Is psychiatry scientific? A letter to a 21st century psychiatry resident

Reflections on the Lack of Consideration of Ethnic Ancestry to Stratify Clozapine Dosing

This review article argues against trusting standard clozapine references, including the US package insert, because they do not include advances in the sciences of pharmacokinetics and pharmacovigilance and ignore the effects of ethnic ancestry on therapeutic dosing. The minimum therapeutic dose leading to the minimum therapeutic concentration of 350 ng/mL in serum/plasma can be used to compare individuals/groups with treatment-resistant schizophrenia. The US clozapine package insert recommends targeting doses of 300-450 mg/day and, subsequently, increments of up to 100 mg with a maximum dose of 900 mg/day. Ethnic ancestry is defined by DNA ancestry group. Asians (people with ancestry ranging from Pakistan to Japan) and Indigenous Americans are similar in clozapine dosing; their average clozapine minimum therapeutic dose ranged from 166 mg/day (female non-smokers) to 270 mg/day (male smokers). For those with European ancestry, average clozapine minimum therapeutic doses ranged from 236 mg/day (female non-smokers) to 368 mg/day (male smokers). Based on limited studies, Black (African sub-Saharan ancestry) patients may be treated with typical US doses (300-600 mg/day), assuming no poor metabolism (PM) status. Ancestry's impact on clozapine lethality in four countries is discussed (two countries with highly homogenous populations, Denmark and Japan, and two countries with increasingly heterogenous populations due to immigration, Australia and the UK). An international guideline with 104 authors from 50 countries/regions was recently published, providing 6 personalized clozapine titration schedules for adult inpatients (3 ancestry groups and PM/non-PM schedules) and recommending c-reactive protein monitoring at baseline and weekly for 4 weeks.

Using Crisis Theory in Dealing With Severe Mental Illness-A Step Toward Normalization?

The perception of mental distress varies with time and culture, e.g., concerning its origin as either social or medical. This may be one reason for the moderate reliability of descriptive psychiatric diagnoses. Additionally, the mechanisms of action of most psychiatric treatments and psychotherapeutic interventions are generally unknown. Thus, these treatments have to be labeled as mostly unspecific even if they help in coping with mental distress. The psychiatric concept of mental disorders therefore has inherent limitations of precision and comprises rather fuzzy boundaries. Against this background, many people question the current process of diagnosing and categorizing mental illnesses. However, many scholars reject new approaches discussed in this context. They rather hold on to traditional diagnostic categories which therefore still play a central role in mental health practice and research and. In order to better understand the adherence to traditional psychiatric concepts, we take a closer look at one of the most widely adopted traditional concepts - the Stress-Vulnerability Model. This model has originally been introduced to tackle some problems of biological psychiatry. However, it has been misapplied with the result of drawing attention preferentially to biological vulnerability instead of a wider array of vulnerability factors including social adversity. Thus, in its current use, the Stress-Vulnerability Model provides only a vague theory for understanding mental phenomena. Therefore, we discuss the advantages and allegedly limited applicability of Crisis Theory as an alternative heuristic model for understanding the nature and development of mental distress. We outline the problems of this theory especially in applying it to severe mental disorders. We finally argue that an understanding of Crisis Theory supported by a systemic approach can be applied to most types of severe psychological disturbances implying that such an understanding may prevent or manage some negative aspects of the psychiatrization of psychosocial problems.

Reflections on US Psychiatry: How the Baton Was Passed From European Psychiatry and the Contributions of US Psychiatry

ABSTRACT

The medical model in psychiatry and descriptive psychopathology were established in Germany by Krapelin's textbook and Jaspers' General Psychopathology. In the United Kingdom, Mayer-Gross' textbook synthesized both books, influencing US psychiatry. US psychiatrists from the World War II generation defeated the US academic psychoanalytic establishment by building three pillars: biological psychiatry (brought by Wortis), the psychopharmacology revolution, and the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III). The psychopharmacology revolution included immigrants (e.g., Gershon), Cole's marketing, and textbooks by Klein and Fink. The "neo-Kraepelinians" introduced the medical model in US psychiatry and defined 15 valid psychiatric disorders. Spitzer supervised DSM-III's development. Its 1980 publication started the world dominance of US psychiatry and the multiplication of diagnoses. Major contributions by US psychiatrists include a) McHugh's update of the Jaspersian approach, b) Fink's inclusion of catatonia as a syndrome in DSM-5 (following Abrams and Taylor's studies), and c) DSM-III's departure from the Jaspersian hierarchy of schizophrenia and affective symptoms.

Training Psychiatry Residents in Descriptive Psychopathology: A Systematic Review

PURPOSE

Descriptive psychopathology (DP, sometimes called psychopathology or phenomenology) is the language of psychiatry and is dedicated to the description of mental symptoms. Due to its importance, there is an ongoing case to put it back at the heart of psychiatry and its training. This study seeks to examine the literature on how to train psychiatry residents in DP, including reported educational interventions and educational methods.

METHOD

The authors conducted a systematic review following the PRISMA and BEME guidelines to identify literature on how to train psychiatry residents in DP. In May 2019, they searched in Embase, ERIC, PsycINFO, PubMed, Scopus, and Web of Science; of 7,199 initial results, 26 sources were finally included for analysis. The assessment tools were the CRAAP test, Kirkpatrick's 4 levels, and (when applicable) the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

The mean CRAAP score was 38.885 of a possible 50 (SD 0.983; range: 36.859-40.910). Fourteen sources (53.8%) had some kind of training evaluation: Kirkpatrick's level 1 was present in nearly all (13) and was the highest in half of them (7). Regarding the educational interventions, the mean MERSQI score was 10.592 of a possible 18 (SD 2.371; range 9.085-12.098). Lectures were the most widely reported educational method (5); among those in clinical settings, the live supervised interview with feedback was the most usual (4).

CONCLUSIONS

Despite its core importance as the language of psychiatry, the literature about training psychiatry residents in DP is scarce and heterogeneous. General lack of training evaluation and ongoing overemphasis on Kirkpatrick's levels 1-2 at the expense of levels 3-4 are causes for concern. During the review process, the authors identified a selection of educational interventions that could serve as the basis for the design of new training efforts in both clinical and nonclinical settings. Topics for future research are also suggested, such as the role of DP in competency-based training frameworks now in vogue and a series of neglected contents. Finally, the combined use of the CRAAP test and the MERSQI may be useful for future systematic reviews in medical education.

The evolution of Kraepelin's nosological principles

Emil Kraepelin developed a new psychiatric nosology in the eight editions of his textbook. Previous papers have explored his construction of particular diagnoses, including dementia praecox and manic-depressive insanity. Here we are providing a close reading of his introductory textbook chapter, that presents his general principles of nosology. We identify three phases: 1) editions 1-4, in which he describes nosological principles in search of data; 2) editions 5-7, in which he declares the mature version of his nosological principles and develops new disease categories; 3) edition 8, in which he qualifies his nosological claims and allows for greater differentiation of psychiatric disorders. We propose that Kraepelin's nosology is grounded in three principles. First, psychiatry, like other sciences, deals with natural phenomena. Second, mental states cannot be reduced to neural states, but science will progress and will, ultimately, reveal how nature creates abnormal mental states and behavior. Third, there is a hierarchy of validators of psychiatric diagnoses, with the careful study of clinical features (signs, symptoms and course) being more important than neuropathologic and etiological studies. These three principles emerged over the course of the eight editions of Kraepelin's textbook and were informed by his own research and by available scientific methods. His scientific views are still relevant today: they have generated and, at the same time, constrained our current psychiatric nosology.

An Integrated Bio-psycho-social Approach to Psychiatric Disorders

The biopsychosocial approach is a model of eclecticism, which consists of multidisciplinary academic fields, reacting against the "neuroscientification" of psychiatry. The biopsychosocial approach was proposed by George Engel following Adolf Meyer's psychobiological and Roy R. Ginker's eclectic approach to psychiatry. Although the use of the biopsychosocial approach is increasing, it has several limitations: First, specific practices cannot be guided by the biopsychosocial approach because it is considered to be "boundless psychiatry." Second, unlike an initial intention, the symptomatic use of psychotropic medications may be justified by the biopsychosocial approach. Third, the economic forces to enhance biological psychiatry cannot be hindered by the biopsychosocial approach. Hence, to overcome the limitations of the current biopsychosocial approach, potential new paradigms including evolutionary psychiatry, pragmatism, integrationism, and pluralism have been proposed. Above all, Eric Kandel presented the link between neuroscience and psychiatry from the perspective of integrationism. In accordance with integrationism and/or pluralism, based on the paradigm shift of the theoretical construct from chemical imbalance to dysfunctional circuit, next-generation treatments for mental disorders have been proposed by Thomas Insel. Thus, a more integrated biopsychosocial approach to managing psychiatric disorders including schizophrenia and panic disorder may be proposed.

[Psychiatry of the future: multidimensionality of the problems of modern psychiatry and development of classification systems]

The success and achievements in the area of neurosciences due to the development of neuroimaging, neurochemical and genome studies provide tasks for psychiatry determined by the necessity to develop new classifications of mental diseases, primarily ICD-11, specify clinical diagnostic criteria and rethink the essence of some mental disorders. In spite of the multiple direction of scientific opinions on the discussed issues, the development of modern psychiatry is characterized by intensive search of biological background of psychiatric disorders and elaboration of effective approaches to the diagnosis and treatment of mental diseases, including medical rehabilitation of patients.

[Psychiatry of the future: an overview of foreign scientists opinions of the position of psychiatry in the modern world]

First part of this review (Chapter 1) demonstrates an ambiguous attitude toward psychiatry among professionals and in society in recent decades. The articles of supporters and opponents of psychiatry are also quoted. The authors describe the dynamics of the reflection of psychopathology in the main widely accepted classifications and manuals. Critical and negative opinions regarding the DSM-5, due to its role in the 'medicalization' processes, for the movement 'World Mental Health', are mentioned. The history of antipsychiatry movement and its results for psychiatry and society are analyzed as well. An analysis of the articles on the scientific basis of psychiatry and its intersections with other sciences is presented. Several examples of studies on brain networks in correlation with clinical data, which may have possible implications for the future, are quoted. The authors call for the 'cure for dichotomy' between mind and brain before treatment of the patient. According to the analysis of available data, this problem seems too hard to be solved, as it requires theological knowledge, of which we probably have not enough knowledge.

The Art of Pharmacotherapy: Reflections on Pharmacophobia

PURPOSE/BACKGROUND

This commentary deals with the neglected issue of the art of psychopharmacology by recounting the authors' journeys.

METHODS/PROCEDURES

First, a model of medical science situated within the history of medicine is described including (1) a limitation of the mathematical model of science, (2) the distinction between mechanistic science and mathematical science, (3) how this distinction is applied to medicine, and (4) how this distinction is applied to explain pharmacology to psychiatrists. Second, the neglected art of psychopharmacology is addressed by explaining (1) where the art of psychopharmacotherapy was hiding in the first author's psychopharmacology research, (2) how the Health Belief Model was applied to the art of medicine, (3) how the second author became interested in the Health Belief Model, and (4) his studies introducing the Health Belief Model in psychopharmacology. The authors' collaboration led to: (1) study of the effect of pharmacophobia on poor adherence and (2) reflection on the limits of the art of psychopharmacology.

FINDINGS/RESULTS

Low adherence was found in 45% (116/258) of psychiatric patients with pharmacophobia versus 22% (149/682) in those with no pharmacophobia, providing an odds ratio of 2.9 (95% confidence interval, 2.2-4.0) and an adjusted odds ratio of 2.5 (95% confidence interval, 1.8-3.5) after adjusting for other variables contributing to poor adherence.

IMPLICATIONS/CONCLUSIONS

Different cognitive patterns in different patients may contribute to poor adherence. Specific interventions targeting these varying cognitive styles may be needed in different patients to improve drug adherence.

Gender and cultural issues in psychiatric nosological classification systems

Much has changed since the two dominant mental health nosological systems, the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), were first published in 1900 and 1952, respectively. Despite numerous modifications to stay up to date with scientific and cultural changes (eg, exclusion of homosexuality as a disorder) and to improve the cultural sensitivity of psychiatric diagnoses, the ICD and DSM have only recently renewed attempts at harmonization. Previous nosological iterations demonstrate the oscillation in the importance placed on the biological focus, highlighting the tension between a gender- and culture-free nosology (solely biological) and a contextually relevant understanding of mental illness. In light of the release of the DSM 5, future nosological systems, such as the ICD 11, scheduled for release in 2017, and the Research Development Criteria (RDoC), can learn from history and apply critiques. This article aims to critically consider gender and culture in previous editions of the ICD and DSM to inform forthcoming classifications.

Self over time: another difference between borderline personality disorder and bipolar disorder

RATIONALE, AIMS AND OBJECTIVES

The nature of the relationship between bipolar disorder and borderline personality disorder has been an intense field of debate in the last two decades. Current diagnostic classifications approach this complex phenomenon using syndromatic definitions based on presence or absence of a restricted set of signs or symptoms that have demonstrated low specificity. One of the several utilities of the phenomenological method in psychiatry is to complement the clinical panorama, helping in the process of identifying potential differences between two separated clinical syndromes. The main objective of this publication is to explore one particular clinical difference between these two conditions - that is, the experience of self-continuity and time perception.

METHODS

the argument explored in this paper is based on previous second-person or phenomenological accounts of sufferers of both conditions.

RESULTS AND CONCLUSIONS

Whereas borderline personality disorder patients tend to experience only the present moment, referring frequent difficulties of drawing experiences of the past in order to determine their own future, bipolar disorder patients are constantly worried about the contradictions in their past experiences and the latent risk of losing control of themselves in future episodes of their disease. This contrast should be, however, corroborated in future research comparing directly the two groups in terms of the continuity of the self and their temporal structures.

The Kraepelinian tradition

Emil Kraepelin (1856-1926) was an influential figure in the history of psychiatry as a clinical science. This paper, after briefly presenting his biography, discusses the conceptual foundations of his concept of mental illness and follows this line of thought through to late 20th-century “Neo-Kraepelinianism,” including recent criticism, particularly of the nosological dichotomy of endogenous psychoses. Throughout his professional life, Kraepelin put emphasis on establishing psychiatry as a clinical science with a strong empirical background. He preferred pragmatic attitudes and arguments, thus underestimating the philosophical presuppositions of his work. As for nosology, his central hypothesis is the existence and scientific accessibility of “natural disease entities” (“natürliche Krankheitseinheiten”) in psychiatry. Notwithstanding contemporary criticism that he commented upon, this concept stayed at the very center of Kraepelin's thinking, and therefore profoundly shaped his clinical nosology.

Phenomenology and neurobiology of self disorder in schizophrenia: Secondary factors

Schizophrenia is a diverse and varying syndrome that defies most attempts at classification and pathogenetic explanation. This is the second of two articles offering a comprehensive model meant to integrate an understanding of schizophrenia-related forms of subjectivity, especially anomalous core-self experience (disturbed ipseity), with neurocognitive and neurodevelopmental findings. Previously we discussed the primary or foundational role of disturbed intermodal perceptional integration ("perceptual dys-integration"). Here we discuss phenomenological alterations that can be considered secondary in a pathogenetic sense--whether as consequential products downstream from a more originary disruption, or as defensive reactions involving quasi-intentional or even volitional compensations to the more primary disruptions. These include secondary forms of: 1, hyperreflexivity, 2, diminished self-presence (self-affection), and 3. disturbed "rip" or "hold" on the cognitive/perceptual field of awareness. We consider complementary relations between these secondary abnormal experiences while also considering their temporal relationships and pathogenetic intertwining with the more primary phenomenological alterations discussed previously, all in relation to the neurodevelopmental model. The secondary phenomena can be understood as highly variable factors involving overall orientations or attitudes toward experience; they have some affinities with experiences of meditation, introspectionism, and depersonalization defense. Also, they seem likely to become more pronounced during adolescence as a result of new cognitive capacities related to development of the prefrontal lobes, especially attention allocation, executive functions, abstraction, and meta-awareness. Heterogeneity in these secondary alterations might help explain much of the clinical diversity in schizophrenia, both between patients and within individual patients over time--without however losing sight of key underlying commonalities.

Phenomenology and neurobiology of self disorder in schizophrenia: Primary factors

Schizophrenia is a heterogeneous syndrome, varying between persons and over course of illness. In this and a companion article, we argue that comprehension of this condition or set of conditions may require combining a phenomenological perspective emphasizing disorders of basic-self experience ("ipseity disturbance") with a multidimensional appreciation of possible neurobiological correlates--both primary and secondary. Previous attempts to link phenomenology and neurobiology generally focus on a single neurocognitive factor. We consider diverse aspects of schizophrenia in light of a diverse, albeit interacting, set of neurocognitive abnormalities, examining both synchronic (structural) interdependence and diachronic (temporal) succession. In this article we focus on the primary or foundational role of early perceptual and motoric disturbances that affect perceptual organization and especially intermodal or multisensory perceptual integration (“perceptual dys-integration”). These disturbances are discussed in terms of their implications for three interconnected aspects of selfhood in schizophrenia, primary forms of: disrupted "hold" or "grip" on the world, hyperreflexivity, diminished self-presence (self-affection). Disturbances of organization or integration imply forms of perceptual incoherence or diminished cognitive coordination. The effect is to disrupt one's ability to apprehend the world in holistic, vital, or contextually grounded fashion, or to fully identify with or experience the unity of one's own body or thinking--thereby generating an early and profound (albeit often subtle) disruption or diminishment of basic or core self and of the sense of existing in a coherent world. We discuss interrelationships or possible complementarities between these three aspects, and consider their relevance for a neurodevelopmental account of schizophrenia.

Is psychiatry only neurology? Or only abnormal psychology? Déjà vu after 100 years

Forgetting history, which frequently repeats itself, is a mistake. In General Psychopathology, Jaspers criticised early 20th century psychiatrists, including those who thought psychiatry was only neurology (Wernicke) or only abnormal psychology (Freud), or who did not see the limitations of the medical model in psychiatry (Kraepelin). Jaspers proposed that some psychiatric disorders follow the medical model (Group I), while others are variations of normality (Group III), or comprise schizophrenia and severe mood disorders (Group II). In the early 21st century, the players' names have changed but the game remains the same. The US NIMH is reprising both Wernicke's brain mythology and Kraepelin's marketing promises. The neo-Kraepelinian revolution started at Washington University, became pre-eminent through the DSM-III developed by Spitzer, but reached a dead end with the DSM-5. McHugh, who described four perspectives in psychiatry, is the leading contemporary representative of the Jaspersian diagnostic approach. Other neo-Jaspersians are: Berrios, Wiggins and Schwartz, Ghaemi, Stanghellini, Parnas and Sass. Can psychiatry learn from its mistakes? The current psychiatric language, organised at its three levels, symptoms, syndromes, and disorders, was developed in the 19th century but is obsolete for the 21st century. Scientific advances in Jaspers' Group III disorders require collaborating with researchers in the social and psychological sciences. Jaspers' Group II disorders, redefined by the author as schizophrenia, catatonic syndromes, and severe mood disorders, are the core of psychiatry. Scientific advancement in them is not easy because we are not sure how to delineate between and within them correctly.

The Kraepelinian tradition

Emil Kraepelin (1856-1926) was an influential figure in the history of psychiatry as a clinical science. This paper, after briefly presenting his biography, discusses the conceptual foundations of his concept of mental illness and follows this line of thought through to late 20th-century "Neo-Kraepelinianism," including recent criticism, particularly of the nosological dichotomy of endogenous psychoses. Throughout his professional life, Kraepelin put emphasis on establishing psychiatry as a clinical science with a strong empirical background. He preferred pragmatic attitudes and arguments, thus underestimating the philosophical presuppositions of his work. As for nosology, his central hypothesis is the existence and scientific accessibility of "natural disease entities" ("natürliche Krankheitseinheiten") in psychiatry. Notwithstanding contemporary criticism that he commented upon, this concept stayed at the very center of Kraepelin's thinking, and therefore profoundly shaped his clinical nosology.

EPA guidance on how to improve the image of psychiatry and of the psychiatrist

Stigma against mental illness and the mentally ill is well known. However, stigma against psychiatrists and mental health professionals is known but not discussed widely. Public attitudes and also those of other professionals affect recruitment into psychiatry and mental health services. The reasons for this discriminatory attitude are many and often not dissimilar to those held against mentally ill individuals. In this Guidance paper we present some of the factors affecting the image of psychiatry and psychiatrists which is perceived by the public at large. We look at the portrayal of psychiatry, psychiatrists in the media and literature which may affect attitudes. We also explore potential causes and explanations and propose some strategies in dealing with negative attitudes. Reduction in negative attitudes will improve recruitment and retention in psychiatry. We recommend that national psychiatric societies and other stakeholders, including patients, their families and carers, have a major and significant role to play in dealing with stigma, discrimination and prejudice against psychiatry and psychiatrists.

Focusing on drug versus disease mechanisms and on clinical subgrouping to advance personalised medicine in psychiatry

Personalised medicine has finally been featured in psychiatric journals, but psychiatrists have mainly focused on the promise of using disease mechanisms to personalise treatment. Psychiatric disorders such as schizophrenia and depression are not diseases, in the medical sense, and are probably more like syndromes. Instead of spending much time and effort focusing on the mechanisms of diseases that may instead be syndromes, the author believes that psychiatrists should (1) learn more about personalising prescription via drug mechanisms, a pharmacological approach to personalised medicine; and (2) reconsider prior attempts by traditional clinical psychopharmacologists to use sophisticated clinical approaches that try to subdivide psychiatric syndromes into groups that may be more homogenous for treatment response.

One hundred years of limited impact of Jaspers' General Psychopathology on US psychiatry

Jaspers, a German psychiatrist, published General Psychopathology in 1913. Jaspers, Schneider, and Mayer-Gross were members of the Heidelberg school. General Psychopathology, indirectly through Schneider's and Mayer-Gross' textbooks and directly by its English translation in 1963, led to a narrow set of schizophrenia criteria in the United Kingdom. General Psychopathology had very limited direct impact on US psychiatry, which adopted a broader schizophrenia definition. The difference between UK and US schizophrenia was a key element in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and the neo-Kraepelinian revolution. General Psychopathology contains two essential interrelated ideas: a) psychiatry is a hybrid scientific discipline that must combine natural and social science methods that provide an explanation of illness that follows the medical model and an understanding of psychiatric abnormalities that are variations of human living, respectively, and b) psychiatric disorders are heterogeneous. Berrios' ideas on the hybridity of psychiatry in the United Kingdom and McHugh's ideas on psychiatric diagnoses in the United States can be considered neo-Jasperian approaches because they further elaborate these two Jasperian concepts in the late 20th century.