A Comparative Study on Mental Disorder Conceptualization: A Cross-Disciplinary Analysis.

The conceptualization of mental disorders varies among professionals, impacting diagnosis, treatment, and research. This cross-disciplinary study aimed to understand how various professionals, including psychiatrists, psychologists, medical students, philosophers, and social sciences experts, perceive mental disorders, their attitudes towards the disease status of certain mental states, and their emphasis on biological versus social explanatory attributions. A survey of 371 participants assessed their agreement on a variety of conceptual statements and the relative influence of biological or social explanatory attribution for different mental states. Our findings revealed a consensus on the need for multiple explanatory perspectives in understanding psychiatric conditions and the influence of social, cultural, moral, and political values on diagnosis and classification. Psychiatrists demonstrated balanced bio-social explanatory attributions for various mental conditions, indicating a potential shift from the biological attribution predominantly observed among medical students and residents in psychiatry. Further research into factors influencing these differing perspectives is necessary.

Explanatory methods in psychiatry: interview with Paul McHugh, MD.

This interview with Paul McHugh, MD, delves into his Perspectives approach to psychiatry. Building on the philosophical work of forerunners such as Adolf Meyer and Karl Jaspers, the Perspectives approach identifies four explanatory methods underlying the practice of the profession: the perspectives of brain diseases, personality dimensions, motivated behaviours, and life encounters. The disease perspective describes how neurobiological injuries can disrupt the functioning of the brain, as with delirium or dementia. The dimensional perspective describes the vulnerabilities of some individuals to emotional unrest tied to aspects of the self-defining features characterising them, as with intellectual disability or personality disorders. The behaviour perspective describes problematic, habit-sustained activities that arise from the teleological features, as with anorexia nervosa or alcohol dependence. The life story perspective describes how emotional distresses is generated by the interaction of life events and the extrinsic/experiential features of mind, as with grief, post-traumatic stress disorder, or demoralisation. The Perspectives approach structures and operationalises the several elements of a psychiatric formulation, with the understanding that the approach to an individual patient requires us to take into account several different aspects of their life and state of mind in making sense of their presentation.

Scepticism of the gentle variety: interview with Derek Bolton, PhD.

This interview with Derek Bolton, PhD, goes into a discussion of his philosophical work on the diagnosis and definition of mental disorder, the basis of the standards or norms by which we judge that a person has a mental disorder, and the validity of the distinction between abnormal and normal mental functioning. Bolton argues that the notion that emerges from a conceptual analysis of psychiatry's diagnostic manuals is not a naturalist notion of disorder, but one that is focussed on harm and suffering, and in which the personal, the social and the biological cannot be clearly distinguished. The implications of this thinking with regards to the relationship between the medical model and the psychological approaches are also discussed. His most recent philosophical work reconceptualizes the biopsychosocial model as a philosophical theory of biopsychosocial causal interactions and he argues that there are causal regulatory functions within the psychological domain, and this is so independent of whether they can be captured by a physicochemical description of brain processes.

Psychiatric disorders as an imperfect community: interview with Peter Zachar, PhD.

This interview with Peter Zachar, PhD, discusses his 2014 book 'A Metaphysics of Psychopathology', and explores his application of the philosophy of scientifically-inspired pragmatism to psychiatric classification, his critique of essentialistic thinking in psychiatry, and his notion of the imperfect community model with regards to psychiatric disorders. The imperfect community is a non-essentialist idea, namely, that the various members of the class of psychiatric disorders have many things in common, but there is no one thing (an essence) that they all have in common that distinguishes them as a group from non-disorders. The resulting domain is, however, not random or arbitrary - new constructs have been introduced for reasons that reflect our scientific goals and pragmatic interests. Zachar is sceptical about the possibility of a single correct and privileged psychiatric classification, but he recognises that the ways in which psychiatric symptoms empirically cluster together places constraints on psychiatric classification that, for instance, don't apply to organising libraries. Classifications are contingent on multiple factors, including our scientific knowledge and goals. Epistemic and evaluative commitments, once identified, work together in a non-arbitrary way to constrain what counts as a good solution to the question of classification.

Conceptual and historical evolution of psychiatric nosology.

Psychiatric taxonomies exist within conceptual frameworks which presuppose certain conceptions of psychiatric distress and offer guiding principles. This article provides an overview of the historical development of psychiatric classifications with an emphasis on their methodological assumptions. After identifying roots of scientific psychiatric classifications in the works of Sydenham and Linnaeus and discussing early classification systems, our survey focuses on the Kahlbaum-Hecker-Kraepelin paradigm (with its emphasis on longitudinal course of illness), the Wernicke-Kleist-Leonhard tradition (with its emphasis on neural systems), the development of the ICD and the DSM classifications (with their roots in medical statistics, their pragmatic nature, and their emphasis on descriptive and operationalized criteria), psychodynamic and idiographic perspectives (e.g. the Psychodynamic Diagnostic Manual), and transdiagnostic approaches (e.g. Research Domain Criteria). The central philosophical questions of nosology (descriptive vs aetiological, symptoms vs course of illness, idiographic vs nomothetic, categorical vs dimensional, etc.) have appeared and reappeared throughout this evolution. Ongoing controversies reflect the epistemological and ontological difficulties inherent in defining and classifying mental illness. It may be that no single taxonomy can satisfy all clinical, research, and administrative needs, and that, echoing the ideas of Aubrey Lewis, multiple systems may be required to serve different needs.

Mental disorder and social deviance.

Social deviance refers to actions or behaviours that violate social norms. Since the declassification of homosexuality and development of DSM-III, one of the aims of a definition of mental disorder has been to make explicit the distinction between mental disorder and social deviance. It is well-recognized that psychiatric disorders frequently manifest as violations of social norms, and the validity of the distinction between disorder and deviance has been of great interest to philosophers of psychiatry. This article provides an overview of some of the major conceptual strategies that have been discussed as a means of discriminating between mental disorder and social deviance, and the extent to which these strategies can be said to be philosophically successful. Specifically, we review DSM's definition of mental disorder, notions of dysfunctions (commonsensical, clinical, naturalist), intrinsic and socially constituted distress, disability, 3E perspectives and functional norms, and ethical and political approaches to this question. Current philosophical strategies don't offer a distinct dividing line between disorder and deviance, but they help illuminate the relevant considerations involved. It may be concluded that the distinction between disorder and deviance is not simply discovered but also negotiated between competing values.

Age-Related Differences in Medication Adherence, Symptoms, and Stigma in Poorly Adherent Adults With Bipolar Disorder.

OBJECTIVE: We present a secondary analysis of data reporting differences in medication adherence, psychiatric symptom severity, and internalized stigma levels in older (age ≥ 55 years) versus younger (age < 55 years) adults with bipolar disorder (BD) and poor medication adherence. METHODS: Data used for this analysis came from 184 participants in a National Institute of Mental Health-funded randomized controlled trial, comparing a customized adherence enhancement (CAE) intervention intended to promote BD medication adherence with a BD-specific educational program (EDU). At screen, study participants were ≥20% nonadherent with BD medications as measured by the Tablets Routine Questionnaire (TRQ). Psychiatric symptoms, functional status, and internalized stigma were measured using validated scales. RESULTS: Older adults had significantly lower anxiety disorder comorbidity (P < .01 for 1 or more anxiety disorders), depressive symptom severity scores (P = .011), and self-stigma scores (P = .001) compared to their younger counterparts. In the analyses evaluating change over time in TRQ between older and younger participants by treatment arm (ie, CAE and EDU), there was a significant finding of interaction between time, age-group, and treatment arm (P = .007). CONCLUSIONS: Older adults may be less anxious and depressed, with less self-stigma, compared to younger people with BD and poor adherence. With respect to medication adherence, older individuals in EDU appear to do less well than younger individuals over time.

Conceptualizations of Mental Disorder at a US Academic Medical Center.

How health care professionals conceptualize mental illness has received relatively little attention in existing literature. This survey explored how health care professionals, academic faculty, and trainees at a US academic medical center (departments of psychiatry, neurology, family medicine, and geriatric medicine, as well as medical students, nurses, and social workers) conceptualize the notion of mental disorder. Respondents (N = 209) were asked to rate their agreement or disagreement with a variety of conceptual statements. Overall, distress and impairment were seen as essential features of mental disorder, and the presence of a biological abnormality was not considered necessary. There was significant correlation between disease status and biological etiology attribution for all conditions except homosexuality. Psychology trainees and psychologists were significantly less likely to call a condition a disease compared with other groups. There was a general lack of consensus regarding conceptual issues fundamental to psychiatry. Conceptualizations of mental disorder held by respondents were complex and did not fit easily within the "biological psychiatry" paradigm.

The Association Between Leukotriene-Modifying Agents and Suicidality: A Review of Literature.

BACKGROUND: In 2008 Food and Drug Administration issued a warning regarding a possible association between leukotriene-modifying agents and suicidality. OBJECTIVE: The warning remains controversial and this review of literature is an attempt to examine the evidence on the matter. METHODS: Literature search on PubMed. RESULTS: The data supporting a relationship between leukotriene-modifying agents and suicidality comes primarily from reviews of individual safety reports in adverse event databases; it is subject to considerable reporting bias and does not control for confounding factors. Case-control and cohort studies as well as data from clinical trials do not support an association between leukotriene-modifying agents and suicidality. The data from ecological studies offers strong evidence of a lack of positive association between leukotriene-modifying agents and suicide outcomes (attempts and deaths) at the population level. Furthermore, there is no pharmacological mechanism that would explain an association between the two. CONCLUSION: Overall, the weight of higher quality evidence casts doubt on the association (especially at population level), but is not enough to conclusively disprove the association at an individual level.

Nonconvulsive Status Epilepticus After Electroconvulsive Therapy: A Review of Literature.

BACKGROUND: The clinical presentation and risk factors of nonconvulsive status epilepticus (NCSE) in the context of electroconvulsive therapy (ECT) are poorly understood, and guidance regarding diagnosis and management remains scarce. In this article, we identify case reports of ECT-induced NCSE from literature, and discuss the presentation, diagnosis, and management of these cases in the context of what is known about NCSE from the neurology literature. METHODS: A literature search on PubMed for case reports of NCSE after ECT. RESULTS: We identified 13 cases for this review. Diagnosis in all cases was based on clinical features and electroencephalogram (EEG) findings. Clinical presentation was altered mental status or unresponsiveness, with subtle motor phenomena in some cases. All cases had nonspecific risk factors that have been associated with prolonged seizures and convulsions, such as recent discontinuation/reduction of benzodiazepines or anticonvulsants, and concurrent use of antipsychotics and antidepressants. All patients were treated with either benzodiazepines or antiepileptic agents. Outcomes in these post-ECT NCSE cases were generally favorable. DISCUSSION: Although rare, post-ECT NCSE should be kept in mind by physicians when confusion or unresponsiveness develops and continues after ECT; multilead EEG is gold standard for diagnosis. An intravenous (IV) antiepileptic drug (AED) challenge can help clarify the diagnosis. Initial treatment is recommended with IV benzodiazepines, with a repeat dose if necessary. If seizures persist, IV AEDs are warranted. NCSE refractory to this treatment should be treated with a scheduled IV or oral AED. Serial multilead EEGs should be used to monitor resolution of symptoms. CONCLUSION: NCSE after ECT is a rare but recognizable clinical event. A high clinical suspicion and low threshold for EEG is necessary for prompt diagnosis.

Associations of Comorbid Anxiety With Medication Adherence and Psychiatric Symptomatology in a Population of Nonadherent Bipolar Disorder Subjects.

This analysis was conducted on baseline data from 178 nonadherent bipolar disorder subjects in a randomized controlled trial. Medication adherence was measured with Tablets Routine Questionnaire as percentage of days with missed doses. Inclusion criteria required at least 20% nonadherence. Medication adherence, symptomatology, and functioning in individuals with and without a comorbid anxiety disorder were compared. There were 78.9% of subjects who had at least one or more current anxiety disorder, with the most common being posttraumatic stress disorder, panic disorder, and generalized anxiety disorder. The percentage of days with missed doses over the past month was significantly lower in those with anxiety disorders compared with those without (40.1% vs 50.5%, p = 0.03). Those with comorbid anxiety disorders and those with greater number of anxiety disorder diagnoses had significantly worse mean scores on the Montgomery-Åsberg Depression Rating Scale, Brief Psychiatric Rating Scale, Clinical Global Impression-Bipolar Version, and Global Assessment of Functioning.

Associations among comorbid anxiety, psychiatric symptomatology, and diabetic control in a population with serious mental illness and diabetes: Findings from an interventional randomized controlled trial.

Objective Serious mental illness and type II diabetes mellitus have a high comorbidity, and both have a higher prevalence of anxiety disorders compared to the general population. Targeted Training in Illness Management is a group-based self-management training approach which targets serious mental illness and type II diabetes mellitus concurrently. This analysis examines data from a randomized controlled trial of Targeted Training in Illness Management intervention to examine the impact of comorbid anxiety on baseline psychiatric symptomatology and diabetic control, and on longitudinal treatment outcomes. Methods We conducted secondary analyses on data from a prospective, 60-week, randomized controlled trial testing Targeted Training in Illness Management versus treatment as usual in 200 individuals with serious mental illness and diabetes. Primary outcomes included measures related to serious mental illness symptoms, functional status, general health status, and diabetes control. Measures were compared between those participants with anxiety disorders versus those without anxiety at baseline as well as over time using linear mixed effects analyses. Results Forty seven percent of the participants had one or more anxiety disorders. At baseline, those with an anxiety diagnosis had higher illness severity, depressive, and other psychiatric symptomatology and disability. Diabetic control (HbA1c) was not significantly different at baseline. In the longitudinal analyses, no significant mean slope differences over time (group-by-time interaction effect) between those with anxiety diagnoses and those without in treatment as usual group were found for primary outcomes. Within the Targeted Training in Illness Management arm, those with anxiety disorders had significantly greater improvement in mental health functioning. Those with anxiety comorbidity in the Targeted Training in Illness Management group demonstrated significantly lower HbA1c levels compared to no anxiety comorbidity and also demonstrated a greater improvement in HbA1c over the first 30 weeks compared to those without anxiety comorbidity. Conclusion Comorbid anxiety in serious mental illness and type II diabetes mellitus population is associated with increased psychiatric symptomatology and greater disability. Individuals from this population appear to experience greater improvement in functioning from baseline with the Targeted Training in Illness Management intervention. Anxiety comorbidity in the serious mental illness and type II diabetes mellitus population does not appear to have a negative impact on diabetic control. These complex relationships need further study. Clinical Trials Registration ClinicalTrials.gov: Improving outcomes for individuals with serious mental illness and diabetes (NCT01410357).

Flibanserin and its discontents.

In August 2015, flibanserin (brand name Addyi) was approved by the Food and Drug Administration (FDA) for treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. This article summarizes and promotes discussion regarding the numerous controversies that have enclosed flibanserin since the very beginning. This includes questions related to flibanserin's safety and efficacy and the validity of the clinical trials. Also included are philosophical considerations surrounding the diagnosis of hypoactive sexual desire disorder and pharmacological treatment of low libido. Based on the review of literature, authors judge flibanserin to be modestly effective and reasonably safe, and discuss the differences in philosophical perspectives with less definitive answers.

Measuring Perceived Educational Impact of a Resident-Led Research Newsletter.

OBJECTIVE: To determine the perceived educational impact of a resident-led psychiatry research newsletter ('Research Watch') on the psychiatry residents at the authors' residency program. METHODS: An anonymous, voluntary paper questionnaire was distributed to all psychiatry residents at the program. The survey inquired about the degree of exposure (quantified as 'exposure index') and contribution to the newsletter. A set of questions asked residents to estimate how much of the improvement they attributed to the influence of the newsletter, rating the attribution between 0 and 100%, in the areas of interest in scholarly activities/research, knowledge of current psychiatric research, and participation in scholarly activities/research. The survey also inquired if the newsletter had any impact on their clinical practice. RESULTS: Of 29 residents in the program who received the survey, 27 (93%) responded. The percentage of residents reporting perceived non-zero impact of the newsletter on specific areas of improvement was as follows: interest in scholarly activities/research (44%), knowledge of current psychiatric research (48%), participation in scholarly activities/research (40%), and clinical practice (40%). Exposure index significantly and positively correlated with self-reported percentage attribution for knowledge (correlation coefficient 0.422, p value 0.028) and self-reported impact on clinical practice (correlation coefficient 0.660, p value 0.000), and degree of contribution significantly and positively correlated with self-reported percentage attribution for knowledge (correlation coefficient 0.488, p value 0.010). CONCLUSIONS: A resident-led research newsletter can have a positive perceived impact on the residents' interest, knowledge, and participation in research, as well as a positive perceived impact on clinical practice.

Pathophysiological Role of HERV-W in Schizophrenia.

Schizophrenia is a neuropsychiatric disorder of complex etiology. Human endogenous retroviruses (HERVs) have been presented as possible candidates explaining the connections between the genetic, infectious, neurodevelopmental, and neuroinflammatory aspects of schizophrenia, with the human endogenous retrovirus type W family (HERV-W) showing the greatest evidence of association. Studies have identified retroviral nucleotide sequences, envelope and capsid proteins, and elevated transcription of HERV-W elements in CSF, blood, and brain samples from individuals with schizophrenia. The HERV-W elements can trigger the immune system in a variety of ways. HERV genetic elements may be activated by various prenatal maternal infections, leading to neuroinflammation and genetic abnormalities, altering the development of the brain, and eventually culminating in the development of schizophrenia. This review presents a concise synthesis of available evidence and theoretical speculation regarding the role of HERV-W in schizophrenia. The need for further investigation is highlighted before any conclusions can be stated with confidence.