The ICD-11 personality disorder model is the first fully dimensional assessment of personality pathology. It consists of a personality disorder dysfunction-severity dimension, which encompasses both self- and interpersonal dysfunction, and six optional qualifiers for five prominent personality traits—Negative Affectivity, Detachment, Dissociality, Disinhibition, and Anankastia —plus a borderline pattern that is defined by the criteria of DSM-IV borderline PD. This article reports on the development of a new self-report measure to assess self- and interpersonal dysfunction and the five trait qualifiers. It (...) is the first comprehensive measure of the ICD-11 PD model in that it is the only one to include both PD dysfunction-severity as well as trait scales and because it is based on the Clinical Description and Diagnostic Guidelines, which are more detailed than the “statistical” model description that is currently on the ICD-11 website. The authors wrote 992 items and then reduced the pool to 300 items by eliminating redundancy and selecting the consensus best few items for each subconstruct. Data were collected using an online sample of 383 Prolific workers. Using exploratory factor analysis, seven domain scales were developed, each of which contained two to four scales assessing components of the domain. These preliminary scales’ psychometrics were excellent, as were the domains’ and their components’ convergent and discriminant validity, with a few generally minor exceptions. Structural analyses at the component level revealed a three-factor structure consisting of two moderately correlated Internalizing factors, one centered on Self Dysfunction with two NA components and a DSN component and the other on Interpersonal Dysfunction with DET and ANK components; as well as an Externalizing factor with DSL and a DSN component that was uncorrelated with the other two factors. Two aspects of the results in particular are striking: ANK was not the opposite end of a DSN dimension, but rather contributed to an Internalizing Interpersonal Dysfunction dimension and DSN had both an Internalizing and an Externalizing component. Implications of the findings and study limitations are discussed. (shrink)

Despite the effort on DSM-5 and ICD-11, few appear satisfied with these classification systems. We suggest that the core reason for dissatisfaction is expecting too much from them; they do not provide discrete categories that map to specific causes of disease, they describe clinical syndromes intended to guide treatment choices. Here we review work on anxiety and anxiety disorders to argue that while clinicians draw a pragmatic distinction between normal and abnormal emotions based on considerations such as severity and duration, (...) understanding the evolutionary origins and utility of the emotions, including the adaptive value of adverse emotions, is key for formulating comprehensive assessments of an individual patient’s symptoms and for providing a conceptual foundation for pharmacotherapy, psychotherapy, and public health. (shrink)

Human trafficking is associated with a variety of adverse health and mental health consequences, which should be accurately addressed and documented in electronic health records.

This article discusses the response of our ethics consultation service to an exceptional request by a patient to have his implantable cardioverter defibrillator removed. Despite assurances that the device had saved his life on at least two occasions, and cautions that without it he would almost certainly suffer a potentially lethal cardiac event within 2 years, the patient would not be swayed. Although the patient was judged to be competent, our protracted consultation process lasted more than 8 months as we (...) consulted, argued with, and otherwise cajoled him to change his mind, all to no avail. Justifying our at times aggressive paternalistic intervention helped us to reflect on the nature of autonomy and the dynamics of the legal, moral, and personal relationships in the clinical decision-making process. (shrink)

This article contributes to Science and Technology Studies on vulnerability by putting cyborgs at center stage. What vulnerabilities emerge when technologies move under the skin? I argue that cyborgs face new forms of vulnerability because they have to live with a continuous, inextricable intertwinement of technologies and their bodies. Inspired by recent feminist studies on the lived intimate relationships between bodies and technologies, I suggest that sensory experiences, material practices, and cartographies of power are important heuristic tools to understand the (...) vulnerabilities of hybrid bodies. Based on an analysis of how patients in the Netherlands and the United States cope with appropriate and inappropriate implantable cardioverter defibrillator shocks, I describe how defibrillators introduce two new kinds of vulnerabilities: vulnerability as an internal rather than an external threat, and as harm you may try to anticipate but can never escape. Despite these vulnerabilities, some heart patients don’t position themselves as passive victims of faulty machines. They actively engage in material practices of resilience by using magnets to stop inappropriate shocks. I conclude that anticipating and taming the improper working of technologies inside bodies constitutes a new form of invisible labor that is crucial to diminishing the existential uncertainties of cyborgs. (shrink)

BackgroundThe 11th revision of the International Classification of Diseases included two distinct trauma-related diagnoses—Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder. The initial diagnostic factor for both disorders is exposure to a traumatic event. This study aimed to explore whether exposure to different traumatic experiences distinguish risk for PTSD and CPTSD.MethodsThe study sample comprised 158 trauma-exposed participants, Mage = 33.61. The Life Events Checklist-Revised was used to evaluate trauma exposure, and the International Trauma Questionnaire was used to assess risk for (...) ICD-11 PTSD and CPTSD. Multinomial logistic regression was used to determine traumatic events as predictors of risk for PTSD and CPTSD.ResultsAnalysis revealed that sexual abuse experienced in childhood or adulthood was associated with both PTSD and CPTSD. History of other unwanted sexual experiences and childhood physical abuse predicted CPTSD compared to PTSD, whereas exposure to natural disasters predicted PTSD compared to CPTSD.ConclusionsThe results showed that experiences of certain traumatic events, such as sexual trauma, childhood physical abuse or natural disasters, might help distinguish risk for PTSD and CPTSD. Nevertheless, future studies on specific aspects of trauma exposure are necessary. (shrink)

Background: Personality pathology does not have to be a contraindication to a bariatric surgery if a proper pre-surgical assessment is done. Indicating subgroups of patients with their specific needs could help tailor interventions and improve surgical treatment outcomes.Objectives: Using the Alternative DSM-5 model for personality disorders and the ICD-11 model for PDs to detect subgroups of patients with obesity based on a specific constellation of maladaptive personality traits and the level of overall personality impairment.Methods: 272 consecutively consented patients who underwent (...) a standard pre-surgical psychological assessment. The majority were women, age range was 22–79 years. Patients’ average body mass index was 43.95 kg/m2. All participants were administered the Personality Inventory for DSM-5 from which Level of Personality Functioning Scale-Self Report and Standardized Assessment of Severity of Personality Disorder scores were gained using the “crosswalk” for common metric for self-reported severity of personality disorder. The k-means clustering method was used to define specific subgroups of patients with obesity and replicated for equality testing to the samples of non-clinical respondents and psychiatric patients.Results: The cluster analysis detected specific groups in the sample of patients with obesity, which differed quantitatively from the samples of non-clinical respondents and psychiatric patients. A vast majority of patients with obesity showed above-average values in most of the PID-5 facets compared to the United States representative general community sample. In two out of the three clusters defined, patients demonstrated moderate to severe personality psychopathology within the Detachment and Negative Affectivity domains according to PID-5, which in one of the clusters corresponded to the mild overall impairment in both, LPFS-SR and SASPD. Moreover, higher levels of psychopathology prove to be associated with higher age and use of psychiatric medication.Conclusions: The dimensional DSM-5 and ICD-11 trait models are suitable procedures for defining specific “characters” of patients in a pre-bariatric setting. As such, they help to identify subgroups of patients with obesity who are different from general population and psychiatric patients. Implications for clinical practice and further research are discussed. (shrink)

In this important new book in the IPPP series, a group of leading thinkers in psychiatry, psychology, and philosophy offer alternative perspectives that address both the scientific and clinical aspects of psychiatric validation, emphasizing throughout their philosophical and historical considerations.

Medical classification systems aim to provide a manageable taxonomy for sorting diagnoses into their proper classes. The question, this paper wants to critically examine, is how to correctly systematise diseases within classification systems that are applied in a variety of different settings. ICD and DSM , the two major classification systems in medicine and psychiatry, will be the main subjects of this paper; however, the arguments are not restricted to these classification systems but point out general methodological and epistemological challenges (...) of classifying diseases for differing purposes. Deciding what qualifies as a disease to be included into a classification system as well as choosing a specific validator for correctly systematising diseases is complicated because the broad applicability of medical classification systems simultaneously appears as aim and challenge. Drawing upon the case study of classifying Alzheimer’s disease, this paper will address three dilemmas in designing ‘good’ medical classification systems. They are due to general epistemological problems of medicine, such as the relationship between individual manifestations of diseases and the necessity of building groups in order to scientifically elucidate causes of diseases. Moreover, they involve pragmatic issues of designing usable classifications that allow for easily discriminating between classes of diseases, restricting, however, the completeness of disease representations. This paper wants to trace how the choice of certain validators is unavoidably value-laden and deeply intertwined with epistemological assumptions of how different uses relate to each other, resulting either in a prioritisation of (constrained) coherence or of (vague) pluralistic connectibility. (shrink)

The field of mental health continues to struggle with the question of how best to structure its diagnostic systems. This issue is of considerable ethical importance, but the implications for public health approaches to mental health have yet to be explored in any detail. In this article I offer a preliminary treatment, drawing out several core issues while sounding a note of caution. A central strand of the debates over diagnosis has been the contrast between categorical and dimensional models, with (...) renewed attention due to recent publication of the DSM-5, launch of the RDoC, and ongoing work on the ICD-11. This dispute involves an interesting assortment of ethical and empirical considerations, many with direct relevance for public health. It has been proposed, for example, that dimensional diagnosis may be morally preferable because it can help reduce the stigma associated with mental disorder. This is a pressing concern, as preventive strategies are expanded in mental health, often operating under dimensional assumptions that target various risk factors. But this type of proposal relies upon an empirical claim and the scientific status of dimensionality remains unresolved, including its relation to stigma. I suggest, then, that the current state of the evidence does not yet warrant clear adjudication between competing frameworks, and thus any implications for public mental health remain highly provisional. More research is needed to help resolve these issues, including ethical analysis. (shrink)

ICD-10 and DSM-5 do not provide clear diagnosing guidelines for DID, making it difficult to distinguish ‘genuine’ DID from imitated or false-positive cases. This study explores meaning which patients with false-positive or imitated DID attributed to their diagnosis. 85 people who reported elevated levels of dissociative symptoms in SDQ-20 participated in clinical assessment using the Trauma and Dissociation Symptoms Interview, followed by a psychiatric interview. The recordings of six women, whose earlier DID diagnosis was disconfirmed, were transcribed and subjected to (...) interpretative phenomenological analysis. Five main themes were identified: (1) endorsement and identification with the diagnosis. (2) The notion of dissociative parts justifies identity confusion and conflicting ego-states. (3) Gaining knowledge about DID affects the clinical presentation. (4) Fragmented personality becomes an important discussion topic with others. (5) Ruling out DID leads to disappointment or anger. To avoid misdiagnoses, clinicians should receive more systematic training in the assessment of dissociative disorders, enabling them to better understand subtle differences in the quality of symptoms and how dissociative and non-dissociative patients report them. This would lead to a better understanding of how patients with and without a dissociative disorder report core dissociative symptoms. Some guidelines for a differential diagnosis are provided. (shrink)

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at risk for life-threatening heart arrhythmias, and their use is increasingly common. However, these devices also confer risk for delivery of unexpected painful shocks during the dying process, thus reducing the quality of palliative care at the end of life. This scenario can be avoided by ICD deactivation in appropriate circumstances but patients will remain unaware of this option if not informed about it. It is not known how often end-of-life implications (...) are discussed with patients prior to ICD implantation, when focus is primarily on the short-term potential complications of the device placement procedure itself. We conducted a retrospective chart review to determine how often end-of-life implications were discussed with patients as part of the informed consent process. We evaluated consent forms and related other chart documentation for 91 patients (ranging from age 60 to 89 years) undergoing first-time ICD placement at a mid-western academic medical center from 2006-2008. Only one chart documented any discussion of end-of-life implications, in a case where the issue was raised by a patient who noted that quality of life was their main focus. Consent was provided by a health care surrogate in only four of the 91 cases. In conclusion, patients giving consent for ICD implantation may be uninformed about the device's potential future impact on end-of-life care, the dying process, and the option for device deactivation. Truly informed consent requires that both short- and long-term potential implications be reviewed with patients. (shrink)

According to the ICD-11 and DSM-5, transgender people’s experienced gender is incongruent with their natal sex or gender and the purpose of gender affirming-healthcare (GAH) interventions is to reduce this incongruence. Vincent argues that this view is conceptually incoherent—the incoherence thesis—and proposes that the ICD and DSM should be revised to understand transgender people as experiencing a merely felt incongruence between their gender and their natal sex or gender—the feelings revision. I argue that (i) Vincent in fact gives us no (...) reason to believe the incoherence thesis and that (ii) we may want to resist the combination of the incoherence thesis and the feelings revision because this combination seems to imply that all transgender people have feelings that are misplaced and are, in an importance sense, incorrect or mistaken. I then give a fit-based account of how trans people’s experienced gender can be incongruent with their natal sex or gender and how GAH can reduce this incongruence. (shrink)

This article examines the supposedly incomprehensibility of schizophrenic delusions. According to the contemporary classificatory systems (DSM-IV-TR and ICD-10), some delusions typically found in schizophrenia are considered bizarre and incomprehensible. The aim of this article is to discuss the notion of understanding that deems these delusions incomprehensible and to see if it is possible to comprehend these delusions if we apply another notion of understanding. First, I discuss the contemporary schizophrenia definitions and their inherent problems, and I argue that the notion (...) of incomprehensibility in these definitions rests heavily on Jaspers’ notions of understanding and empathy. Secondly, I discuss two Wittgensteinian attempts to comprehend bizarre delusions: (a) Campbell’s proposal to conceive delusions as framework propositions and (b) Sass’s suggestion to interpret delusions in the light of solipsism. Finally, I discuss the phenomenological conception of schizophrenia, which conceives delusion formation as resulting from alterations of the structure of experiencing and from underlying self-disorders. I argue that although a psychological understanding that seeks to grasp meaning in terms of motivations, desires, and other more straightforward psychological connections between mental states is impossible in schizophrenia, we can in fact have a philosophical understanding of the schizophrenic world and of the emergence of delusions typically found in schizophrenia. (shrink)

Premenstrual dysphoric disorder was recently moved to a full category in the DSM-5 . It also appears set for inclusion as a separate disorder in the ICD-11 . This paper argues that PMDD should not be listed in the DSM or the ICD at all, adding to the call to recognise PMDD as a socially constructed disorder. I first present the argument that PMDD pathologises understandable anger/distress and that to do so is potentially dangerous. I then present evidence that PMDD (...) is a culture-bound phenomenon, not a universal one. I also argue that even if medication produces a desired effect, there are biological correlates with premenstrual anger/distress, such anger/distress seems to occur monthly, and women are more likely than men to be diagnosed with affective disorders, none of these factors substantiates that premenstrual anger/distress is caused by a mental disorder. I argue that to assume they do is to ignore the now accepted role that one’s environment and psychology play in illness development, as well as arguments concerning the social construction of mental illness. In doing so, I do not claim that there are no women who experience premenstrual distress or that their distress is not a lived experience. My point is that such distress can be recognised and considered significant without being pathologised and that it is unethical to describe premenstrual anger/distress as a mental disorder. Further, if the credibility of women’s suffering is subject to doubt without a clinical diagnosis, then the way to address this problem is to change societal attitudes towards women’s suffering, not to label women as mentally ill. The paper concludes with some broader implications for women and society of the change in status of PMDD in the DSM-5 as well as a sketch of critical policy suggestions to address these implications. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.3 (2002) 219-227 [Access article in PDF] The Practical Kinds Model as a Pragmatist Theory of Classification Peter Zachar Pragmatist theories of scientific classification are intended to be pluralistic models that recognize different ways of cutting up the world as valuable, but do not require us to adopt whatever-goes relativism or metaphysical antirealism. How ironic that my application of pragmatism to psychopathology has been charged (...) with not being sufficiently pluralistic because it tries to fit all psychiatric disorders into the Procrustean bed of practical kinds. The Practical Kinds Model in General As a point of clarification, the practical kinds model is not a description of a type of category combined with an argument that all psychiatric disorders should be seen as belonging to that type. If it were that kind of model, I would fully agree with Haslam that practical kinds, fuzzy kinds, and discrete kinds are all potential types of psychiatric disorders. Like Nick Haslam, I believe that there are many different things in the DSM-IV and the ICD-10, and they cannot neatly be classified as the same type of thing.Rather than identifying a type of category, the practical kinds model is a general theory of scientific classification. It is a nonessentialistic theory. Essentialism is the view that things have real essences. In the Aristotelian version of essentialism, an essence is an internal structure, and it is the internal structure that makes anything be the kind of thing it really is. In this classical category model, category members either have the essence or they do not, and everything that has the appropriate essence is a member of that category. The world is supposed to therefore have a well-defined structure, and the job of the scientist is to discover that structure. Ian Hacking (1999) has termed this view of categorization inherent structurism.The practical kinds model does not deny that things have internal structures; it only denies that internal structure by itself determines category membership. Internal structure is an important consideration in identifying categories, but external criteria can always play a role. External or relational criteria play more important roles in some cases than they do in others, but they cannot be eliminated once and for all. Essentialistic theories, which favor an almost exclusive focus on inherent structures, have the advantage of being more parsimonious, but they do so by ignoring real complexity.The best way to illustrate this point is to examine a category whose identification is heavily weighted in terms of internal criteria, or an inherent structure, such as a chemical element. [End Page 219] For example, hydrogen is defined as the element that has an atomic number of 1. This means that it has one proton in its nucleus and normally one electron orbiting its nucleus. The atomic number reflects an internal property, and anything that has an atomic number of 1 is hydrogen. The same is true for the other elements. Anything that has an atomic number of 79 is gold; anything that has an atomic number of 19 is potassium, and so on. Also part of the essentialistic view is the notion that all the important properties of an element are systematically (or lawfully) related to its internal structure.It would be foolish to deny the practical utility of the atomic theory of chemistry. But even in this strongest of cases, external criteria can potentially play a role in how we decide to carve up the world and what we identify as the relevant categories. The point can be clearly illustrated with a Gedanken experiment based on the ideas of Donnellan (1983). Assume that we were to make contact with extraterrestrial life, and the result of that contact was our initiation into a larger galactic community like those portrayed on Star Trek or Babylon 5. Fortunately for us, it turns out that all planets in the community use a gold-based currency, just like we do on Earth. What we call gold, however, is too common to be the galactic basis of a currency, but a particular isotope... (shrink)

In this article, I argue that there is a moral difference between deactivating an implantable cardioverter defibrillator and turning off a cardiac pacemaker. It is, at least in most cases, morally permissible to deactivate an ICD. It is not, at least in most cases, morally permissible to turn off a pacemaker in a fully or significantly pacemaker-dependent patient. After describing the relevant medical technologies—pacemakers and ICDs—I continue with contrasting perspectives on the issue of deactivation from practitioners involved with these devices: (...) physicians, nurses, and allied professionals. Next, I offer a few possible analyses of the situation, relying on recent work in medical ethics. Considerations of intention, responsibility, and replacement support my distinguishing between ICDs and CPs. I conclude by recommending a change in policy of one of the leading cardiac societies. (shrink)

BackgroundInstitutional review boards (IRBs) have been criticised for delays in approvals for research proposals due to inadequate or inexperienced IRB staff. Artificial intelligence (AI), particularly large language models (LLMs), has significant potential to assist IRB members in a prompt and efficient reviewing process.MethodsFour LLMs were evaluated on whether they could identify potential ethical issues in seven validated case studies. The LLMs were prompted with queries related to the proposed eligibility criteria of the study participants, vulnerability issues, information to be disclosed (...) in the informed consent document (ICD), risk–benefit assessment and justification of the use of a placebo. Another query was issued to the LLMs to generate ICDs for these case scenarios.ResultsAll four LLMs were able to provide answers to the queries related to all seven cases. In general, the responses were homogeneous with respect to most elements. LLMs performed suboptimally in identifying the suitability of the placebo arm, risk mitigation strategies and potential risks to study participants in certain case studies with a single prompt. However, multiple prompts led to better outputs in all of these domains. Each of the LLMs included all of the fundamental elements of the ICD for all case scenarios. Use of jargon, understatement of benefits and failure to state potential risks were the key observations in the AI-generated ICD.ConclusionIt is likely that LLMs can enhance the identification of potential ethical issues in clinical research, and they can be used as an adjunct tool to prescreen research proposals and enhance the efficiency of an IRB. (shrink)

The notion of harm has been a recurring and a significant notion in the characterization of mental disorder. It is present in eminent diagnostic manuals such as DSM and ICD, as well as in the discussion on mental disorders in philosophy of psychiatry. Recent demotion of harm in the definition of mental disorders in DSM-5 shows a general trend towards reducing the significance of harm when thinking about the nature of mental disorders. In this paper, we defend the relevance of (...) the notion of harm in the characterization of mental disorder against some of these attacks. We approach this issue by using the method of conceptual explication pioneered by Rudolf Carnap. Within this framework, we argue that keeping the notion of harm not only helps to discriminate what is pathological from the nonpathological but also prevents potential misuses of psychiatric authority. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical Bioethics at NIH:History and A New VisionJohn C. Fletcher (bio)On July 3, 1995, Dr. John I. Gallin, Director of the Magnuson Clinical Center of the National Institutes of Health (NIH), convened a one-day "Conference on the Future of Clinical Bioethics at the National Institutes of Health Intramural Program." Conferees included NIH officials and a panel of consultants from bioethics programs around the nation.1 The subject was the future (...) of NIH's intramural bioethics program and specifically a vision of a new multi-component program, presented by Dr. Gallin, the first speaker. Dr. Harold Varmus, Director of NIH, was there to assure his support for Dr. Gallin's vision. This author, honored to be second speaker, was invited to sketch a brief history of bioethics at NIH. The present article reviews some of this history and then reports on Dr. Gallin's proposal, points of consensus among speakers and conferees, and the search for a Chief of the Clinical Bioethics Program.History of Bioethics at NIHIt is often said that NIH is a well-kept secret as the nation's leading biomedical research facility. Also, few people know that NIH has a long history in bioethics. Some key events in that history are shown in Figure 1, beginning with two that occurred prior to the birth of bioethics. NIH made an early policy response to protect human subjects of research and to find acceptable limits for scientific freedom. The Clinical Center (CC), a 550-bed research hospital, opened in 1953. A subcommittee of the Medical Board, the Clinical Research Committee (CRC), was formed for prior group review of all studies with normal volunteers. The traditional practice was for researchers themselves to decide when studies would begin, which subjects to recruit, and whether informed consent would be sought. The CRC intervention bit into this tradition. In addition, patient studies that posed significant risks or departed widely from medical practice were reviewed by referral from the Clinical Directors of the various Institutes. Was this CRC an early institutional review [End Page 355] board (IRB)? As a guest researcher, I was permitted to observe the CRCs meetings between 1966 and 1969. It functioned much like an IRB but had no community or non-scientist members. Other IRB-like review groups undoubtedly existed prior to the CRC. Robert Levine (personal communication, September 7, 1995) recalls that Beth Israel Hospital in Boston had one in 1938. Historical research is clearly needed on the earliest forms of research review.Table 1. Bioethics at NIHEventYearClinical Research Committee1953Surgeon-General's PPO #1291966NIGMS funds Hastings Genetics Group1973OPRR's Mission1974NLM's grant to KennedyInstitute for Bibliography of Bioethics1974Recombinant DNA Advisory Committee1974STEP Series Bioethics Speakers1975Pre-IRBs at the CC1975-76Assistant for Bioethics to Director, CC1977RAC-Human Gene Therapy Subcommittee1983Lipsett Proposal (ICD)1983Liaison Group, CC1983Bioethics Program, CC1985Durable Power of Attorney for Researchwith Incapacitated Subjects1985-86NLM funds National Reference Centerfor Bioethics Literature1985National Institute for Nursing Research1986Bioethics Post-Doctoral Fellows Program1989ELSI Program1989Bioethicists on CC-IRBs1989CC-Ethics Committee1990Office of Human Subjects Research1992 [End Page 356]Between 1963 and 1967, the media exposed instances of ethically troubling research, and Beecher (1966) and Pappworth (1967) published sharp criticisms of the weak state of research ethics. In 1966, Surgeon-General William Stewart and NIH Director James Shannon issued a policy requiring local group review of all research involving human subjects before making an application for NIH peer review (Surgeon General 1966). The policy was the first in any nation to mandate ethics committees for clinical research. However, it did not apply to the NIH intramural program until Congress passed the National Research Act in 1974 (Public Law 93-348; 202, 88 Stat. 342, 1974). This lag permitted NIH intramural investigators the luxury of feeling above the norms imposed on ordinary mortals and guaranteed more resistance to the inevitable change to come. Resistance to change marked the intramural program from the mid-1960s to the mid-1970s... (shrink)

The catch 22 situation in psychiatry is that for precise diagnostic categories/criteria, we need precise investigative tests, and for precise investigative tests, we need precise diagnostic criteria/categories; and precision in both diagnostics and investigative tests is nonexistent at present. The effort to establish clarity often results in a fresh maze of evidence. In finding the way forward, it is tempting to abandon the scientific method, but that is not possible, since we deal with real human psychopathology, not just concepts to (...) speculate over. Search for clear-cut definitions/diagnostic criteria in psychiatry must be relentless. There is a greater need to be ruthless and blunt in this, rather than being accommodative of diverse opinions. Investigative tests - psychological, serum, CSF, or neuroimaging - are only corroborative at present; they need to become definitive. Medicalisation appears most prominent in psychiatry; so, diagnostic proliferation and fuzziness appear inevitable. And yet, the established diagnostic entities need to forward greater and conclusive precision. Also, the need for clarity and precision must outweigh pandering to and mollifying diverse interests, moreso in the upcoming revision of diagnostic manuals. This is specially because the DSM-5, being an Association manual, may need to accommodate powerful member lobbies; and ICD-11 may similarly need to cater to diverse country lobbies. Finding precise biological correlates of psychiatric phenomena, whether through neuroimaging, molecular neurobiology and/or neurogenomics, is the right way forward. It is in the 1.5-kg structure in the cranium that all secrets of psychiatric conditions lie. Social forces, behavioural modification, psychosocial restructuring, study of intrapsychic processes, and philosophical insights are not to be discounted, but they are supplementary to the primary goal - studying and deciphering those brain processes that result in psychiatric malfunction. Experimental breakthroughs, both in psychiatric aetiology and therapeutics, will come mainly from biology and its adjunct, psychopharmacology; while supplementary and complementary breakthroughs will come from the psychosocial, cognitive and behavioural approaches; the support base will come from phenomenology, epidemiology, nosology and diagnostics; while insights and leads can hopefully come from many fields, especially the psychosocial, the behavioural, the cognitive and the philosophical. Major energies must now be marshalled towards finding biomarkers and deciphering the precise phenotype-genotype-endophenotype axis of psychiatric disorders. Energies also need to be focussed on unravelling those critical processes in the brain that tip the scale towards psychiatric disorders. At how those critical processes are set into motion by forces de novo, in utero, in the genes and their expression, by the environment's psychopathological social forces - stress, peer pressure, poverty, deprivation, alienation, malnutrition, discrimination of various types (caste, gender, race, etc.), mass conflicts (war, terror attacks, etc.), disasters (natural and man-made), religious/ideological fascism - or social institutions like marriage, family, work place, political governance, etc. Ultimately, we must decipher how the brain goes into malfunction when such varied forces impinge on it, which precise cortical areas and neuronal cellular and molecular processes are involved in such malfunction and its manifestation, as also which of these are involved when malfunction ceases and health is restored, and the psychosocial processes and institutions which aid such health restoration, as also those which promote well-being and help in primary prevention. Emphasis on the brain and its intimate neurological and molecular mechanisms will not impinge on, or nullify, importance of the 'mind,' wherein subtle and gross brain functions in the form of behaviour, thought and emotions in all their ramifications will continue to be the focus of psychological, cognitive, sociological, psychopharmacological, behavioural and philosophical research. Progress in brain research must move in tandem with progress in 'mind' research. (shrink)

BackgroundThe emergence of artificial intelligence (AI) in medicine has prompted the development of numerous ethical guidelines, while the involvement of patients in the creation of these documents lags behind. As part of the European PROFID project we explore patient perspectives on the ethical implications of AI in care for patients at increased risk of sudden cardiac death (SCD).AimExplore perspectives of patients on the ethical use of AI, particularly in clinical decision-making regarding the implantation of an implantable cardioverter-defibrillator (ICD).MethodsSemi-structured, future scenario-based (...) interviews were conducted among patients who had either an ICD and/or a heart condition with increased risk of SCD in Germany (n = 9) and the Netherlands (n = 15). We used the principles of the European Commission’s Ethics Guidelines for Trustworthy AI to structure the interviews.ResultsSix themes arose from the interviews: the ability of AI to rectify human doctors’ limitations; the objectivity of data; whether AI can serve as second opinion; AI explainability and patient trust; the importance of the ‘human touch’; and the personalization of care. Overall, our results reveal a strong desire among patients for more personalized and patient-centered care in the context of ICD implantation. Participants in our study express significant concerns about the further loss of the ‘human touch’ in healthcare when AI is introduced in clinical settings. They believe that this aspect of care is currently inadequately recognized in clinical practice. Participants attribute to doctors the responsibility of evaluating AI recommendations for clinical relevance and aligning them with patients’ individual contexts and values, in consultation with the patient.ConclusionThe ‘human touch’ patients exclusively ascribe to human medical practitioners extends beyond sympathy and kindness, and has clinical relevance in medical decision-making. Because this cannot be replaced by AI, we suggest that normative research into the ‘right to a human doctor’ is needed. Furthermore, policies on patient-centered AI integration in clinical practice should encompass the ethics of everyday practice rather than only principle-based ethics. We suggest that an empirical ethics approach grounded in ethnographic research is exceptionally well-suited to pave the way forward. (shrink)

Riassunto: In questo contributo analizzeremo il criterio del danno, presente nella definizione generale di disturbo mentale del DSM. La questione ha rilevanza sia da un punto di vista filosofico, perché il danno è una componente normativa e valoriale, non oggettiva, sia da un punto di vista clinico, perché chi ha difeso il criterio del danno ha spesso sostenuto che in sua assenza avremmo troppi falsi positivi. Infine, ha importanza dal punto di vista socio-sanitario in relazione al rapporto tra la psichiatria (...) e la medicina non psichiatrica, nello specifico tra il DSM e l’ICD. Sosterremo che ci sono buone ragioni per non mantenere il danno come criterio necessario nella definizione generale del disturbo mentale. Dopo una breve introduzione, forniremo una panoramica storica sul ruolo del criterio del danno nelle varie edizioni del DSM. Successivamente si illustrerà la principale obiezione contro l’inclusione del criterio del danno nella definizione generale di disturbo mentale, ossia il problema dei falsi negativi, per poi presentare e discutere ulteriori ragioni – medico-pratiche e concettuali – che depongono a sfavore dell’attribuzione di un forte peso al criterio del danno. In sede conclusiva ribadiamo come la decisione presa dalla task force del DSM-5 di escludere il criterio del danno dalla definizione generale di disturbo mentale debba essere sostenuta. Parole chiave: Danno; Disabilità; Disagio; Disturbo mentale; DSM “Harm” as Criterion for the Definition of Mental Disease in DSM. Some Epistemological Reflections: In this paper, we analyse the harm requirement in the general definition of mental disorder in the Diagnostic and Statistical Manual for Mental Disorders. This issue has both philosophical and clinical relevance: on the one hand the harm requirement is a normative, value-laden, non-objective component in the definition of mental disorder; on the other hand, the harm requirement has often been defended on the grounds that it prevents an increase in false positives. The issue is also important in assessing the relationship between psychiatry and somatic medicine, more precisely, between the DSM and the International Classification of Diseases. We argue that there are good reasons not to maintain the harm requirement in the general definition of mental disorder. After a brief introduction, we overview the history of the harm requirement across the various editions of the DSM. Then, we examine the main objection to the inclusion of the harm requirement in the general definition of mental disorder, that is, the problem of false negatives, and also present several other points – both practical and conceptual – that help demonstrate why the harm requirement is inadequate as a definiens of mental disorder. To conclude, we stress that the decision of the DSM-5 task force not to regard the harm requirement as a necessary component of mental disorder should be endorsed. Keywords: Harm; Disability, Distress; Mental Disorder; DSM. (shrink)

The community representative plays a very important role in an institutional review board but there is sparse data about their understanding of their role in an IRB. This study was conducted to assess perceptions of community members serving on IRBs of one region in India. A validated questionnaire was administered to community members of IRBs in a prospective cross-sectional study. The questions related to demography, perceptions of their role in the IRB, experiences while serving on the IRBs, difficulties faced by (...) them, and suggestions to improve their contributions. Of the 56 IRBs contacted, all 15 of the public institutions shared details of their community members, while only 26 of the 41 IRBs of private institutions responded. When questioned about why they joined the IRB, one third of the respondents said either that there was “no specific reason” for joining or that they accepted the invitation to serve on the insistence of other members of the IRBs or the head of their institution. All except one felt that community members were needed for optimal functioning. Six participants said that they did not review informed consent documents, and 10 were unaware that their presence was vital for quorum to be met. Twenty-eight said they participated actively in meetings and did not feel intimidated by the presence of clinicians. Twelve reported difficulties in understanding medical terminologies in ICDs. Although the majority of participants were aware about their role in an IRB, some did not review important documents such as ICDs. Restricted participation by private hospital IRBs was a striking observation in our study. There is a need to define eligibility criteria and develop targeted training modules for community members to ensure their effective contribution to effective oversight of clinical research. (shrink)

Current psychiatric classification adopts a disorder-focused diagnostic approach, as exemplified within ICD-11 and DSM-V. Although this approach has improved reliability of categorization, its validity and utility has been questioned (Harvey, Watkins, Mansell, & Shafran, 2004; Insel et al., 2009; Sanislow et al., 2010). Limitations include high comorbidity between supposedly distinct disorders; heterogeneity within diagnoses; limited treatment efficacy; and similarities across disorders in aetiology, latent symptom structure, and underlying biology. There is also evidence of transdiagnostic cognitive-behavioural processes (Harvey et al., 2004). (...) An alternative approach is therefore to focus on fundamental underlying mechanisms of psychopathology rather than observed symptom clusters. This article considers the possible benefits, hurdles, and steps towards implementation of this transdiagnostic mechanistic approach, using the example of repetitive negative thought. (shrink)

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. Addiction is currently classified as a medical disorder in DSM-5 and ICD-10. It is further labeled a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Lewis argues that the changes result instead from normal neuroplasticity (...) and learning in response to the intense rewards provided by addictive substances, thus that addiction is not a brain disease and by implication not a medical disorder at all. I argue that even if one accepts Lewis’s reinterpretation of the brain evidence, his conclusions do not follow. Relying on my harmful-dysfunction analysis of medical disorder, I defend the view that substance addiction is in fact a medical disorder and a brain disorder. In Part 1, I identify five arguments Lewis puts forward against the brain-disease view and evaluate them as arguments that addiction is not a disorder: Addiction is not a chronic, relapsing condition; There is no clear boundary between addiction and other strong desires; Negative consequences are not unique to disorders; The brain disease model does not account for behavioral addictions; and, Addiction is like love. I argue that Lewis’s arguments are invalid because they fail to take account of the context of addiction and its relation to biological design. (shrink)

Physicians are frequently consulted by people with physical symptoms that, after having ruled out an "organic" pathology, we suspect they are related to the most frequent psychological conditions in the usual consultation: the various forms of reaction to severe stress (Acute Stress Reaction and Adjustment Disorder, from ICD 11), "functional" pathologies, burn out syndrome, and anxiety disorders, especially Generalized Anxiety Disorder, with or without associated depression. They are usually given a brief explanation about these problems and how they affect their (...) health, given a brochure, or suggested a website with information. And then they are encouraged to visit a mental health practitioner. But there are some challenges to this seemingly simple scenario:Not all patients are ready or willing to hear that their health problem might be related to their life or emotions. Many are strongly influenced by mind-body dualism. Others have an intuition that such a relationship exists but bringing that to consciousness is not an easy process, because it can awaken emotions that are difficult to handle. This is quite frequent in people suffering chronic anxiety (DSM-5 Generalized Anxiety Disorder) who prefer to consult medical providers rather than psychologists (Wittchen H. U. et al. 2002), because they do not consider their constant and excessive worry to be related to their discomfort. In their worrying they are hoping for a straightforward solution. Often these patients ask th... (shrink)

Both the doctor and the patient have rights to terminate an implantable cardioverter-defibrillator device for reasons of futility or autonomyImplantable devices have a long history in medicine with artificial hips being implanted since 1925, pacemakers since 1957, Starr-Edwards heart valve since 1961, artificial hearts since 1982 and ventricular assist devices since 1991. The ethics of deactivation or removal of these devices were not an issue until the use of implantable cardioverter defibrillator device, as the ICD can produce considerable distress from (...) defibrillation shocks in end-of-life patients. However, development of a clear ethics for ICD is critical as the massive technological advances in implantable heart failure devices will soon produce an epidemic of patients with implanted devices and end-of-life diseases. Should one turn off a biventricular pacer at the request of a patient who is having recurrent disabling heart failure? Should one turn off an AbioCor artificial heart in a patient who developed a severe disabling stroke from the device? Who has the right to turn off the device? Does the doctor have the right to turn it off, against the patient’s wishes, for reasons of futility? Does the patient have the right to turn it off, against the doctor’s wishes, and if so, for what reasons?In this issue of the Journal of Medical Ethics, England et al1 argue that the classification of an implantable device determines the rights of device deactivation. At the one end of the spectrum, there are semi-implanted devices like an intra-aortic balloon pump or a ventilator, where the doctor has the right to turn off the supportive therapy by commission on grounds …. (shrink)

The youngest population in society is recognized as that at the healthiest stage of life but is burdened by the occurrence of premature death that should be avoidable. There is a need to use adequate statistical methods in assessing the health status of the population of developmental age. The aim of the study was to analyze trends of mortality in children and adolescents by age and gender in the Podlaskie Voivodeship in the years 2003-2012 by joinpoint regression and to identify (...) the causes of mortality. The mortality rate was analysed according to gender and the age groups: 0, 1-4, 5-9, 10-14 and 15-19 years in the Podlaskie Voivodeship. The data were obtained from the Central Statistical Office for the period 2003-2012. Differences in mortality levels between age and gender subgroups were obtained by the Wilcoxon signed-rank test. Join- point regression was used to analyze the trends in mortality. The nomenclature of ICD-10 was used to assess the causes of mortality of children and adolescents. In the Podlaskie Voivodeship in the years 2003-2012 in the 0-19-year-old age group, the highest proportion of deaths (42.4%) occurred during the first year of life. There were differences in mortality rates between boys (8.0/104) and girls (3.1/104) in the 15-19-year-old age group (p < 0.01), and also between the 1-14-year-old and 15-19-year-old age groups (p < 0.01), both among boys (2.1/104 vs. 8.0/104) and girls (1.5/104 vs. 3.1/104). Monotonous trends were shown regarding total mortality rates in infants. There was a drop in the mortality rate of infant girls (AAPC = 5.3%, p < 0.05) and boys (AAPC = 4.7%, p < 0.05). Changes in the direction of the total mortality rate trend were visible in the population of boys aged 1-14 years, in which, between 2003 and 2010, a significant reduction in mortality (AAPC = 9.5%) was observed, while in the years 2010-2012 the trend was not significant. No statistical evidence was found that mortality changed among girls in the 1-14-year-old and 15-19-year-old age groups. Deaths in infancy were due to perinatal conditions and congenital mal- formations. The main causes of mortality in the 1-19-year-old age group were external causes, mainly traffic accidents and intentional self-harm. Joinpoint regression indicated a uniform decrease of mortality in the years 2003-2012 except for boys from 1-14 years old, for whom the decreasing trend was for the years 2003-2010 with subsequent stabilization. The main problems are still infant deaths due to perinatal conditions, traffic accidents and intentional self-harm in boys in the 15-19-year-old age group. (shrink)

Social anxiety disorders (SAD) are among the most prevalent mental disorders (lifetime prevalence: 7–12%), with high impact on the life of an affected social system and its individual social system members. We developed a manualized disorder-specific integrative systemic and family therapy (ISFT) for SAD, and evaluated its feasibility in a pilot randomized controlled trial (RCT). The ISFT is inspired by Helm Stierlin’s concept of related individuation developed during the early 1980s, which has since continued to be refined. It integrates solution-focused (...) language, social network diagnostics, and genogram work, as well as resource- and problem orientation for both case conceptualization and therapy planning. Post-Milan symptom prescription to fluidize the presented symptoms is one of the core interventions in the ISFT. Theoretically, the IFST is grounded in radical constructivism and “Cybern-Ethics,” multi-directional partiality, and a both/and attitude toward a disorder-specific vs. non-disorder-specific therapy approach. SAD is understood from the viewpoint of social systems theory, especially in adaptation to a socio-psycho-biological explanatory model of social anxiety. In a prospective multicenter, assessor-blind pilot RCT, we included 38 clients with SAD (ICD F40.1; Liebowitz Social Anxiety Scale, LSAS-SR > 30): 18 patients participated in the ISFT, and 20 patients in Cognitive Behavioral Therapy (CBT; age:M = 36 years,SD = 14). Within-group, simple-effect intention-to-treat analyses showed significant reduction in social anxiety (LSAS-SR; ISFT:d = 1.67; CBT:d = 1.04), while intention-to-treat mixed-design ANOVA demonstrated the advantage of ISFT (d = 0.81). Per-protocol analyses supported these results. The remission rate based on blind diagnosticians’ ratings was good to satisfactory (Structured Clinical Interview, SCID; 78% in ST, 45% in CBT,p = 0.083); this has yet to be verified in a subsequent confirmatory RCT. The article will present the ISFT rationale and manual, including a special focus on multi-person settings, and the central findings from our pilot RCT. (shrink)

This article begins with arguments evident at the time of writing about the 5th revision of the Diagnostic and Statistical Manual of the American Psychiatric Association. The historical lineages of those arguments are international and not limited to the USA (the current focus in the DSM-5 controversy). The concern with psychiatric diagnosis both internationally and in the USA came to the fore at the end of the Second World War with the construction of the American Psychiatric Association’s Diagnostic and Statistical (...) Manual ( DSM-I) and the World Health Organization’s classification of ‘Diseases, Injuries and Causes of Death’ (ICD-6). However, the linkage between categories of morbidity, assumptions about natural biological categories and treatment specificity with ‘magic bullets’ emerged in the middle of the 19th century in physical medicine. This article explores the legitimacy of current psychiatric diagnoses in the light of that international, not national, history of medical knowledge. In conclusion it explores judgements about current cultural imperialism (at times made about US psychiatry) and an older picture of Eurocentrism, which is now being refracted in more recent globalizing knowledge-claims about mental disorder. (shrink)

The two main psychiatric taxonomies set out codifications of psychiatric diagnoses via lists of symptoms with the aim of maximizing the reliability of diagnostic judgements. This approach has been criticized, however, for failing to capture the precise connection between diagnostic judgements and symptoms as detected by skilled clinicians. Assuming that this criticism is correct, this chapter offers two related accounts of why this might be so. First, skilled diagnostic judgement may be an exercise of tacit knowledge: a practical skill the (...) exercise of which requires the presence of the patient. Second, the conception of criteria implicit in the DSM and ICD is based on a mistaken view of how what people say and do connects to their mental states. On an alternative account, in an overall gestalt diagnostic judgement the various criteria are abstractions from a whole that directly expresses the underlying psychopathological state of patients or clients. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 57-62 [Access article in PDF] Listening to People Or Listening to Prozac?Another Consideration of Causal Classifications Jennifer Hansen Keywords causal classification, descriptivism, melancholia, neurasthenia, depression, cultural relativism. The shape and detail of depression have gone through a thousand cartwheels, and the treatment of depression has alternated between the ridiculous and the sublime, but the excessive sleeping, inadequate eating, suicidiality, withdrawal from social interaction, (...) and relentless despair are all as old as the hill tribes, if not as old as the hills. In the years since man achieved the capacity for self-reference, shame has come and gone; treatments for bodily complaints have alternated and crossed with treatments for spiritual ones; pleas to external gods have echoed pleas to internal demons. To understand the history of depression is to understand the invention of human being as we now know and are him. Our Prozac-popping, cognitively focused, semi-alienated postmodernity is only a stage in the ongoing understanding and control of mood and character. (Solomon 2001, 286) ALTHOUGH ANDREW SOLOMON clearly believes that "the shape and detail of depression have gone through a thousand cartwheels," Jennifer Radden gives us pause before assuming that depression is just another name for Dame Melancholy. Solomon's claim depends on a deeper metaphysical claim about the nature of depression and its causes. The current method of psychiatric nosology, descriptivism, does not necessarily support equating melancholia and depression. Furthermore, it appears that adopting descriptivism as the sole method of classifying mental disorders commits us to cultural relativist psychiatry. Below I reconsider whether we want to rule out causal classifications and suggest that embracing both descriptivism and causal classifications offer us greater possibilities in understanding human illness and culture.Although the occasion for Jennifer Radden's essay is to investigate whether or not melancholia and depression refer to the same thing, her essay detours into a consideration of extra-descriptivist models of psychiatric illness versus the descriptivism of current psychiatric nosology. This detour turns out to be warranted; her purely academic question yields to a timelier question concerning the proper methodology for classifying mental disorders. Whereas debates about psychiatric nosology are perennial, the recent success of the new generation of antidepressants [End Page 57] is reviving biological psychiatry and its search for the neurochemical origins of depression. Hence, embedded in Radden's question concerning whether or not melancholia is the same thing as clinical depression, is another important question concerning the causes of mental illness, particularly depression.Currently, with its descriptivist approach, the Diagnostic and Statistical Manual of Mental Disorders (DSM) does not classify mental illness, such as clinical depression, based on underlying causes. The cluster of symptoms and behavioral signs that lead a clinician to diagnose one as depressed that are contained in either the DSM or the International Classification of Diseases (ICD) may be too fuzzy or elusive to give any clear distinction between major depression, mild depression, and the blues. For example, one group of epidemiologists points out that [t]he DSM-III, DSM-III-R, and DSM-IV acknowledge that depression, like many mental disorders, has no currently obvious natural classes... If natural classes of depression exist, then their nosology awaits the discovery of distinct and reliable genetic, biological, clinical, or other predictors of risk, severity, or clinical course. Clinicians have a tradition of separating depressions into subtypes; however, this subtyping has not yet led to clear-cut delineations of syndromes in populations. (Kaelber 1995, 4) The evidence is still insufficient to establish the biological or psychological origins of depression. Although many theories exist that explain why people become depressed, scientifically we are not yet in a position to determine which is the right theory. From a pragmatic perspective, however, whether or not we know what causes depression, we can nonetheless attempt to alleviate suffering from depression. And it is with this goal in mind that the DSM-IV and ICD-10 classify mental disorders.Now, given that our current methodology for psychiatric nosology does not establish causes, it is also insufficient for determining what... (shrink)

„Errors are the greatest obstacles to the progress of science; to correct such errors is of more practical value than to achieve new knowledge,“ asserted Eugen Bleuler. Basic error of several prevailing classification schemes of pathological conditions, as for example ICD-10, lies in confusing and mixing symptoms with diseases, what makes them unscientific. Considering the need to bring order into the chaos and light into terminological obscureness, I introduce the Causal classification of diseases originating from the notion of bodily wholeness (...) and causality of its loss. (shrink)

Gender Identity Disorder is classified as a mental illness and included in the DSM-IV and ICD-10. It will also be included in the DSM-V. The psychiatric diagnosis, in spite of some apparent advantages, has significant psychological and social adverse implications. This paper discusses some of the main epistemological reasons to consider gender variance as a mental disorder. It will also evaluate whether reasons of other kinds may justify the inclusion of gender variance amongst mental illnesses.

In this chapter, I provide an overview of phenomenological approaches to psychiatric classification. My aim is to encourage and facilitate philosophical debate over the best ways to classify psychiatric disorders. First, I articulate phenomenological critiques of the dominant approach to classification and diagnosis—i.e., the operational approach employed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-10). Second, I describe the type or typification approach to psychiatric classification, which I distinguish into three different (...) versions: ideal types, essential types, and prototypes. I argue that despite their occasional conflation in the contemporary literature, there are important distinctions among these approaches. Third, I outline a new phenomenological-dimensional approach. I show how this approach, which starts from basic dimensions of human existence, allows us to investigate the full range of psychopathological conditions without accepting the validity of current diagnostic categories. (shrink)

There is growing evidence that dopamine replacement therapy (DRT) used to treat Parkinson’s Disease can cause compulsive behaviours and impulse control disorders (ICDs), such as pathological gambling, compulsive buying and hypersexuality. Like more familiar drug-based forms of addiction, these iatrogenic disorders can cause significant harm and distress for sufferers and their families. In some cases, people treated with DRT have lost their homes and businesses, or have been prosecuted for criminal sexual behaviours. In this article we first examine the evidence (...) that these disorders are caused by DRT. If it is accepted that DRT cause compulsive or addictive behaviours in a significant minority of individuals, then the following ethical and clinical questions arise: Under what circumstances is it ethical to prescribe a medication that may induce harmful compulsive behaviours? Are individuals treated with DRT morally responsible and hence culpable for harmful or criminal behaviour related to their medication? We conclude with some observations of the relevance of DRT-induced ICDs for our understanding of addiction and identify some promising directions for future research and ethical analysis. (shrink)

Transgender issues and transgender rights have become increasingly a matter of media attention and public policy debates. Reflecting changes in psychiatric perspectives, the diagnosis of “trans‐sexualism” first appeared in the International Statistical Classification of Diseases and Related Health Problems in 1975 and shortly thereafter, in 1980, in the Diagnostic and Statistical Manual of Mental Disorders. Since that time, international standards of care have been developed, and today those standards are followed by clinicians across diverse cultures. In many instances, treatment of (...) older adolescents and adults is covered by national health care systems and, in some cases, by private health insurance. Most recently, the Medicare ban on coverage for gender reassignment surgery was lifted in 2014.In contrast to the relative lack of controversy about treating adolescents and adults, there is no expert clinical consensus regarding the treatment of prepubescent children who meet diagnostic criteria for what was referred to in both DSM‐IV‐TR and ICD‐10 as gender identity disorder in children and now in DSM‐5 as gender dysphoria. One reason for the differing attitudes has to do with the pervasive nature of gender dysphoria in older adolescents and adults: it rarely desists, and so the treatment of choice is gender or sex reassignment. On the subject of treating children, however, as the World Professional Association for Transgender Health notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue into adulthood, and only 6 to 23 percent of boys and 12 to 27 percent of girls treated in gender clinics showed persistence of their gender dysphoria into adulthood. Further, most of the boys’ gender dysphoria desisted, and in adulthood, they identified as gay rather than as transgender.In an effort to clarify best treatment practices for transgender individuals, a recent American Psychiatric Association Task Force on the Treatment of Gender Identity outlined three differing approaches to treating prepubescent gender dysphoric children. (shrink)

In recent decades, the phenomenon of grief, when you lose a loved one, has been the subject of exploration and discussion among researchers. Because of this, prolonged grief is now recognized as a possible mental disorder as the latest version of the diagnosis manual; ‘International Classification of Diseases’ (ICD‐11) being published in 2018 is featuring a new diagnosis called ‘prolonged grief disorder’. The commencement of this new disorder indicates a shift in the way grief is being articulated why the notion (...) of rupture from the French philosopher Michel Foucault is applied as a philosophical approach in this paper. A Foucault‐inspired discourse analysis has been prepared and by considering the issue historically and tracing how the concept of grief has been articulated in different time periods throughout history, the aim is to map out the discursive transformation that has taken place and to gain insight into how the societal context has supported and enabled this transformation. This paper takes a historical look back from the 1800s to present and identifies when changes can be observed in the way grief is being articulated. These changes or ruptures are identified in the work of Søren Aabye Kierkegaard, Sigmund Freud and Margaret Stroebe & Henk Schut who all must be assumed to have contributed significantly to how grief is perceived in various historical time periods. The discourse analysis identifies how prominent thinkers have articulated grief in each period and how today's perception of grief, as a possible mental disorder, both relates to these prominent thinkers but also reflects dominant societal values and ideologies. (shrink)

Math difficulties manifest across various domain-specific and domain-general abilities. However, the existing cognitive profile of MD is incomplete and thus not applicable in typical settings such as schools or clinics. So far, no review has applied inclusion criteria according to DSM or ICD, summarized domain-specific abilities or examined the validity of response time scores for MD identification. Based upon stringent clinical criteria, the current meta-analysis included 34 studies which compared cognitive performances of a group with MD and a group without (...) MD. Criteria according to DSM and ICD were applied to identify MD. Effect sizes for 22 abilities were estimated and separated by their level and type of scoring. A cognitive profile of MD was identified, characterized by distinct weaknesses in: computation, number sense, and visual-spatial short-term storage [AC]. No particular strength was found. Severity of MD, group differences in reading performance and IQ did not significantly moderate the results. Further analyses revealed that effects are larger when dealing with numbers or number words than with quantities, MD is not accompanied by any weakness in abilities typically assigned to reading, and weaknesses in visual-spatial short-term storage emphasize the notion that number and space are interlinked. The need for high-quality studies investigating domain-general abilities is discussed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Anthropological Perspectives in Psychiatric NosologyJuan J. López-Ibor Jr. (bio) and María-Inés López-Ibor (bio)KeywordsDSM, etiology, Aristotelian causes, social dramasPsychiatry and clinical psychology, as we learn in this paper, are disciplines in need of an ontological perspective. Very few branches of contemporary learning share this characteristic. Probably only theoretical physic and theology—as the rest have long ago given up trying to define and understand the essence of their object, for example, (...) life in the case of biology or mind in psychology. Consequently, the paper by Pérez-Álvarez, Sass and García-Montes, “The Ontology of Mental Disorders in Constructivist Perspective,” (2008) should be welcomed and indeed included in the reading lists for trainees in psychiatry and clinical psychology.The authors propose an approach to the understanding of mental disorders that is extremely attractive and well articulated, and which also has practical implications for clinicians. It is not just another “philosophical divertimento” devoid of scientific and practical importance. Let us analyze the article in an orderly way.Less DsmThe authors of the target paper disapprove of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III/IV approach to defining illnesses by starting from the symptoms that are present—on the grounds that this may lead clinicians to assume that their sole role is to identify, fight, and suppress the symptoms by whichever procedure. They propose an alternative that is dear to myself because it follows the path of the so-called “anthropological” psychiatry of Binswanger, von Gebsattel, Erwin Strauss, Zutt, López-Ibor, Sr., and others. In essence, this is a phenomenological approach to the meaning of mental diseases, one that emphasizes how the illness is revealed to the patient him- or herself.The target article’s criticism of DSM should be considered in the context of the abuses committed on its behalf. The DSM is not a textbook of psychiatric disorders, nor does it contain a definition of the diseases. The DSM does not tell what a disease is (Klerman et al. 1984)—something that is impossible with a classification system based on the manifestations of the diseases, the signs and symptoms. The DSM, as its title states, is just a diagnostic and statistical manual, which does not contain anything about the origin of [End Page 259] any disease nor an explanation of why it exists or what it means. The DSM is, in fact, just a tool to determine whether a disease is present, and therefore to facilitate communication between professionals and with other individuals, without saying anything about the disease’s aitia—a key term (associated with notions of essence as well as cause) to be discussed below. In theory, most clinicians should understand these limitations; it may be, however, that this is not really the case for many who read or use the DSM. In the world there are around 200,000 psychiatrists; since 1980 the number of DSM copies sold is in the order of several hundred thousand.The misuse of a classification system is even more noticeable in the International Classification of Diseases (ICD)-10 Research Version. The instructions for the use of this version recommend that the first step is to make an inventory of all the symptoms present, and then to construct a diagnosis based on them. This how all computer-assisted systems work. This procedure can, however, only be valid if the clinician has already reached a diagnostic conclusion by other means—a diagnosis then to be confirmed for research purposes. It may be that this is one of the reasons why the ICD-10 Research Version has almost never actually been used for research.Furthermore, the concept of symptoms in psychiatry applies only to organic mental disorders (Schneider 1959), conditions in which the patient’s attitude and way of experiencing the symptoms do not play the kind of role that they play in schizophrenia and other mental disorders. The quotation from the important paper by Sass and Parnas in this context is most appropriate. It is indeed that case that “subjective experience can play an important causal role in the progressive experiential transformations of a developing schizophrenic illness... (shrink)