has sowed seeds in the past that will destroy its future. Some think it may be torn apart in a civil war between neurobiological research and psychodynamic or psychosocial extremists. The expanse of the specialty is great, and difficuk to protect. As we understand more about the neural bases of mental illnesses/the boundaries between psychiatry and neurology become more permeable. Some fear psychiatry may abandon or lose its identity altogether, transplanted to the realm of clinical psychology. Psychopharmacological management, a complex skill that requires specialty training, is sometimes done by family practitioners. Will there be anything left of psychiatry 50 years from now? Or will a few psychiatrists remain, writing increasingly large numbers of prescriptions for patients they see for increasingly short periods of time? Despite this pessimistic scenario, I believe that psychiatry has a great future. First, psychiatrists specialise in treating mental illnesses, diseases that may ultimately arise from brain but that are expressed as mind. Mental illnesses are among the most important medical diseases by any measure chosen: morbidity, mortality, economic cost, or cost in personal suffering. Mental illnesses may ultimately be understood on the -basis of brain mechanisms, but they afflict individuals who live in personal and social contexts, and treatment must be provided in those contexts. Understanding how schizophrenia arises from the brain does not equip one for talking with and caring for a delusional or suicidal person. Only psychiatrists are uniquely trained to work at the complex interface between brain, the individual, and society. Second, psychiatry has lost its aura of hopelessness, as newer and better treatments have been developed. Its therapeutic future is even more promising. At present psychiatrists are able to offer complete remission of symptoms to many patients who present with syndromes such as anxiety, panic, or depression, and substantial improvement to most others. Most patients with psychotic disorders now live in the community. New atypical neuroleptic drugs markedly reduce symptoms with minimal side-effects. The promise of early and rapid pharmacological intervention combined with sensitive psychosocial and psychotherapeutic treatments holds out substantial hope of effective reintegration into the community and the possibility of a productive life, Increasingly, pharmacological treatments are rationally rather than empirically derived, based on our rapidly growing knowledge of neurotransmitter distribution and function, signal transduction, neural circuits and systems, and cognitive neuroscience. The partnership between clinical and basic research in neuroscience has given psychiatry a solid foundation for understanding how treatments work. In the future, this will lead to Changing boundaries in psychiatry

Boundaries of psychiatry.

Boundaries of psychiatry.

Psychiatry before the year 2000: the long view.

The author assesses psychiatry's accomplishments during the past quarter century and the challenges the profession faces in a changing political, economic, and medical environment. He believes that several of the policy decisions of the early 1960s, particularly the deinstitutionalization movement, were based on faulty premises and that their consequences hold valuable lessons for future policy planning. Among psychiatry's major challenges are advancing its knowledge base through intensive research; increasing the accessibility and quality of existing therapeutic services despite constrained resources; and enhancing confidence of the voting and paying public, including other physicians, in the field's unique capabilities. Such confidence will be conditioned on a rigorous redefinition of the boundaries of psychiatry, acknowledging both the field's limitations and its responsibilities to other than the "traditional" psychiatric patient.

More and more is less and less the myth of massive psychiatric need.

The idea of massive unmet need for mental health services is a myth, generated and perpetuated by processes within the system which provides psychiatric care and within society. Diffusion of the traditional boundaries of mental health care, lack of norms and standards, medicalisation and 'healthism', specialoid practice and patient selection, diversion of resources from the long-term mentally ill and their absorption by better-functioning patients, substitution and development of new mental health service providers, and changes in the threshold for help-seeking all affect our assumptions of need. Needs are less massive, if the boundaries of psychiatry are defined so as to include only those disorders which the profession is best able to treat.