Non-standard diagnostic assessment reliability in psychiatry: a study in a Brazilian outpatient setting using Kappa.

The use of Structured Diagnostic Assessments (SDAs) is a solution for unreliability in psychiatry and the gold standard for diagnosis. However, except for studies between the 50 s and 70 s, reliability without the use of Non-SDAs (NSDA) is seldom tested, especially in non-Western, Educated, Industrialized, Rich, and Democratic (WEIRD) countries. We aim to measure reliability between examiners with NSDAs for psychiatric disorders. We compared diagnostic agreement after clinician change, in an outpatient academic setting. We used inter-rater Kappa measuring 8 diagnostic groups: Depression (DD: F32, F33), Anxiety Related Disorders (ARD: F40-F49, F50-F59), Personality Disorders (PD: F60-F69), Bipolar Disorder (BD: F30, F31, F34.0, F38.1), Organic Mental Disorders (Org: F00-F09), Neurodevelopment Disorders (ND: F70-F99) and Schizophrenia Spectrum Disorders (SSD: F20-F29). Cohen's Kappa measured agreement between groups, and Baphkar's test assessed if any diagnostic group have a higher tendency to change after a new diagnostic assessment. We analyzed 739 reevaluation pairs, from 99 subjects who attended IPUB's outpatient clinic. Overall inter-rater Kappa was moderate, and none of the groups had a different tendency to change. NSDA evaluation was moderately reliable, but the lack of some prevalent hypothesis inside the pairs raised concerns about NSDA sensitivity to some diagnoses. Diagnostic momentum bias (that is, a tendency to keep the last diagnosis observed) may have inflated the observed agreement. This research was approved by IPUB's ethical committee, registered under the CAAE33603220.1.0000.5263, and the UTN-U1111-1260-1212.

Mental illness among 500 people living homeless and referred for psychiatric evaluation in Lisbon, Portugal.

BACKGROUND: Our goal was to identify the demographic profile of the people living homeless with mental illness in Lisboa, Portugal, and their relationship with the national healthcare system. We also tried to understand which factors contribute to the number and duration of psychiatric admissions among these homeless people. METHODS: We used a cross-sectional design, collecting data for 4 years among homeless people, in Lisboa, Portugal, that were referred as possible psychiatric patients to Centro Hospitalar Psiquiátrico de Lisboa (CHPL). In total, we collected data from 500 homeless people, then cross-checked these people in our CHPL hospital electronic database and obtained 467 patient matches. RESULTS: The most common psychiatric diagnosis in our sample was drug abuse (34%), followed by alcohol abuse (33%), personality disorder (24%), and acute stress reaction (23%). Sixty-two percent of our patients had multiple diagnoses, a subgroup with longer follow-ups, more psychiatric hospitalizations, and longer psychiatric hospitalizations. The prevalence of psychotic disorders was high: organic psychosis (17%), schizophrenia (15%), psychosis not otherwise specified (14%), and schizoaffective disorder (11%), that combined altogether were present in more than half (57%) of our homeless patients. CONCLUSION: The people living homeless with multiple diagnoses have higher mental health needs and worse determinants of general health. An ongoing effort is needed to identify and address this subgroup of homeless people with mental illness to improve their treatment and outcomes.

Psychophysiological Synchrony During Verbal Interaction in Romantic Relationships.

Previous studies about romantic relationships have shown that the reciprocal influence between partners occurs not only at the behavioral and socio-emotional levels, but also at the psychophysiological level. This reciprocal influence is expressed in a pattern of physiological synchrony between partners (i.e., coordinated dynamics of the physiological time series). The main aim of the present study was to explore the presence of a pattern of physiological synchrony in electrodermal activity (EDA) during a couple interaction task. A second objective was to compare the synchrony levels during a negative interaction condition versus a positive interaction condition. Finally, we analyzed the association between synchrony and self-perception of empathy, dyadic empathy, and relationship satisfaction. Thirty-two couples (64 individuals) participated in this study. Each couple performed a structured interaction task while the EDA of both partners was being registered. The quantification of synchrony was based on the cross-correlation of both members' EDA time-series. In order to control for coincidental synchrony, surrogate datasets were created by repeatedly shuffling the original data of spouses X and Y of a dyad and computing synchronies on the basis of the shuffled data (pseudosynchrony values). Our results confirmed the presence of significant EDA synchrony during the interaction. We also found that synchrony was higher during the negative interactions relative to the positive interactions. Additionally, physiological synchrony during positive interaction was higher for those couples in which males scored higher in dyadic empathy. The clinical implications of these findings are discussed.

Estudios anteriores acerca de las relaciones amorosas han demostrado que la influencia recíproca entre las parejas no solo ocurre en los niveles conductuales y socioemocionales, sino también en el nivel psicofisiológico. Esta influencia recíproca se expresa en un patrón de sincronía fisiológica entre los integrantes de la pareja (p. ej.: la dinámica coordinada de las series temporales fisiológicas). El objetivo principal del presente estudio fue analizar la presencia de un patrón de sincronía fisiológica en la actividad electrodérmica (AED) durante una tarea de interacción de la pareja. Un segundo objetivo fue comparar los niveles de sincronía durante una situación de interacción negativa frente a una situación de interacción positiva. Finalmente, analizamos la asociación entre la sincronía y la autopercepción de empatía, la empatía diádica y la satisfacción con la relación. Treinta y dos parejas (64 personas) participaron en este estudio. Cada pareja llevó a cabo una tarea de interacción estructurada mientras se registraba la AED de ambos integrantes de la pareja. La cuantificación de la sincronía se basó en la correlación cruzada de las series temporales de la AED de ambos miembros. A fin de controlar la sincronía simultánea, se crearon conjuntos de datos sustitutos entremezclando continuamente los datos originales de los cónyuges X e Y de una díada y computando las sincronías sobre la base de los datos mezclados (valores de seudosincronía). Nuestros resultados confirmaron la presencia de una sincronía considerable de la AED durante la interacción. También descubrimos que la sincronía fue mayor durante las interacciones negativas respecto de las interacciones positivas. Además, la sincronía fisiológica durante la interacción positiva fue mayor en aquellas parejas en las cuales los hombres obtuvieron un puntaje más alto en la empatía diádica. Se debaten las consencuencias clínicas de estos resultados.

Association of Isotretinoin With Depression and Suicide: A Review of Current Literature.

Acne vulgaris, a condition that can affect people at any age, is the most common cause of referral to a dermatologist. Isotretinoin (ITT) is the most effective treatment available, but serious adverse effects, including a possible association with depression and suicide, limit its use. We review the current literature regarding the association of ITT with depression and suicide. Case reports and database studies show a clear association, and this association is biologically plausible. Although prospective studies have opposite results, limitations make them unsuitable to identify a subgroup of patients who may be at risk of developing depression or suicidal ideation with ITT. Overall, it seems some people might be at risk, particularly those with a personal or family history of mental disorder, but further studies are needed to identify those patients who would benefit from an early referral to a mental health professional when ITT is initiated. Currently, no conclusions can be drawn, and it seems appropriate to regularly screen all patients on ITT for depressive symptoms and suicidal ideation and promptly refer them to a mental health professional if any are found.

Jaspers' Phenomenology.

Karl Jaspers published the first edition of 'General Psychopathology' in 1913. Now, coinciding with its 100th anniversary whose importance was consecrated through multiple congresses, we see a parallelism and a return to the dilemma of the 'Methodenstreit', which led Karl Jaspers to introduce the phenomenological method for psychopathology to understand the subjective manifestations of the mind. Phenomenology is part of the research and clinical methods in psychiatry and psychology as a way to capture the subjective in psychopathology. However, phenomenology is nowadays wrongly used. In this article, we attempt to rediscover and present in a clear way the origins and meaning of Jaspers' phenomenology, whose bases, although forgotten, remain current. This will be done by revising its fundamental concepts such as objective and subjective manifestations, understanding and its four types, causal explanation, empathy, intuition, presuppositions and preconceptions, phenomenological description and comprehensive 'seeing'.

Validation of the Portuguese version of the Psychotic Symptom Rating Scales (PSYRATS).

The Psychotic Symptom Rating Scales (PSYRATS) is a clinical assessment tool that focuses on the detailed measurement of delusions and hallucinations in patients with psychosis. The goal of this study was to examine the psychometric properties of the Portuguese version of the PSYRATS. A sample of 92 outpatients suffering from schizophrenia or schizoaffective disorders and presenting persistent psychotic symptoms was assessed using the PSYRATS and the Positive and Negative Syndrome Scale (PANSS). Good inter-rater reliability, test-retest reliability, concurrent validity and internal consistency were found. Factor analysis of the auditory hallucinations scale items disclosed a four-factor solution: emotion characteristics and disruption factor (factor 1), a physical characteristics factor (factor 2), a control characteristics factor (factor 3) and a cognitive attribution factor (factor 4). Regarding the delusions scale items, a two-factor solution was found: cognitive interpretation and disruption factor (factor 1) and an emotional characteristics (factor 2). The Portuguese version of the PSYRATS partially replicates previously published results in other countries.

Treatment of Cognitive Deficits in Alzheimer's disease: A psychopharmacological review.

The growing and aging population has contributed to the increased prevalence of Alzheimer's disease (AD) and other types of dementia in the world. AD is a progressive and degenerative brain disease with an onset characterized by episodic memory impairments, although progressive deficits can be observed in several domains including language, executive functions, attention and working memory. The relationship between cognitive impairments and the topography and progression of brain neuropathology is well established. The pathophysiologic mechanisms and processes that underline the course of cognitive and clinical decline have been the theoretical support for the development of pharmacological treatments for AD. Cholinesterase inhibitors (ChEIs) and N-methyl-D-aspartate (NMDA) antagonists are the main drugs used in the management of global cognitive impairment and several studies also explore the effects of both in specific cognitive measures. Recent research trends also examine the effects of combination therapy using both compounds. This review aims to update practical recommendations for the treatment of global cognitive functioning and specific neurocognitive deficits in AD using ChEIs, NMDA antagonists and combination therapy with both drugs.

A psychosomatic approach to severe nausea and vomiting in liver transplant recipients with familial amyloid polyneuropathy: clinical outcome in 10 cases.

After transplant, patients with familial amyloid polyneuropathy may manifest several medical and psychiatric symptoms that can be difficult to diagnose and treat. We describe 10 liver transplant candidates with familial amyloid polyneuropathy who had severe somatic signs and symptoms (nausea and vomiting) after transplant. Their physical examinations were performed by physicians from different specialties. Before transplant, the patients' evaluations did not reveal relevant medical or psychiatric symptoms. After transplant, they had severe nausea and vomiting and high scores on the Hospital Anxiety and Depression Scale. A psychopharmacological trial with a selective serotonin reuptake inhibitor plus an antiemetic drug was unsuccessful. Remission was obtained with tricyclic antidepressants and low-dose atypical antipsychotic agents. Previous researchers had concluded that the mental quality of life in patients with familial amyloid polyneuropathy was worse after receiving a liver transplant, unlike other transplant recipients. The 10 cases described in this study are a good example of comorbid physical and mental symptoms occurring after transplant in patients with familial amyloid polyneuropathy. The conclusions of this study have implications for clinical practice, showing how a careful holistic approach in the posttransplant period is relevant in these cases.

The Neurobiology of Formal Thought Disorder.

The concept of Formal Thought Disorder (FTD) is an ambiguous and disputed one, even though it has endured as a core psychopathological construct in clinical Psychiatry. FTD can be summarized as a multidimensional construct, reflecting difficulties or idiosyncrasies in thinking, language, and communication in general and is usually subdivided into positive versus negative. In this article, we aim to explore the putative neurobiology of FTD, ranging from changes in neurotransmitter systems to alterations in the functional anatomy of the brain. We also discuss recent critiques of the operationalist view of FTD and how they might fit in its biological underpinnings. We conclude that FTD might be the observable phenotype of many distinct underlying alterations in different proportions.

Anxiety and depression in patients with giant cell arteritis.

Objectives: To compare the prevalence of anxiety and depression in patients with GCA with that in the general population, using the Hospital Anxiety and Depression Scale (HADS), and to identify independent predictors of these psychiatric manifestations in patients with GCA. Methods: We conducted a cross-sectional study including all patients diagnosed with GCA followed during 1 year in a vasculitis outpatient clinic. The HADS and 36-item Short Form (SF-36) questionnaires were prospectively collected. Patients' HADS results were compared with an age- and gender-matched control group. HADS anxiety (HADS-A) and HADS depression (HADS-D) scores between 8 and 10 defined possible anxiety and depression and ≥11 defined probable anxiety and depression, respectively. Results: We included 72 patients and 288 controls. Compared with controls, patients with GCA had a statistically significant higher prevalence of HADS-A ≥8 (48.6% vs 26.4%), HADS-A ≥11 (30.6% vs 12.2%) and HADS-D ≥11 (33.3% vs 18.1%). GCA was an independent predictor of HADS-A ≥8 [odds ratio (OR) 3.3 (95% CI 1.9, 5.9)], HADS-A ≥11 [OR 3.8 (95% CI 2.0, 7.4)] and HADS-D ≥11 [OR 2.6 (95% CI 1.4, 4.7)]. Among patients with GCA, a negative correlation was observed between HADS-A/D and SF-36 mental health scores (r = -0.780 and r = -0.742, respectively). Glucocorticoid therapy was a predictor of HADS-A ≥8 [OR 10.4 (95% CI 1.2, 94.2)] and older age of HADS-D ≥8 [OR 1.2 (95% CI 1.1, 1.3)] and HADS-D ≥11 [OR 1.1 (95% CI 1.0, 1.2)]. Conclusions: Compared with the general population, patients with GCA have a higher prevalence of anxiety and depression and GCA is an independent predictor of these symptoms. Glucocorticoid treatment and older age are predictors of anxiety and depression, respectively, in patients with GCA.

Operational criteria application does not change clinicians' opinion on the diagnosis of mental disorder: a pre- and post-intervention validity study.

Objective: Our objective was to check if the ICD-10 operational criteria application changes non-operational, prototype-based diagnoses obtained in a real-life scenario. Methods: Psychiatry residents applied the diagnostic criteria of the ICD-10 as a "diagnostic test" to five outpatient patients they were already following who had a prototype-based diagnosis. Tests were used to ascertain whether changes in opinion were significant and if any of the diagnostic groups were more prone to change than others. The present paper is part of the study with UTN U1111-1260-1212. Results: Seventeen residents reviewed their last five case files, retrieving 85 diagnostic pairs of non-operational-based vs. operational-based diagnoses. The Stuart-Maxwell test did not indicate a significant opinion change (χ2 = 5.25, p = 0.39; power = 0.94) besides 30% of diagnostic changes. Despite not being statistically significant, 20.2% of all evaluations resulted in a change that would affect treatment choices. Using ICD-10 operational criteria slightly increased the number of observed diagnoses, but probably without clinical relevance. None of the non-operational diagnoses have a higher tendency to change with operational criteria application (χ2 = 11.6, p = 0.07). The female gender was associated with a higher diagnostic change tendency. Conclusion: Applying ICD-10 operational criteria as a diagnostic test does not induce a statistically significant diagnostic opinion change in residents and no diagnostic group seems more sensible to diagnostic change. Gender-related differences in diagnostic opinion changes might be evidence of sunk cost bias. Although not statistically significant, using operational criteria after diagnostic elaboration might help to deal with subjects without adequate treatment response.

The operational paradigm in psychiatry: How valid is it?

BACKGROUND: One of the criticisms of the operational/diagnostic criteria, generalised since DSM-III, has been that they were shaped solely to achieve the best inter-peer reliability with no considerations for validity. This does not fully reflect reality since throughout the development of the criteria, there was an effort to define and fulfil some validity requirements. However, despite several attempts to create alternative diagnostic systems, there is still a widespread misunderstanding of the epistemological foundations that support this paradigm. METHODS: In this article, we intend to analyse the epistemological context in which the operational criteria (OC) emerged and some of the validation processes they have undergone since their conception. RESULTS: On the epistemological basis of these operational criteria (OC) the influence of Hempel has been widely discussed. However, the group from St. Louis and, also the DSM-III editors, never openly acknowledged his role and his contribution and revealed other influences such as other medical specialties (that used and validated several OC in the diagnosis of their diseases). On the other hand, contrary to what has often been mentioned there has been a continuous attempt to validate the OC since their conception. In the implementation and development of the operational paradigm, a more instrumental trend was followed, focused on utility, but with successive attempts to achieve realistic validity by searching for biological or psychological causality. The methodologies were initially expert-driven and gradually more data-driven and included some variables external to the construct itself, such as familial aggregation, diagnostic consistency over time, prognostic and other psychometric measures.

Inter-Rater Reliability between Structured and Non-Structured Interviews Is Fair in Schizophrenia and Bipolar Disorders-A Systematic Review and Meta-Analysis.

We aimed to find agreement between diagnoses obtained through standardized (SDI) and non-standardized diagnostic interviews (NSDI) for schizophrenia and Bipolar Affective Disorder (BD). METHODS: A systematic review with meta-analysis was conducted. Publications from 2007 to 2020 comparing SDI and NSDI diagnoses in adults without neurological disorders were screened in MEDLINE, ISI Web of Science, and SCOPUS, following PROSPERO registration CRD42020187157, PRISMA guidelines, and quality assessment using QUADAS-2. RESULTS: From 54231 entries, 22 studies were analyzed, and 13 were included in the final meta-analysis of kappa agreement using a mixed-effects meta-regression model. A mean kappa of 0.41 (Fair agreement, 95% CI: 0.34 to 0.47) but high heterogeneity (Î2 = 92%) were calculated. Gender, mean age, NSDI setting (Inpatient vs. Outpatient; University vs. Non-university), and SDI informant (Self vs. Professional) were tested as predictors in meta-regression. Only SDI informant was relevant for the explanatory model, leaving 79% unexplained heterogeneity. Egger's test did not indicate significant bias, and QUADAS-2 resulted in "average" data quality. CONCLUSIONS: Most studies using SDIs do not report the original sample size, only the SDI-diagnosed patients. Kappa comparison resulted in high heterogeneity, which may reflect the influence of non-systematic bias in diagnostic processes. Although results were highly heterogeneous, we measured a fair agreement kappa between SDI and NSDI, implying clinicians might operate in scenarios not equivalent to psychiatry trials, where samples are filtered, and there may be more emphasis on maintaining reliability. The present study received no funding.

Guidelines' recommendations for the treatment-resistant depression: A systematic review of their quality.

INTRODUCTION: Depression is a serious and widespread mental health disorder. A significant proportion of patients with depression fail to remit after two antidepressant treatment trials, a condition named treatment-resistant depression (TRD). Clinical practice guidelines (CPGs) are instruments aimed to improve diagnosis and treatment. This study objective is to systematically appraise the quality and elaborate a comparison of high-quality CPGs with high-quality recommendations aimed at TRD. METHODS AND ANALYSIS: We searched several specialized databases and organizations that develop CPGs. Independent researchers assessed the quality of the CPGs and their recommendations using AGREE II and AGREE-REX instruments, respectively. We selected only high-quality CPGs that included definition and recommendations for TRD. We investigated their divergencies and convergencies as well as weak and strong points. RESULTS: Among seven high-quality CPGs with high-quality recommendations only two (Germany's Nationale Versorgungs Leitlinie-NVL and US Department of Veterans Affairs and Department of Defense-VA/DoD) included specific TRD definition and were selected. We found no convergent therapeutic strategy among these two CPGs. Electroconvulsive therapy is recommended by the NVL but not by the VA/DoD, while repetitive transcranial magnetic stimulation is recommended by the VA/DoD but not by the NVL. While the NVL recommends the use of lithium, and a non-routine use of thyroid or other hormones, psychostimulants, and dopaminergic agents the VA/DoD does not even include these drugs among augmentation strategies. Instead, the VA/DoD recommends ketamine or esketamine as augmentation strategies, while the NVL does not mention these drugs. Other differences between these CPGs include antidepressant combination, psychotherapy as a therapeutic augmentation, and evaluation of the need for hospitalization all of which are only recommended by the NVL. CONCLUSIONS: High-quality CPGs for the treatment of depression diverge regarding the definition and use of the term TRD. There is also no convergent approach to TRD from currently high-quality CPGs.

Factors associated with higher quality of clinical practice guidelines and their recommendations for the pharmacological treatment of depression: a systematic review.

OBJECTIVE: The objective of this study was to assess the quality of clinical practice guidelines (CPGs) for the pharmacological treatment of depression along with their recommendations and factors associated with higher quality. DESIGN: We conducted a systematic review that included CPGs for the pharmacological treatment of depression in adults. DATA SOURCES: We searched for publications from 1 January 2011 to 31 December 2021, in MEDLINE, Cochrane Library, Embase, PsycINFO, BVS and 12 other databases and guideline repositories. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included CPGs containing recommendations for the pharmacological treatment of depression in adults at outpatient care setting, regardless of whether it met the U.S. National Academy of Medicine criteria, or not. If a CPG included recommendations for both children and adults, they were considered. No language restriction was applied. DATA EXTRACTION AND SYNTHESIS: Data extraction was also conducted independently and in duplicate, a process that was validated in a previous project. The quality of the CPGs and their recommendations were assessed by three independent reviewers using Appraisal of Guidelines for Research and Evaluation (AGREE II) and Appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX). A CPG was considered to be of high quality if AGREE II Domain 3 was ≥60%; while their recommendations were considered high if AGREE-REX Domain 1 was ≥60%. RESULTS: Seventeen out of 63 (27%) CPGs were classified as high quality, while 7 (11.1%) had high-quality recommendations. The factors associated with higher-scoring CPGs and recommendations in the multiple linear regression analyses were 'Handling of conflicts of interest', 'Multiprofessional team' and 'Type of institution'. 'Inclusion of patient representative in the team' was also associated with higher-quality recommendations. CONCLUSIONS: The involvement of professionals from diverse backgrounds, the handling of conflicts of interest, and the inclusion of patients' perspectives should be prioritised by developers aiming for high-quality CPGs for the treatment of depression.

Psychosocial predictors of adherence after liver transplant in a single transplant center in Portugal.

CONTEXT: Nonadherence has important implications for morbidity and mortality, reduced quality of life, and increased medical costs after transplant. OBJECTIVE; To investigate which psychiatric and psychosocial factors determine adherence after liver transplant. DESIGN: A group of 150 consecutive transplant candidates attending the outpatient clinics of the transplant unit of Hospital de Curry Cabral were studied between January 1,2006, and December 1, 2007. Among these, 84 received a transplant and of those 84, 11 recipients died, 3 received another transplant, and 8 refused to finish the study (62 patients remained). MEASURES: Before transplant, prospective recipients were assessed via the Hospital Anxiety and Depression Scale, the NEO Five-Factor Inventory, and the revised Illness Perception Questionnaire. Both before and after transplant, patients were assessed with the Multidimensional Adherence Questionnaire. RESULTS AND CONCLUSIONS: Adherence to medication improved significantly from before to after transplant. This kind of adherence after transplant was associated with adherence to medication before transplant and high scores on the personal control dimension of the Illness Perception Questionnaire before transplant. Therefore it might be useful to focus on patients with poor adherence to medication and low scores on the personal control dimension of the Illness Perception Questionnaire before transplant in order to design interventions for them.

Values in mental and medical disorder concepts: Their presence is not the point, being aware of them is.

BACKGROUND: Both in medicine and in psychiatry, it's essential to find a general definition for medical and mental disorders. For this we have to analyze the concepts behind these definitions. In this article, we intend to review the proximity between the concepts of mental and medical disorders regarding the presence of values, and to propose a way to deal with the different kinds of values that might be present. METHODS: The method used in this paper was a conceptual review/analysis. RESULTS: Regarding the concept of medical disorder, it has resorted to different sub-concepts such as dysfunction and harm (distress disability). The concept of dysfunction, apparently being less value-laden, has been prioritized in relation to the harm component although several authors have already proved that implicitly and explicitly this concept is value laden. In medical-surgical disorder it is very unlikely to find any diagnostic information that includes moral values. In this type of disorder, the values in question are universally non-moral: pain, disability, distress (or risk for these) and risk of death. On the other hand, in several mental disorders, moral values have often been included in their diagnostic criteria. CONCLUSION: It is concluded that values are present in the main concepts that have been used to define medical or mental disorder. What is essential is to understand what is descriptive and what is value and to try to avoid moral values in this context.

A commentary on Effective Connectivity Between the Orbitofrontal Cortex and the Precuneus Differentiates Major Psychiatric Disorders: Results from a Transdiagnostic Spectral DCM Study

Translational psychiatry has been a hot topic in Neurosciences research. The authors present a commentary on the relevant findings from a transdiagnostic study applicable to clinic practice. Additional discussion on conceptual and clinical insight into this current broad line of research is explored in the integration of multi-level paradigm in Psychiatry research.

How to define today a medical disorder? Biological and psychosocial disadvantages as the paramount criteria.

BACKGROUND: The 20th century has seen great developments in the concept of disease. Marked by the biopsychosocial paradigm, several strategies for disease definition were added to previous descriptive organic views, but a final concept is still out of reach. METHOD: A critical review was carried out on thorough analysis of articles and textbooks to describe the main concepts and definitions of disease. RESULTS: The concept 'disease' is a pragmatic construct, not a natural kind. Three main ways to define disease were identified, and characterized: Biological (disease as a lesion, disadvantage/deviation from normal and dysfunction), Psychosocial (distress and disability, existential potentials, descriptive prototype, and prototype typification), and values-based definition. CONCLUSION: All the paradigms have advantages and flaws, but progressive use of all criteria in disease definition adds validity and reliability to diagnostic constructs. Such constructs must be, above all, useful for practice and research. Biological paradigm is relevant, but fails to cover all the complexity that involves human illness and the treatment process. An emphasis on distress, dysfunction, and carefully selected value-laden characteristics might be the right direction for useful diagnostic construct conceptions.