Mindlessness and brainlessness in psychiatry

Pathways and identity: toward qualitative research careers in child and adolescent psychiatry

OBJECTIVE

Qualitative research methods are based on the analysis of words rather than numbers; they encourage self-reflection on the investigator's part; they are attuned to social interaction and nuance; and they incorporate their subjects' thoughts and feelings as primary sources. Despite appearing well suited for research in child and adolescent psychiatry (CAP), qualitative methods have had relatively minor uptake in the discipline. We conducted a qualitative study of CAPs involved in qualitative research to learn about these investigators' lived experiences, and to identify modifiable factors to promote qualitative methods within the field of youth mental health.

METHODS

We conducted individual, semi-structured 1-h long interviews through Zoom. Using purposive sample, we selected 23 participants drawn from the US (n = 12) and from France (n = 11), and equally divided in each country across seniority level. All participants were current or aspiring CAPs and had published at least one peer-reviewed qualitative article. Ten participants were women (44%). We recorded all interviews digitally and transcribed them for analysis. We coded the transcripts according to the principles of thematic analysis and approached data analysis, interpretation, and conceptualization informed by an interpersonal phenomenological analysis (IPA) framework.

RESULTS

Through iterative thematic analysis we developed a conceptual model consisting of three domains: (1) Becoming a qualitativist: embracing a different way of knowing (in turn divided into the three themes of priming factors/personal fit; discovering qualitative research; and transitioning in); (2) Being a qualitativist: immersing oneself in a different kind of research (in turn divided into quality: doing qualitative research well; and community: mentors, mentees, and teams); and (3) Nurturing: toward a higher quality future in CAP (in turn divided into current state of qualitative methods in CAP; and advocating for qualitative methods in CAP). For each domain, we go on to propose specific strategies to enhance entry into qualitative careers and research in CAP: (1) Becoming: personalizing the investigator's research focus; balancing inward and outward views; and leveraging practical advantages; (2) Being: seeking epistemological flexibility; moving beyond bibliometrics; and the potential and risks of mixing methods; and (3) Nurturing: invigorating a quality pipeline; and building communities.

CONCLUSIONS

We have identified factors that can support or impede entry into qualitative research among CAPs. Based on these modifiable findings, we propose possible solutions to enhance entry into qualitative methods in CAP (pathways), and to foster longer-term commitment to this type of research (identity).

Autistic phenomenology: past, present, and potential future

We are now at a transition point in autism conceptualisation, science, and clinical practise, where phenomenology could play a key role. This paper takes a broad view of the history of phenomenological perspectives on the autism concept and how this has evolved over time, including contemporaneous theory and methods. Early inquiry from a clinical perspective within the tradition of classical continental phenomenology, linked closely to the consideration of schizophrenia, is contrasted with emerging observations of child development and a period in the second half of the twentieth century of scientific inquiry into a behavioural autistic phenotype where there was little or no phenomenological aspect; a phenotype that has determined the recent scientific and clinical conceptualisation of autism within current nosology. We then mark a more recent reawakening of interdisciplinary interest in subjective experience and phenomenological inquiry, which itself coincides with the increasing prominence and salience of the neurodiversity movement, autistic advocacy, and critical autism studies. We review this emerging phenomenological work alongside a contemporaneous clinical phenomenology perspective and representations of autistic experience from within the extensive literature (including life writing) from autistic people themselves; all perspectives that we argue need now be brought into juxtaposition and dialogue as the field moves forward. We argue from this for a future which could build on such accounts at a greater scale, working toward a more co-constructed, systematic, representative, and empirical autistic phenomenology, which would include citizen and participatory science approaches. Success in this would not only mean that autistic experience and subjectivity would be re-integrated back into a shared understanding of the autism concept, but we also argue that there could be the eventual goal of an enhanced descriptive nosology, in which key subjective and phenomenological experiences, discriminating for autism, could be identified alongside current behavioural and developmental descriptors. Such progress could have major benefits, including increased mutual empathy and common language between professionals and the autistic community, the provision of crucial new foci for research through aspects of autistic experience previously neglected, and potential new supportive innovations for healthcare and education. We outline a programme and methodological considerations to this end.

Psychodynamic practice in psychiatry

OBJECTIVE

The aim is to identify and illustrate the place of psychodynamic practice and the therapeutic relationship in psychiatry, including consideration of the need for psychodynamic formulation and longer-term psychotherapies, in the context of debate over guidelines for depression management.

CONCLUSIONS

Effective psychiatric practice requires a working understanding of psychodynamic principles. Effective management planning is underpinned by psychodynamic formulation. A full range of therapeutic options need to be available for optimal care.

Articulating biological and social approaches in child and adolescent psychiatry

Child and adolescent psychiatry has been based on numerous fields of research and theories, including neuroscience, physiology, psychology (developmental, psychodynamic, systemic, cognitive-behavioral, etc.), anthropology, sociology, and education sciences. Integrating transdisciplinary knowledge in multi-level models is an ongoing challenge for the future that is not immediately applicable in clinical practice and research. Articulating, i.e., to connect, to be jointed, (psycho)biological and (psycho)social approaches in child and adolescent psychiatry is a daily challenge for clinicians and researchers. Research is often limited to specific fields whereas real-life clinical practice needs a pluralistic approach. Research designs, tools, and clinical training need to provide knowledge applicable to the necessarily pluralistic daily clinical practice. This article provides some perspectives on how to articulate biological and social approaches, from research to clinical practice, and discusses the concept of pluralistic approaches, multimodal interventions, and how to provide articulated mental health care and training. Suggestions to better articulate biological and social approaches are provided: (I) State that the research object can be approached from different theoretical, research and clinical angles and explain the one chosen; (II) Propose synthesis articles that articulate biological and social knowledge; (III) Design biological studies that take into account social factors, and design social studies that take into account biological factors; (IV) Design transcultural tools; (V) Build pluralistic interventions, i.e., therapeutic modalities and mental health care settings that articulate biological and social approaches; (VII) Develop training in pluralistic articulated care.

Blots and brains. A note on the centenary of Hermann Rorschach's death

This historical note is a commemorial of Rorschach, the person, and Rorschach the test. Hermann Rorschach died 100 years ago, not quite a year after the publication of his book containing the 10 inkblots. These have reached an iconic status, but the "Rorschach Test" as used in psychiatry, legal organizations and aptitude assessments is not quite what Hermann Rorschach designed it for in the first line. A first section of this article introduces Hermann Rorschach as a man with very broad interests and an inclination to ask cognitive science questions that are still challenging today. A second section provides a critical summary of the fate of the ten inkblots after Rorschach's death - how they conquered the whole world in a time with a pronouced "psychometric attitude", and also how they failed in some attempts to measure personality traits in special populations. A final section focuses on recent research on one particular aspect of a testee's associations to the inkblots: "movement responses", i.e. the perception of implied motion. Here, neural and behavioral correlates have been demonstrated by modern neuroimaging techniques. One study, which set out to validate both the Rorschach as a personality test and the view that the two cerebral hemispheres correspond to divergent "personalities" is also summarized. The viewpoint concludes by suggesting that future work with inkblots should consider Rorschach's original intention to use inkblots to uncover basic laws of perception. Modern applications of computer-generated pseudorandom stimuli (random dot arrays or stochastic noise) would have been embraced by Hermann Rorschach as he appreciated the impact of visual noise for the study of vision and visual cognition.

Returning to basic principles to develop more effective treatments for central nervous system disorders

Development of new treatments for diseases of the central nervous system (CNS) is stalled. Of candidate drugs developed through costly preclinical research, 93% fail clinical trials. Hoped-for improvements in diagnosis or treatment from decades of positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) imaging have yet to materialize. To understand what we are doing wrong, I begin with recognition that all aspects of life, including the brain and mind, are physical phenomena consistent with processes described by physicists. Two processes, emergence and entropy, are of particular relevance in complex arrangements of matter that constitute life in general and the brain in particular. The human brain functions through dynamically reconfiguring and hierarchically organized neural functional systems with emergent properties of cognition, emotion, and conscious experience. These systems are shaped and maintained by negentropic environmental input transformed by sensory receptors into neural signals that trigger epigenetic neuroplastic processes. CNS diseases produce clinical disorders by disrupting these systems. As researchers seek appropriate levels of system organization at which to characterize and treat illness, focus has been on medications that impact processes at lower levels or transcranial electric or magnetic stimulation that impact broad contiguous swaths of tissue. Neither align with the brain’s neurosystem organization and therefore lack specificity necessary to be effective and to limit side effects. Digital neurotherapies (DNTs), in contrast, align with neurosystem organization and achieve the needed specificity using the same input pathways and neuroplastic processes that created the neural systems organization to repair it. The omission of DNTs from major systems-based initiatives represents powerful residua of dualist thinking. Interventions based on perceptual and cognitive processes are not thought of as being as physical as drugs or electric or magnetic stimulation through the skull. In fact, they are examples of the most basic processes that create and support life itself.

Making It Real: From Telling to Showing, Sharing, and Doing in Psychiatric Education

OBJECTIVE

Innovations in contemporary medical education could inform remedies to address enduring challenges such as the marginalization and stigmatization of psychiatry, of mental illnesses, and of those affected by them.

METHODS

In blending the works of Bleakley, Bligh, and Brown (2011) and of Kumagai and Naidu (2015), we developed an overarching heuristic with practical relevance and concrete applications to psychiatric education.

RESULTS

We identify three areas to enhance psychiatric education embedded into this blended framework: 1) Showing, or the more accurate depiction or imaging of mental illnesses and of psychiatric practice, as exemplified by the incorporation into didactic content of asynchronous video-based clinical materials produced with specific educational objectives in mind; 2) Sharing, or addressing the image problem of mental illnesses, of those living with or affected by them, and of psychiatry as a profession, as exemplified by psychiatrists embracing their role as experts by professional and personal experience when sharing their own journeys with mental illness, treatment, and recovery; and 3) Doing, or reimagining reflective psychiatric practice, as exemplified by the novel methodology of co-constructive patient simulation (CCPS), through which learners can engage in reflective practice and supervision in a participatory and democratic setting that does not privilege participants' hierarchical standing.

CONCLUSION

The blended model and the sample applications we describe offer a range of teaching, learning, and professional development opportunities, should psychiatric educators choose to pursue them and reap their promise.

Top-down causation in psychiatric disorders: a clinical-philosophical inquiry

Psychiatry has long debated whether the causes of mental illness can be better explained by reductionist or pluralistic accounts. Although the former relies on commonsense scientific bottom-up causal models, the latter (which typically include environmental, psychological, and/or socio-cultural risk factors) requires top-down causal processes often viewed with skepticism, especially by neuroscientists. We begin with four clinical vignettes which illustrate self-interventions wherein high-order psychological processes (e.g. religious beliefs or deep interpersonal commitments) appear to causally impact the risk for or the course of psychiatric/behavioral disorders. We then propose a model for how to understand this sort of top-down self-causation. Our model relies centrally on the concept of a control variable which, like a radio tuning dial, can implement a series of typically unknown physical processes to obtain the desired ends. We set this control variable in the context of an interventionist account of causation that assumes that a cause (C) produces an effect (E) when intervening on C (by manipulating it) is associated with a change in E. We extend this framework by arguing that certain psychological changes can result from individuals intervening on their own mental states and/or selection of environments. This in turn requires a conception of the self that contains mental capacities that are at least partially independent of one another. Although human beings cannot directly intervene on the neurobiological systems which instantiate risk for psychiatric illness, they can, via control variables at the psychological level, and/or by self-selection into protective environments, substantially alter their own risk.

The Neuroscientification of Psychology: The Rising Prevalence of Neuroscientific Concepts in Psychology From 1965 to 2016

The apparent convergence of psychology and brain science has been the subject of both celebration and critique, but it has never been systematically charted. We examined historical trends in the representation of neuroscientific concepts in a corpus of 798,402 psychology journal articles published over the past half century, from 1965 to 2016. A dictionary of 522 uniquely neuroscience-related terms was developed, and the percentage of article abstracts in which at least one term appeared was calculated for each year. This percentage grew from 9.15% to 16.45% over the study period, whereas the percentage containing a subset of 199 terms containing the prefix "neur-" rose much more steeply, from 2.30% to 10.06%. From the mid-1970s, the growing representation of neuroscience in psychology was linear. Proportions were highest among journals covering neuropsychology and physiological psychology and behavioral neuroscience, lowest in those covering social psychology and developmental and educational psychology, and intermediate in those covering experimental and cognitive psychology and clinical psychology. The steepest rises were found in social and clinical psychology journals. Changes in the most salient neuroscientific terms revealed historical shifts in technology, topic, and anatomical focus, which may contribute to our understanding of relationships among mind, brain, and behavior.

Uncertainty Promotes Neuroreductionism: A Behavioral Online Study on Folk Psychological Causal Inference from Neuroimaging Data

INTRODUCTION

Increased efforts in neuroscience try to understand mental disorders as brain disorders. In the present study, we investigate how common a neuroreductionist inclination is among highly educated people. In particular, we shed light on implicit presuppositions of mental disorders little is known about in the public, exemplified here by the case of body integrity dysphoria (BID) that is considered a mental disorder for the first time in ICD-11.

METHODS

Identically graphed, simulated data of mind-brain correlations were shown in 3 contexts with presumably different presumptions about causality. 738 highly educated lay people rated plausibility of causality attribution from the brain to mind and from mind to the brain for correlations between brain structural properties and mental phenomena. We contrasted participants' plausibility ratings of causality in the contexts of commonly perceived brain lesion-induced behavior (aphasia), behavior-induced training effects (piano playing), and a newly described mental disorder (BID).

RESULTS

The findings reveal the expected context-dependent modulation of causality attributions in the contexts of aphasia and piano playing. Furthermore, we observed a significant tendency to more readily attribute causal inference from the brain to mind than vice versa with respect to BID.

CONCLUSION

In some contexts, exemplified here by aphasia and piano playing, unidirectional causality attributions may be justified. However, with respect to BID, we critically discuss presumably unjustified neuroreductionist inclinations under causal uncertainty. Finally, we emphasize the need for a presupposition-free approach in psychiatry.

The presentation of the mind-brain problem in leading psychiatry journals

Objective:

The mind-brain problem (MBP) has marked implications for psychiatry, but has been poorly discussed in the psychiatric literature. This paper evaluates the presentation of the MBP in the three leading general psychiatry journals during the last 20 years.

Methods:

Systematic review of articles on the MBP published in the three general psychiatry journals with the highest impact factor from 1995 to 2015. The content of these articles was analyzed and discussed in the light of contemporary debates on the MBP.

Results:

Twenty-three papers, usually written by prestigious authors, explicitly discussed the MBP and received many citations (mean = 130). The two main categories were critiques of dualism and defenses of physicalism (mind as a brain product). These papers revealed several misrepresentations of theoretical positions and lacked relevant contemporary literature. Without further discussion or evidence, they presented the MBP as solved, dualism as an old-fashioned or superstitious idea, and physicalism as the only rational and empirically confirmed option.

Conclusion:

The MBP has not been properly presented and discussed in the three leading psychiatric journals in the last 20 years. The few articles on the topic have been highly cited, but reveal misrepresentations and lack of careful philosophical discussion, as well as a strong bias against dualism and toward a materialist/physicalist approach to psychiatry.

Who owns the brain?

As usual, I bought my wife Vogue magazine for Christmas. It always serves well as, in North America parlance, a ‘stocking stuffer’. This year it had further value as it highlighted the brain. A well-known psychiatrist, Nancy Andreasen, set out to inform America about modern psychiatry (Andreasen, 1990). The article is entitled ‘Brave New Brain’ with the subtitle being ‘Modern Psychiatry has Left the Couch for the Laboratory’. She takes the reader through neuro-imaging, molecular genetics and psycho-pharmacology. It is an elegant synopsis and worthy of someone who had a doctorate in English before she took up medicine. Importantly, however, she prefaced her serious material with a mock-comic story about a conversation she had had with someone at a New York hospital recently. She was phoning about the retrieval of a brain for research and the ingenuous person at the hospital just could not put the idea of psychiatry and brains together. Another sad tale of psychiatric breast-beating? Those of us who trained in psychiatry in Britain a generation ago might give a wry smile. After all, biological psychiatry was all that we ever knew. When I entered the Maudsley in 1964, part of the orientation for registrars consisted of going to the laboratories. A mouse was popped into a jar containing liquid nitrogen, it went rock hard and the group was advised that freezing the neurotransmitters in that way was the royal road to solving problems.

Mental Ill-Health and the Epidemiology of Representations

One of major challenges facing contemporary psychiatry is the insufficient grasp of relationship between individual and collective mental pathologies. A long tradition of diagnosing "mental illness" of society-exemplified by Erich Fromm-stands apart from approach of contemporary social psychiatry and is not perceived as relevant for psychiatric discourse. In this Perspective article, I argue that it is possible to uphold the idea of a supra-individual dimension to mental health, while avoiding the obvious pitfalls involved in categorical diagnosing of society as suffering from mental illness. I argue for an extended notion of public mental ill-health, which goes beyond the quantitative understanding of mental health as an aggregate of individual diseased minds captured in statistics, and which can be conceived as a dynamic, emergent property resulting from interactions of individual brains/minds in social space. Such a notion, in turn, presents a challenge of how to account for the interfacing between individual minds/brains and the collective mental phenomena. A suitable theoretical framework is provided by the notion of epidemiology of representations, originally formulated by cognitive anthropologist Dan Sperber. Within this framework, it is possible to highlight the role of public (material) representations in inter-individual transfer of mental representations and mental states. It is a suitable conceptual platform to explain how the troubling experiences with causal or mediating role on mental health, to a significant degree arise through a person's direct interaction with material representations and participation in collective mental states, again generated by material representations.

The National Institute of Mental Health Research Domain Criteria: A Bridge Too Far

The National Institute of Mental Health is actively promoting Research Domain Criteria as a new model for the research on mental disorders. Research Domain Criteria approaches disorders through a matrix, linking units of analysis with domains, based on the assumption that psychopathology reflects abnormal connectivity in the brain. This review suggests that the Research Domain Criteria perspective is likely to fail to provide an adequate basis for clinical psychiatric theory and practice. First, it uses models from neuroscience that are insufficiently developed. Second, it is based on the premise that mental phenomena and mental disorders can be reduced to neural activity, without consideration of cognition, experience, and social interaction. Third, it downplays psychosocial factors in psychopathology and treatment. Research Domain Criteria may therefore prove inadequate for providing a neuroscientific basis for psychiatric nosology and treatment and needs to be supplemented with a broader view that incorporates insights from social sciences, psychology, and phenomenology.

The multiaxial assessment and the DSM-III: a conceptual analysis

With the release of the DSM-III, multiaxial assessment, which was a new concept, was introduced to daily clinical practice. This article will review the history and the development of the concept of multiaxial assessment and will focus on the its relationship to the DSM-III. In conclusion I will discuss different critiques of the concept.

From Family Therapy to Family Intervention

For many, family therapy refers to sessions in which all family members are present. Yet in contemporary psychiatry there are many ways to work with families in addition to this classic concept. This article proposes family intervention as an encompassing term for a new family paradigm in child and adolescent psychiatry. Developmental psychopathology is a guiding principle of this paradigm. A full range of ways to work with families clinically is described with clinical examples.

Epidemiology in a changing world: implications for population-based research on mental disorders

Introduction and objectives. Population-based research on mental disorders needs to keep pace with trends in general epidemiology. At present, this requirement is complicated by uncertainty within the parent discipline about its future development. The present study examines proposals for new directions in strategy and methods and considers their significance for psychiatric epidemiology. Method. Narrative review, cross-checked by search of English-language journals of epidemiology for new trends and developments reported in the years from 2000 onwards. Results. The proposals reviewed here are divided into three groups: 1. A new research paradigm of 'eco-epidemiology', which includes both individual risk factors and macro-environmental systems that mediate population levels of health and sickness. 2. Improved 'translation' of research findings - i.e. more rapid and effective implementation of epidemiological evidence into health policy and practice. 3. Adaptation of epidemiology to a globalised economy, with firmer regulation of funding and resources. Conclusions. Each of these proposals has implications for psychiatric epidemiology. Workers in this field, however, are still preoccupied by relatively specific problems of definition, measurement and classification, and so far the current debates in general epidemiology are scarcely reflected. The proposals outlined above call for: • a working model of eco-epidemiology as it relates to psychiatric disorders; • implementation strategies to encourage more active participation in epidemiological research by community health services and caregiver organisations; • international collaborative projects that offer practical benefits in training and service facilities for the countries taking part.

Biologism in Psychiatry: A Young Man's Experience of Being Diagnosed with "Pediatric Bipolar Disorder"

Pediatric bipolar disorder is a diagnosis that arose in the mid 1990s in the USA and has mostly remained confined to that nation. In this article a young American man (under a pseudonym) describes his experience of having the diagnosis throughout his adolescent years. His story was conveyed via correspondence and a meeting with the author, an Australian child psychiatrist. The young American's story reveals several issues that afflict contemporary psychiatry, particularly in the USA, where social and economic factors have contributed to the rise of a dominant biomedical paradigm-or "biologism". This focus on the "bio" to the relative exclusion of the "psychosocial" in both diagnosis and treatment can have serious consequences as this young man's story attests. The author explores aspects of his tale to analyze how the pediatric bipolar disorder "epidemic" arose and became emblematic of a dominant biologism. This narrative points to the need, depending on the service and country, to return to or retain/improve a balanced biopsychosocial perspective in child and adolescent mental health. Child psychiatry needs to advocate for health systems that support deeper listening to our patients. Then we can explore with them the full range of contextual factors that contribute to symptoms of individual and family distress.

The Endurance of Uncertainty: Antisociality and Ontological Anarchy in British Psychiatry, 1950–2010

Research into the biological markers of pathology has long been a feature of British psychiatry. Such somatic indicators and associated features of mental disorder often intertwine with discourse on psychological and behavioral correlates and causes of mental ill-health. Disorders of sociality – particularly psychopathy and antisocial personality disorder – are important instances where the search for markers of pathology has a long history; research in this area has played an important role in shaping how mental health professionals understand the conditions. Here, I characterize the multiplicity of psychiatric praxis that has sought to define the mark of antisociality as a form of “ontological anarchy.” I regard this as an essential feature of the search for biological and other markers of an unstable referent, positing that uncertainties endure – in part – precisely because of attempts to build consensus regarding the ontology of antisociality through biomedical means. Such an account is suggestive of the co-production of biomarkers, mental disorder, and psychiatric institutions.

Integrative change model in psychotherapy: Perspectives from Indian thought

Different psychotherapeutic approaches claim positive changes in patients as a result of therapy. Explanations related to the change process led to different change models. Some of the change models are experimentally oriented whereas some are theoretical. Apart from the core models of behavioral, psychodynamic, humanistic, cognitive and spiritually oriented models there are specific models, within psychotherapy that explains the change process. Integrative theory of a person as depicted in Indian thought provides a common ground for the integration of various therapies. Integrative model of change based on Indian thought, with specific reference to psychological concepts in Upanishads, Ayurveda, Bhagavad Gita and Yoga are presented. Appropriate psychological tools may be developed in order to help the clinicians to choose the techniques that match the problem and the origin of the dimension. Explorations have to be conducted to develop more techniques that are culturally appropriate and clinically useful. Research has to be initiated to validate the identified concepts.

Psychotropic marketing practices and problems: implications for DSM-5

The descriptive diagnostic model since DSM-III has often led to "cookbook" diagnosis and assumptions of "chemical imbalance" for psychiatric disorders. Pharmaceutical companies have exploited this in their marketing. This includes promoting self-diagnosis with online checklists. Significant overprescribing of psychotropics has resulted. DSM-5 will provide new disorders and broader diagnostic criteria that will likely exacerbate this. Most psychotropic prescribing is done by primary care physicians, who are problematically excluded from DSM-5 field trials and are influenced by industry funded key opinion leaders who may promote diagnosis of subthreshold cases. More lax criteria will increase diagnosis of subthreshold cases. Expansion of not otherwise specified (NOS) categories can be used to justify off-label promotion. Pediatric bipolar disorder, constructed within the bipolar disorder NOS category, became an "epidemic" in the United States, fuelled by diagnostic upcoding pressures. Disruptive mood dysregulation disorder may similarly cause overdiagnosis and excessive prescribing, as will other new disorders and lower diagnostic thresholds.

Comorbid anxiety and depression: bête noire or quick fix?

The common territory shared by anxiety and depression has always been a contentious subject. Research in favour of anxious depression as a potentially treatment-relevant subtype has been limited by diagnostic dilemmas and crude measurement. The most recent evidence from genetics, neuropeptide systems and functional neuroimaging suggests a valid diagnostic construct.

Pediatric bipolar disorder in an era of "mindless psychiatry"

OBJECTIVE

Pediatric bipolar disorder (PBD) reflects shifts in conceptualizing bipolar disorder among children and adolescents since the mid-1990s. Since then, PBD diagnoses, predominantly in the United States, have increased dramatically, and the diagnosis has attracted significant controversy. During the same period, psychiatric theory and practice has become increasingly biological. The aim of this paper is to examine the rise of PBD in terms of wider systemic influences.

METHOD

In the context of literature referring to paradigm shifts in psychiatry, we reviewed the psychiatric literature, media cases, and information made available by investigative committees and journalists.

RESULTS

Social historians and prominent psychiatrists describe a paradigm shift in psychiatry over recent decades: from an era of "brainless psychiatry," when an emphasis on psychodynamic and family factors predominated to the exclusion of biological factors, to a current era of "mindless psychiatry" that emphasizes neurobiological explanations for emotional and behavioral problems with limited regard for contextual meaning. Associated with this has been a tendency within psychiatry and society to neglect trauma and attachment insecurity as etiological factors; the "atheoretical" (but by default biomedical) premise of the Diagnostic and Statistical Manual of Mental Disorders (3rd and 4th eds.); the influence of the pharmaceutical industry in research, continuing medical education, and direct-to-consumer advertising; and inequality in the U.S. health system that favors "diagnostic upcoding." Harm from overmedicating children is now a cause of public concern.

CONCLUSION

It can be argued that PBD as a widespread diagnosis, particularly in the United States, reflects multiple factors associated with a paradigm shift within psychiatry rather than recognition of a previously overlooked common disorder.

Child and adolescent psychiatry: past scientific achievements and challenges for the future

The worldwide history of scientific achievements in child and adolescent psychopathology is reviewed from the mid-twentieth century onwards. Attention is drawn, e.g., to diagnostic distinctions, measures of psychopathology, the several roles of epidemiological longitudinal studies, temperament and personality, developmental psychopathology, the use of 'natural experiments' to test causal inferences, environmental risks, the importance of gene-environment interplay, the relative coming together of initially diverse psychological therapies, the use of randomized-controlled trials to assess treatment efficacy, and the value and limitations of pharmacotherapy. The article ends with a look ahead to the most important opportunities and challenges for child and adolescent psychiatry, plus the hazards that need to be avoided.

Clustering of psychiatric and somatic illnesses in the general population: multimorbidity and socioeconomic correlates

The distribution of psychiatric disorders and of chronic medical illnesses was studied in a population-based sample to determine whether these conditions co-occur in the same individual. A representative sample (N = 1464) of adults living in households was assessed by the Composite International Diagnostic Interview, version 1.1, as part of the São Paulo Epidemiological Catchment Area Study. The association of sociodemographic variables and psychological symptoms regarding medical illness multimorbidity (8 lifetime somatic conditions) and psychiatric multimorbidity (15 lifetime psychiatric disorders) was determined by negative binomial regression. A total of 1785 chronic medical conditions and 1163 psychiatric conditions were detected in the population concentrated in 34.1 and 20% of respondents, respectively. Subjects reporting more psychiatric disorders had more medical illnesses. Characteristics such as age range (35-59 years, risk ratio (RR) = 1.3, and more than 60 years, RR = 1.7), being separated (RR = 1.2), being a student (protective effect, RR = 0.7), being of low educational level (RR = 1.2) and being psychologically distressed (RR = 1.1) were determinants of medical conditions. Age (35-59 years, RR = 1.2, and more than 60 years, RR = 0.5), being retired (RR = 2.5), and being psychologically distressed (females, RR = 1.5, and males, RR = 1.4) were determinants of psychiatric disorders. In conclusion, psychological distress and some sociodemographic features such as age, marital status, occupational status, educational level, and gender are associated with psychiatric and medical multimorbidity. The distribution of both types of morbidity suggests the need of integrating mental health into general clinical settings.