Understanding Of Mental Disorders Research Articles

Post-Classical Phase Transitions and Emergence in Psychiatry: Beyond George Engel's Model of Psychopathology

This paper explores the flaws underlying Engel's biopsychosocial paradigm of psychiatric illness and offers a quantum-neurodynamical alternative that addresses these defects. It is argued that the current conceptual foundations of biopsychosocial psychiatry, insofar as they rest upon analogies between neural network theory and classical statistical mechanics, are plagued by tensions and inconsistencies among notions of causation, physical scale, and objectivity. The recent rise of a potentially more adequate post-classical paradigm, grounding cognitive neuroscience in quantum principles, is described. The possibility is advanced that this developing quantum perspective on mind and brain can transform psychiatry's understanding of mental disorders through an explanatory adequacy and a theoretical coherence superior to Engel's classically limited ideas.

The British Mental Health Survey Programme: achievements and latest findings

TheBritish National Psychiatric Morbidity Survey Programme (http://www.mentalhealthsurveys.co.uk/) started in 1993, and it seems timely now, with the publication of the most recent survey [39], to take stock of its impact on our understanding of mental disorders and of what the next steps should be. The survey programme was designed to improve knowledge and understanding of mental illness, its causes and consequences, in order to inform governmental objectives for mental health [18]. These comprised prevention, treatment and rehabilitation of mental disorders; improvement of quality of life; prevention of mortality; provision of services and interventions; mental health promotion; tackling fear, ignorance and stigma around mental illness; and continued research into the causes, consequences and care of specific mental disorders, together with their contribution to social exclusion. The survey programme has provided a key source of continuous information to government, commissioners and researchers. Most recently it has informed the Foresight Report on Mental Capital and Wellbeing (www.foresight.gov.uk, [8]).

Power laws in covariability of anxiety and depression among newly diagnosed patients with major depressive episode, panic disorder and controls

Although symptoms of anxiety and depression correlate, they may covary in irregular and unpredictable ways. This non-linear covariation may be important to psychiatric diagnosis, treatment and relapse. This non-linear anxiety-depression interaction suggests that power laws may be observed. Power laws are statistical distributions found when systems vary in complex ways at the interface between chaotic dynamics and periodic dynamics, such that data points vary randomly but are still partially correlated with each other. Such non-linear dynamics and relationships should result in characteristic patterns of interaction among patients, stressors and treatment. This is important because non-linear dynamics could affect our understanding of mental disorders, the need for varied treatment approaches and patterns of early response to treatment. To determine whether the relationships between anxiety and depression levels, changes and rates of change follow power law distributions among patients with newly diagnosed major depressive episode (MDE), panic disorder (PD) and neither disorder (controls). Time series of hourly mood variation. Setting Acute and continuity primary care clinics. Five adult patients presenting each with MDE, PD and controls based on DSM-IV criteria. Four patients in each group completed 30 days of assessments. MAIN AND SECONDARY OUTCOME MEASURES: Hourly self-assessments (while awake) of levels of anxiety and depression using visual analogue scales for a 30-day period. Covariation in level of symptoms, in the change of symptoms and in the rate of change were assessed. Anxiety-depression matrices were prepared for pooled subjects. Power laws were sought using log-log plots of frequency versus order of that frequency. Although visual inspection of plots for symptoms levels, change and rates of change all suggest power laws, statistical assessments provide stronger support for power laws in symptom change than for either symptom levels or rates of change. Adjusted R(2) terms are larger for MDE and PD subjects compared with controls while the inverse slope is about 2.5 for controls and 1.7-1.9 for those with MDE or PD. This study found that power laws may be present in both the symptom change data for all three diagnostic groups. Evidence for power laws in symptom levels and rates of change was less compelling. The inverse slopes suggest that the anxiety-depression relationships among subjects with PD and major depression are similar but differ from those among controls. First, power laws suggest a scale-free relationship; the differences seen in transition from symptom level to change level may reflect that complex events at the level of mood assessment affect change in mood. Second, this covariation may be due to external factors acting on the patient or multiple internal interrelated factors. Third, different factors and populations can yield different slopes. Future research is needed to confirm these preliminary findings and to understand the origin of these dynamics.

René J. Muller, Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession

Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession by Rene J. Muller powerfully challenges the current paradigm of mental illness. Muller’s arguments are the culmination of 10 years of clinical observation and frustration in three urban psychiatric hospitals. Muller successfully compels professionals of all levels of expertise to examine psychiatric diagnosis and treatment from what has become an unconventional angle. Muller reemphasizes the significance of the human being and free will into a practice that has become so heavily reliant on brain dysfunction. Initially, Muller describes the evolution of the Diagnostic and Statistical Manual of Mental Disorders. To support his arguments, Muller integrates various case examples. In addition, misconceptions about schizophrenia, bipolar disorder, paranoia, and depression are explained. Muller proposes a novel and refined method of conceptualizing mental disorders that emphasizes a dimensional approach. A major strength of Muller’s Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession is the relevance of his perspective to a wide-range of individuals. In his writing, Muller is not afraid to go against the grain of current societal beliefs. The radical approach that Muller adopts gives his stories universal appeal. Although the arguments are most specifically directed towards psychiatrists and psychologists, all mental health and medical professionals may be influenced by Muller’s arguments. Furthermore, Muller’s perspective has the ability to challenge how mental health patients and lay members of society view personal struggles with mental illness. Muller effectively confronts the role of marketing and sales in the current conceptualization and treatment of mental illness. Consequently, Muller’s extreme arguments also have relevance to business and legal professionals. Muller’s perspective is supported by theory and knowledge gathered from various realms of scholarly work. He criticizes the current approach to mental diagnosis and treatment on the grounds that biology is overemphasized and psychology is underemphasized. In contrast, Muller successfully integrates theories of the mind, philosophical ideas, and biological science into a comprehensive theory. Muller manages to raise questions about the biological evidence being used to support current theories. Furthermore, Muller emphasizes that true understanding of mental disorders cannot be accomplished without accepting a multidisciplinary approach. In Doing Psychiatry Wrong, Muller effectively reintroduces the importance of understanding the distinctiveness of each patient. Muller argues that in psychiatric practice, human beings have been reduced to neurons and brain structures. Although Muller believes that symptoms are relevant to diagnosis, he argues that the meaning underlying symptoms is of greater importance. Muller suggests that symptoms should be understood before a diagnosis is given. In addition, he argues that patient motivation and free will should be assessed. Muller successfully emphasizes the importance that patients’ unique life stories have to a profession dedicated to helping individuals. In the final chapter of the book, Muller provides an alternative approach to diagnosis that can be implemented by psychologists or psychiatrists. Muller emphasizes a dimensional approach in his model. The guidelines provided are simple, straightforward, and encompass transtheoretical approaches. Despite the practicality of these A. L. Marquart (&) Psychology Department, Case Western Reserve University, Mather Memorial Building #103, 11220 Bellflower Road, Cleveland, OH 44106-7123, USA e-mail: Abby.marquart@gmail.com; abby.marquart@case.edu

Presidential Address: Our Voice in Action: Advancing Science, Care, and Our Profession

Presidential Address: Our Voice in Action: Advancing Science, Care, and Our Profession

The promises and challenges of early intervention in psychotic disorders

The promises and challenges of early intervention in psychotic disorders

Relationships With Industry Must be Open, Transparent

Back to table of contents Previous article Next article From the PresidentFull AccessRelationships With Industry Must be Open, TransparentCarolyn Robinowitz, M.D.Carolyn RobinowitzSearch for more papers by this author, M.D.Published Online:18 Apr 2008https://doi.org/10.1176/pn.43.8.0003©Sylvia Johnson Photography 2007Few topics have elicited more heated discussion in medicine than its relationship with the pharmaceutical industry, particularly as industry's role in research and health care has expanded over the past decade. Currently, industry is responsible for some 60 percent of research funding, as the federal government does not support drug development and funds few clinical trials.Industry has funded professional education (CME) for more than two decades. Over time, and in the face of increased regulation and requirements from the Accreditation Council for Continuing Medical Education (ACCME), these educational programs have evolved from near-total industry control to control of topic, format, faculty, and content by sponsors such as medical professional organizations (or specialty societies). Industry also funds marketing, including exhibits at professional meetings, practitioner visits (“detailing”), and advertising aimed at both physicians and the public to inform them about new products and indications, with the goal of increased use.Social-science research demonstrates that even highly educated physicians respond to formal advertising, but also to relationships with industry representatives and to gifts regardless of value. In our capitalistic society, these promotional activities have been an acceptable part of a business plan, with a goal of profitability. Increases in marketing budgets (as well as consumer education) have been accompanied by an increase in the number of prescriptions filled.Media reports of these activities have influenced public perceptions: policymakers have launched their own investigations of the role of industry in shaping physician behavior, and patients have voiced concerns about how their care is being affected. While the advent of effective psychiatric medications has lowered costs of care, there also is concern that industry practices have fostered unnecessary treatments or medical expense. And of course, controversies fuel the rhetoric of antipsychiatry forces.What are the issues for APA? Industry funds are valuable and have helped APA hold national dues at the same level for a dozen years. Funding comes from advertisements in publications, exhibits, industry-supported education, and enrichment programs, such as the chief residents' conference. As a membership organization, APA does not provide direct care, but our products influence care. Thus, APA must ensure that all our programs for members and the public are based on the best scientific information and are free from bias regardless of funding source. Simply put, we must have full disclosure and control.The research investigator who receives outside industry support must disclose the source of funding and have full control of the research activity, including subjects, methodology, data collection, and statistical analyses and reporting results. All phase 2 and phase 3 clinical trials must be reported on ClinicalTrials.gov. While journals have been hesitant to accept reports that do not show positive results, that hesitation seems to be changing. In any case, negative results should be available to other scientists and the public. Education faculty must provide complete personal disclosure and take total responsibility for program content, which must be free from bias or favoritism, presenting a full account of data, risks, and benefits.APA follows the requirements of the ACCME (which in its last re-accreditation survey awarded APA the highest category, as well as commendations for management of industry support). We require disclosures of conflicts from component members including those involved in program planning and evaluation, candidates for election to the Board of Trustees, and authors of books and studies published in our journals. There is expanded disclosure for members who work on practice guidelines as well as DSM (which also requires limits on industry support). APA maintains full control of all educational programs including planning, content, faculty, and outcome evaluation. Slides and hand-outs of industry-supported symposia are reviewed in advance for quality and absence of bias—in short, these symposia are thoroughly evaluated. We also maintain complete control of enrichment programs for which we receive outside funding, appointing member-based oversight committees free from conflicts of interest to set goals, review competitive nominations/applications, design and implement content, and perform evaluations.What else should APA do? APA should educate trainees and practitioners about physician-industry relationships and assist them to evaluate data critically and recognize the impact of marketing. At the same time, we should not demonize industry or encourage what begins to seem like the Salem Witch Trials. The availability of effective medications has been a boon to those who suffer from mental illness. Rather, we need to develop appropriate partnerships that are open and transparent, with a goal to improving awareness and understanding of mental disorders and to promoting the highest quality patient care. ▪ ISSUES NewArchived

The Brain's Default Network

Thirty years of brain imaging research has converged to define the brain's default network-a novel and only recently appreciated brain system that participates in internal modes of cognition. Here we synthesize past observations to provide strong evidence that the default network is a specific, anatomically defined brain system preferentially active when individuals are not focused on the external environment. Analysis of connectional anatomy in the monkey supports the presence of an interconnected brain system. Providing insight into function, the default network is active when individuals are engaged in internally focused tasks including autobiographical memory retrieval, envisioning the future, and conceiving the perspectives of others. Probing the functional anatomy of the network in detail reveals that it is best understood as multiple interacting subsystems. The medial temporal lobe subsystem provides information from prior experiences in the form of memories and associations that are the building blocks of mental simulation. The medial prefrontal subsystem facilitates the flexible use of this information during the construction of self-relevant mental simulations. These two subsystems converge on important nodes of integration including the posterior cingulate cortex. The implications of these functional and anatomical observations are discussed in relation to possible adaptive roles of the default network for using past experiences to plan for the future, navigate social interactions, and maximize the utility of moments when we are not otherwise engaged by the external world. We conclude by discussing the relevance of the default network for understanding mental disorders including autism, schizophrenia, and Alzheimer's disease.

Reports of Our Death Have Been Greatly Exaggerated

Back to table of contents Previous article Next article From the PresidentFull AccessReports of Our Death Have Been Greatly ExaggeratedCarolyn Robinowitz, M.D.Carolyn RobinowitzSearch for more papers by this author, M.D.Published Online:7 Sep 2007https://doi.org/10.1176/pn.42.17.0003©Sylvia Johnson Photography 2007In the almost 40 years since I finished residency, there have been several predictions of the death of psychiatry. Late in the 20th century, two psychiatrists—E. Fuller Torrey, M.D., and Thomas Detre, M.D., envisaged our becoming neurologists, based on the growth of neuroscience and the limits they perceived psychotherapy had in treating mental illness. This reductionistic forecast has not come to fruition. Even as research has led to a tremendous increase in neuroscience, research also has demonstrated the importance of psychotherapies in patient care, and we have come to a greater awareness of the crucial role of psychiatric physicians in providing care.Now, we are informed of a similar prediction from a past president of the American Psychological Association. It is tempting to speculate on his motivation or how he came to this determination, but neither matters since his prediction is so far from reality at a time when our profession continues to grow immensely in its science base, stature, and effectiveness.Public understanding of mental disorders and psychiatry's role in providing care has never been so high. Our partnerships with national advocacy organizations such as the National Alliance on Mental Illness and Mental Health America, as well as the contributions of celebrities who have spoken openly about their illness and the success of their treatment, have helped reduce stigma, fear, and blame and have united professionals, patients, families, and the public in support of research and access to nondiscriminatory care.Federal lawmakers view us positively. The public agrees that good mental health is as important as good physical health, and research consistently has demonstrated their connections. There is broad recognition that mental disorders are real medical disorders that can be treated effectively without breaking the bank, as demonstrated by numerous health services research studies. Even the business community has recognized that good care for its employees is not only the right thing to do, but that it enhances productivity and provides benefits that far offset the cost of care. (I will discuss our extensive efforts with the business community in a future column.) And attacks on psychiatric care, motivated by emotion and prejudice, have been successfully fended off with science and data.Our relationships with our colleagues in the rest of medicine, through the AMA and medical specialty organizations, are extremely positive and have included their support on key issues such as insurance parity and legislation to remove the Medicare discriminatory copayment for psychiatric care. Psychiatrists are highly valued leaders in medical centers where they serve as presidents and deans; research in academic departments of psychiatry is funded and flourishing, ranging from studies of psychotherapies to cellular biology. We are welcomed in our medical communities.With the diminution of reductionistic approaches to care, psychiatrists have a more sophisticated integration of psychotherapy and psychopharmacology. When senior psychoanalysts such as Glen Gabbard, M.D., discuss treatment, they may include not only psychodynamics, but also behavioral genetics and adaptation over the life cycle, biological markers and pharmacogenomics, as well as the use of medications. PET scans demonstrate the impact of psychotherapy, mirroring changes in behavior and mood. Although many results of neuroscience research may not yet be applicable in everyday practice, this work demonstrates the importance of a biopsychosocial approach both in patients with psychiatric disorders only and those with other medical disorders as well.With these advances come challenges to psychiatry residency training, as faculty must address the ever-expanding knowledge base, new systems and venues of care, and the associated economics, while ensuring time for the skill development so vital to good treatment. As we define and measure competencies in residency, we must also consider ways to ensure growth, maturation, and continued integration of scientific developments. My interactions with residents during my travels as president, as well as observation of residents serving on APA components and in the Assembly, add to my optimism about the strong future of psychiatry. Nonetheless, our continued success depends on hard-nosed and nondefensive examination of our professional function, as well as the education and training of the residents who represent our future. To that end, our Board approved a new committee on graduate education, which has just begun its deliberations.Psychiatry's health is strong. Spread the word. Work for our future.▪ ISSUES NewArchived

A View From Riggs: Treatment Resistance and Patient Authority—Introduction to Paper III: “What is Psychodynamic Psychopharmacology? An Approach to Pharmacologic Treatment Resistance”, by David Mintz and Barri Belnap

As our field has moved inexorably toward a biologically reductionistic medical model for understanding mental disorders, with a concomitant preference for “evidence-based” treatments, the problem of treatment resistance has emerged as a prominent one. As we have noted throughout this evolving series of articles, efforts to approach the problem of treatment resistance generally focus on the development of biological treatment algorithms, with little attention to psychosocial factors or to meaning. I often think our field is in much the same place physics was nearly a century ago. At that time Newtonian physics was preeminent, and seemed able to explain nearly everything. Among other things, it was quite clear that light was a wave, and not a particle. The focus on light as a wave allowed tremendous advances, including an understanding of the electromagnetic spectrum, and the development of lenses that enhanced vision, advanced our understanding of cells and bacteria, and allowed us to deepen our understanding of our solar system and the universe, to name only a few. In much the same way, mental illness is currently seen by most as caused by disordered biology—the Newtonian stance of “Light is a wave” of our profession in this time. Einstein was a visionary who looked beyond light as a wave. He refused to be limited by Newtonian physics, threw aside conventional ideas, and came to the recognition that light was also a particle—not a particle instead of a wave, but a particle in addition to a wave. Recognition that light had qualities of a particle as well as of a wave, though it initially seemed counterintuitive to most, allowed the further elabora-

Main features of narrow sociological theories explaining mental disorders

In the introduction, the author states that sociological theories explaining mental disorders in the narrow sense have originated as an opposition to medical, i.e. biological model of interpreting mental disorders. With regard to this, the following sociological theories explaining mental disorders are presented in more detail: theory of anomie by Durkheim and Merton (with Merton’s typology of deviant behavior), social roles theory by Parsons, labeling theory by Scheff and other authors, theoretical career model of the mentally ill, the concept of psychic disorder of etnomethodology and finally, the anti-psychiatric interpretation of mental disorders. It is concluded that, although historically older, sociological theories of the onset of mental disorders are filling the epistemological void that occurred in understanding the role of society on the whole and a series of social factors particularly on the different aspects of understanding mental disorders.

A Psychological Model of Mental Disorder

A coherent conceptualization of the role of psychological factors is of great importance in understanding mental disorder. Academic articles and professional reports alluding to psychological models of the etiology of mental disorder are becoming increasingly common, and there is evidence of a marked policy shift toward the provision of psychological therapies and interventions. This article discusses the relationship between biological, social, and psychological factors in the causation and treatment of mental disorder. It argues that simple biological reductionism is not scientifically justified, and also that the specific role of psychological processes within the biopsychosocial model requires further elaboration. The biopsychosocial model is usually interpreted as implying that biological, psychological, and social factors are co-equal partners in the etiology of mental disorder. The psychological model of mental disorder presented here suggests that disruption or dysfunction in psychological processes is a final common pathway in the development of mental disorder. These processes include, but are not limited to, cognitive processes. The model proposes that biological and social factors, together with a person's individual experiences, lead to mental disorder through their conjoint effects on those psychological processes. Implications for research, interventions, and policy are discussed.

Psychiatrische Diagnose heute notwendiges Hilfsmittel oder stigmatisierendes Etikett?

Often psychiatric diagnoses are the starting point of controversial debates about psychiatry not only within the scientific community, but also in the public field. This article discusses the development of the concept ofpsychiatric diagnosis, which, of course, cannot be separated from the conceptual history of nosology. Nowadays, there is a focus on operationalised diagnoses as represented by ICD-10 and DSM-IV-TR. The theoretical background of this approach is therefore highlighted in this article, too. Psychiatry as a scientific as well as a practical field is much more influenced by political and sociocultural factors than any other medical specialty. And that is why basic questions like mind-body-relationship, anthropological framework or ethical values like human rights cannot, though theoretical in nature, be ignored in psychiatric practice. There were two main factors in the 2nd half of the 20th century that led to the development of operationalised psychiatric diagnostic systems: first, the low reliability of former psychiatric diagnoses that originated from highly heterogeneous theoretical concepts in different parts of the world and even within one part, e.g. the different usage of the term schizophrenia in the United States and in the United Kingdom as shown by a large WHO study. Second, the development of completely new research techniques like brain imaging and of new drugs that had to be evaluated. Researchers in these fields were (and are) depending on reliable diagnoses as basis of their work. Theoretically spoken, there are three main approaches to the conceptualisation of mental disorders: (1) the realistic approach, regarding mental disorder as an object that can be detected by means of natural sciences, i.e. quantitatively, like in other medical disciplines. (2) The nominalistic approach, defining mental disorder not in itself (like the first approach), but by the terms that are used to describe it, e.g. the term schizophrenia. Diagnoses are here seen as psychopathological conventions enriched by further empirical data (e.g. biological findings) wherever possible and agreed upon by experts. The two most prominent examples are ICD-10 and DSM-IV-TR. (3) The biographical approach has its focus on the understanding of mental disorders as reactions to events and developments within the person's biography. This represents the subjective pole of the methodological spectrum. The advantages and limitations of modern diagnostic criteria are discussed in some detail. In conclusion, it should be kept in mind that diagnostic criteria and diagnosis itself are important psychiatric tools, but nothing more. Operationalised manuals must not be identified with psychiatry on the whole as there are clinical phenomena and scientific topics which up to now or, maybe, principally are not accessible by this approach. For example, there is no valid and reliable psychiatric diagnosis without the element of personal relationship between the patient and the doctor, and this, too, should be studied scientifically. Last but not least, the potential of scientific and political abuse of psychiatric diagnoses must be realised, especially with regard to what the history of psychiatry tells us in this context.

From degeneration to genetic susceptibility, from eugenics to genethics, from Bezugsziffer to LOD score: the history of psychiatric genetics

Reviewing the history of psychiatric genetics is a difficult task, since—in contrast to genetic research into most other disorders—it cannot simply be done by chronologically listing methodological achievements and major findings. Instead, it necessitates a comprehensive assessment of how the aetiological concept of mental disorders has developed since as early as the world of ancient Greece. Furthermore, it has to touch upon the sensitive issue of the eugenic movement that was closely linked to the study of heredity in mental disorders in the first half of the 20th century and, in Nazi Germany, led to the systematic mass murder of psychiatric patients. Finally, reviewing the scientific dimensions, history of psychiatric genetics is at the same time a walk through the history of complex genetics in general. In our review, we try to pay tribute to this complexity. We argue that psychiatric genetics has not only propelled our understanding of mental disorders but has significantly benefited genetic research into other complex disorders through the development of methodologically robust approaches (e.g., systematic phenotype characterisation, methods to control for ascertainment biases, age-correction). Given the recent reasons for new optimism, i.e., the identification of susceptibility genes for psychiatric phenotypes, a continued methodologically sound approach is needed more than ever to guarantee robust results. Finally, psychiatric genetic research should never again be performed in an environment void of ethical standards.

Perception and beliefs about mental illness among adults in Karfi village, northern Nigeria.

BackgroundThis study was designed to examine the knowledge, attitude and beliefs about causes, manifestations and treatment of mental illness among adults in a rural community in northern Nigeria.MethodsA cross sectional study design was used. A pre-tested, semi-structured questionnaire was administered to 250 adults residing in Karfi village, northern Nigeria.ResultsThe most common symptoms proffered by respondents as manifestations of mental illness included aggression/destructiveness (22.0%), loquaciousness (21.2%), eccentric behavior (16.1%) and wandering (13.3%). Drug misuse including alcohol, cannabis, and other street drugs was identified in 34.3% of the responses as a major cause of mental illness, followed by divine wrath/ God's will (19%), and magic/spirit possession (18.0%). About 46% of respondents preferred orthodox medical care for the mentally sick while 34% were more inclined to spiritual healing. Almost half of the respondents harbored negative feelings towards the mentally ill. Literate respondents were seven times more likely to exhibit positive feelings towards the mentally ill as compared to non-literate subjects (OR = 7.6, 95% confidence interval = 3.8–15.1).ConclusionsOur study demonstrates the need for community educational programs in Nigeria aimed at demystifying mental illness. A better understanding of mental disorders among the public would allay fear and mistrust about mentally ill persons in the community as well as lessen stigmatization towards such persons.

Healing psychiatry: a pragmatic approach to bridging the science/humanism divide.

Competing urges to think of human mental suffering as comprehensible and susceptible to scientific formulation, or as deeply complex and beyond the reach of scientific analysis, have torn at the fabric of psychiatry for many years and have left the field conceptually divided between science and humanism. Conceptual reparation of psychiatry is now a core mission of a field that is trying to heal itself so that it is equipped to heal the patients it serves. To formulate their cases comprehensively and provide patients with cutting-edge care, psychiatrists must heal the conceptual wounds that have resulted from dividing the human individual into an object of scientific scrutiny and a subject of personal experience. They must synthesize science and humanism in order to generate new understanding of mental disorders and to train future clinicians and researchers. Principles of classical American pragmatism, I argue in this article, can help to transcend the science/humanism divide in psychiatry. Clinical pragmatism focuses on favorable treatment outcomes by respecting the practical, pluralistic, participatory, and provisional aspects of psychiatric care. It demands that psychiatrists have the skill and flexibility to use multiple explanatory concepts in a collaborative, open-ended process with their patients. These themes are explored from the perspectives of contemporary psychiatric treatment, training, and research.

Values in the definition of mental disorder

There has been rapidly increasing interest in the concept of mental disorder in the last few years. One of the main forces behind this has been the increasing importance and sophistication of diagnostic manuals such as DSM-IV and ICD-10, alongside continuing discontent about psychiatric diagnosis (e.g. Kutchins and Kirk, 1997). Critiques of the medical model have charged it with being a means by which individuals or groups are, among other things, disqualified, stigmatized and socially excluded, and these concerns continue to be pressed by patients and their advocates. We have seen concerns about community care, the beginnings of compulsory community treatment orders, uncertainty about response to dangerousness associated with ‘personality disorder’, as well as the growing influence of the service user movement. Further, advances in the sciences – biological, psychological and social – modify our concept of mind, its biological and social basis, and hence our ways of understanding mental disorder. The arguments and perspectives on mental disorder move in and around these themes: the medical model, social values and the sciences.

The ABCs of Psychobiology

This column may be more conversational in tone than previous columns because I want to outline a few basic concepts that are needed if you are to be conversant in today's changed world of psychiatric nursing. First, calling an article the ABCs of anything might suggest a certain level of arrogance on the part of the author. If the title provokes that image for you, discard it immediately. This writer is very clear about the mountains of information he has yet to climb. Second, there is only so much that can be covered in a few pages, but over the years I have learned that psychiatric nursing practice improves significantly when nurses understand the basics of brain biology. Such knowledge informs our understanding of mental disorders, improves treatment with psychotropic drugs, and helps shift our thinking in an empathic direction. Thus a brief review of the ABCs of brain biology is presented: Anatomy, Biochemistry, and Connections. Anatomy The adult brain weighs about 3 to 4 lb, but weighs only a quarter of that at birth. Neuronal numbers change little, if at all, over the years between birth and adulthood, but brain size and weight change dramatically. A significant portion of the size and weight is related to axonal and dendritic growth patterns that result in a quadrillion synaptic connections. These connections occur over time in a development sequence orchestrated in a manner some have likened to a hound dog following a trail. Somehow, in healthy individuals, axons find the right targets, covering microscopic miles to do so. As noted, these connections or pathways are programmed before birth to occur in a relative stable sequence, the last major connections occurring in late adolescence to early adulthood. It is thought that an insult (of many origins) can occur to a particular pathway and remain relatively silent for years. Knowledge of certain brain nuclei is important for psychiatric nurses. Just as it is often dangerous to start thanking people at certain functions due to the risk of leaving someone unmentioned, I also run the risk of omitting brain sites you deem crucial. Nonetheless, the basics, in my opinion, include a discussion of the major divisions of the brain, cortex, basal ganglia, motor strip, hypothalamus, hippocampus, and nucleus accumbens. Major divisions of the brain. The brain is divided into the cerebrum, brainstem, and cerebellum. The cerebrum is further divided into four lobes: frontal, temporal, parietal, and occipital. Although perhaps an oversimplification, the frontal lobe is associated with cognition, movement, emotions, and inhibition. The temporal lobe is associated with auditory functions, the occipital lobe with vision, and the parietal lobe with sensations from the periphery. The brainstem is composed from the top (rostrally) down (caudally) into the midbrain, pons, and medulla. As is noted later, three important neurotransmitters are synthesized in the brainstem. The cerebellum is a poorly understood structure, yet it contains more neurons than the rest of the brain combined. It is known that cerebellar lesions cause impaired movement. The cortex. The cortex is the outer layer of gray matter (i.e., neuronal cell bodies and dendrites) and is described as the workhorse of the brain. It is about one-eighth of an inch thick. Our brain surface dips in and out of grooves (sulci), permitting more space for its work. The fact that I write this article and you can read it testifies to functioning cortices. The basal ganglia. The basal ganglia are subcortical nuclei near the center of the brain. They are subcortical because they are located beneath the cortex. They are nuclei because they are composed of gray matter. Both idiopathic Parkinson's disease and extrapyramidal side effects (EPSEs) result from impaired basal ganglia function. The motor strip (aka precentral gyrus). The motor strip lies on the surface of the brain and is the most dorsal frontal gyrus. …

Parity Is Cost-Effective and Affordable, APA Tells Senators

Parity Is Cost-Effective and Affordable, APA Tells Senators

Ethical issues in psychiatric care: geneticisation and community care.

This paper will examine two different though related themes in current debates about ethical issues in psychiatric care. There is, first, the general question of who should be the main focus of the debate: the individual, the family, the local community, or the wider society? Secondly, the current controversies about the genetic basis of mental disorders will be explored with reference to their implications for both images and understanding of mental disorders and for psychiatric care. Would the understanding of the genetic causes of mental disorder lead to better treatments and better acceptance or to the potential for increased discrimination and stigmatisation?