Retiring Categorical Systems and the Biomedical Model of Mental Illness: The Why and the How-A Clinician's Perspective (original) (raw)
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I t’s time for a necessary paradigm shift in re-conceptualizing the nosology, epidemiology, etiology, and treatment of major psychiatric disorders, including schizophrenia, bipolar disorder, major depressive disorder (MDD), autism spectrum disorder, attentiondeficit/hyperactivity disorder (ADHD), anxiety, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and substance use disorders. For a long time, and prior to the neuroscience revolution that enabled probing the human brain and exploring the neurobiology of psychiatric disorders, the field of psychiatry was descriptive and simplistic. It categorized psychiatric disorders essentially as silos, defined by a set of signs and symptoms. If one or more psychiatric conditions co-occurred with a “primary diagnosis,” they were labeled as “comorbidities,” with no implications of a shared etiology or biology. Amazingly, despite the rapid accrual of evidence of shared developmental or genetic etiopathogenesis, shared ...
Transdiagnostic approaches to mental health problems: Current status and future directions
Journal of Consulting and Clinical Psychology, 2020
Despite a longstanding and widespread influence of the diagnostic approach to mental ill health, there is an emerging and growing consensus that such psychiatric nosologies may no longer be fit for purpose in research and clinical practice. In their place, there is gathering support for a "transdiagnostic" approach that cuts across traditional diagnostic boundaries or, more radically, sets them aside altogether, to provide novel insights into how we might understand mental health difficulties. Removing the distinctions between proposed psychiatric taxa at the level of classification opens up new ways of classifying mental health problems, suggests alternative conceptualizations of the processes implicated in mental health, and provides a platform for novel ways of thinking about onset, maintenance, and clinical treatment and recovery from experiences of disabling mental distress. In this Introduction to a Special Section on Transdiagnostic Approaches to Psychopathology, we provide a narrative review of the transdiagnostic literature in order to situate the Special Section articles in context. We begin with a brief history of the diagnostic approach and outline several challenges it currently faces that arguably limit its applicability in current mental health science and practice. We then review several recent transdiagnostic approaches to classification, biopsychosocial processes, and clinical interventions, highlighting promising novel developments. Finally, we present some key challenges facing transdiagnostic science and make suggestions for a way forward. What is the public health significance of this article? Traditional diagnostic systems may no longer be fit for purpose for classifying mental ill health, facilitating understanding of its core underlying biopsychosocial processes, nor driving clinical developments. Here we propose that 'transdiagnostic' approaches have the potential to better represent the clinical and scientific reality of mental health problems, reflecting the complexity, dimensionality and comorbidity that is the norm in clinical practice.
Attachment, Neurobiology, and Mentalizing along the Psychosis Continuum
In this review article, we outline the evidence linking attachment adversity to psychosis, from the premorbid stages of the disorder to its clinical forms. To better understand the neurobiological mechanisms through which insecure attachment may contribute to psychosis, we identify at least five neurobiological pathways linking attachment to risk for developing psychosis. Besides its well documented influence on the hypothalamic-pituary-adrenal (HPA) axis, insecure attachment may also contribute to neurodevelopmental risk through the dopaminergic and oxytonergic systems, as well as bear influence on neuroinflammation and oxidative stress responses. We further consider the neuroscientific and behavioral studies that underpin mentalization as a suite of processes potentially moderating the risk to transition to psychotic disorders. In particular, mentalization may help the individual compensate for endophenotypical impairments in the integration of sensory and metacognitive information. We propose a model where embodied mentalization would lie at the core of a protective, resilience response mitigating the adverse and potentially pathological influence of the neurodevelopmental cascade of risk for psychosis.
Attachment in the Psychiatric Curriculum
Psychodynamic Psychiatry
Psychiatric trainees are expected to learn the fundamental concepts of psychodynamic psychotherapy, but they often struggle to understand and appreciate the relevance of this work. An introduction to attachment theory can go a long way toward assisting our trainees in understanding the relevance of psychodynamic psychiatry. To help programs develop this component of their curriculum, we summarize the history of the development of the attachment paradigm including the Strange Situation and Adult Attachment Interview (AAI), useful tools to teach these concepts, as well as ramifications of this work. We provide a summary of information regarding the evidence base connected to this paradigm, potential clinical relevance, health implications, work from neuroscience, and infant intervention models to assist in bringing psychodynamic concepts to life. Exposure to the attachment paradigm provides a model of intervention, prevention, and hope for our trainees as they transition from learning phenomenologic models of psychiatric diagnostics to other paradigms of human development and intervention.
ABSTRACT: Psychiatry is one of the oldest specialty professions in medicine, arising after 1800 in small communities of European, British, and American physicians who were physically, socially, and professionally isolated in asylums for the care and management of persons suffering from severe disturbances of thought, emotion, and behavior (“insanity”). In the twentieth century psychiatry turned its attention to milder psychiatric conditions (e.g.,“neurosis” or “neurasthenia”) in the general population, changing its mission and treatment methods. Competing views of mental disorder as biologically specifiable categories of disease (promoted by Emil Kraepelin), as dimensional psychosocial “reactions” (Adolf Meyer), or as mental mechanisms of personality (Sigmund Freud) have not been resolved by biomedical, psychological, or statistical methods.
Revitalizing Psychopathology and Making Valid Diagnoses
This remarkable book fills a substantial gap in psychiatric research and practice , which, though often unrecognized, has fueled the current state of crisis in psychiatry and brought along not only scientific stagnation but also inadequate treatment of the patients, whose care is the raison d´être of the discipline. What I am alluding to here is the very bedrock of psychiatry, namely psychopathology (i.e. symptoms and signs) and how to assess it properly in the diagnostic interview. In the absence of extra-clinical markers, mental disorders are defined on the basis of sets of diagnostic criteria that contain specific symptoms and signs (along with duration, functional, and exclusion criteria). Allocating diagnoses to patients is not a goal in itself but a first, necessary step to provide adequate treatment for the patients and to further the understanding of mental disorders through research. In other words, everything hinges on getting the diagnosis right, which of course is tantamount to saying that we must get the psychopathology right. Unfortunately, therein lies the problem: far too often, we don't get the psychopathology and diagnosis right. If psychiatry is to recover from its current crisis, a restoration of psychopathological knowledge, of differential-diagnostic know-how, and of the art of psychiatric interviewing is urgently needed. This book delivers on all these parameters. The book is written by two highly experienced clinicians and researchers, who have extensive knowledge of psychopathology, differential-diagnosis, and psychiatric interviewing. The book is divided into two parts. The first part explores the essentials of the diagnostic interview, and the second part deals with the question of how to navigate between the different diagnostic spectra , including organic pathology, schizophrenia spectrum disorders, affective disorders, anxiety disorders, and personality disorders. Given the complexity of the topics covered in this book, I will in this review focus narrowly on, what I consider, two of its most significant contributions to the field, namely the authors' discussion of the nature of the psychiatric interview and of the necessity of grasping the psychopathological Gestalt in any differential-diagnostic assessment. To fully appreciate these contributions, I will also try to elucidate the current way of diagnosing, which this book problematizes and offers solutions to rectify.
Psychiatric Diagnosis: Lessons from the DSM-IV Past and Cautions for the DSM-5 Future
Annual Review of Clinical Psychology, 2012
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders provides the authoritative list of what are considered to be mental disorders. This list has a tremendous impact on research, funding, and treatment, as well as a variety of civil and forensic decisions. The development of this diagnostic manual is an enormous responsibility. Provided herein are lessons learned during the course of the development of the fourth edition. Noted in particular is the importance of obtaining and publishing critical reviews, restraining the unbridled creativity of experts, conducting field trials that address key issues and concerns, and conducting forthright risk-benefit analyses. It is suggested that future editions of the diagnostic manual be developed under the auspices of the Institute of Medicine. The goal would be broad representation, an evidence-based approach, disinterested recommendations, and a careful attention to the risks and benefits of each su...