Sobre alucinação e realidade: a psicose na CID-10, DSM-IV-TR e DSM-V e o contraponto psicanalítico / À propos de l’hallucination et la réalité: la psychose dans la CID-10, DSM-IV-TR et DSM-V et la et le contrepoint psychanalytique / Acerca de la alucinación y la realidad: la psicosis en la CID-10, DSM-IV-TR y DSM-V y el contrapunto psicoanalítico / Regarding hallucination and reality: the psychosis in ICD-10, DSM-IV-TR, and DSM-V and the psychoanalytic counterpoint

A psicose é um dos poucos termos da psicopatologia clássica e da psicanálise que permanece nos sistemas classificatórios atuais, como o DSM (Manual Diagnóstico Estatístico de Transtornos Mentais) e a CID (Classificação Internacional de Doenças), o que nos dá condições para investigarmos as diversas maneiras de pensar o sofrimento psíquico. Desse modo, analisamos criticamente como o DSM-IV-TR, a sua atual edição (DSM-V) e a CID-10 definem e utilizam o termo “psicose”. A apropriação desse conceito ampara-se em definição meramente descritiva como estratégia de recusa ao debate etiológico. A alucinação, um dos critérios para a classificação dos “transtornos psicóticos”, é definida partindo-se de realismo ingênuo em que a realidade é tomada objetivamente como um dado. Assim, apresentamos o contraponto psicanalítico para essa apropriação: a psicanálise aponta para a relevância da estruturação simbólica dos fenômenos perceptivos e para a realidade como construção subjetiva.

La psychose est l’un des rares termes de psychopathologie et de la psychanalyse classique qui restent dans les systèmes de classification actuels, tels que le Manuel diagnostique et statistique des troubles mentaux (DSM) et la Classification internationale des maladies (CID), qui nous donne les conditions pour enquêter sur les différents façons de penser la détresse psychologique. Ainsi, nous verrons comment le DSM-IV-TR, son numéro actuel (DSM-V) et la CID-10 définissent et utilisent le terme psychose. L’appropriation de ce concept se prend comme une définition purement descriptive de refus de stratégie de débat étiologique. L’hallucination, l’un des critères pour la classification des «troubles psychotiques¼ est définie à partir d’un réalisme naïf où la réalité est prise comme une donnée objective. Ainsi, nous présentons le contrepoint psychanalytique de cette appropriation: les points psychanalyse à la pertinence de la structuration symbolique des phénomènes de perception et la réalité comme une construction subjective.

La psicosis es uno de los pocos términos de la psicopatología clásica y el psicoanálisis que permanecen en los sistemas de clasificación actuales, tales como el Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM) y la Clasificación Internacional de Enfermedades (CID), que nos da las condiciones para investigar las distintas formas de pensar sobre la angustia psicológica. Por lo tanto, se discute cómo el DSM-IV-TR, su edición actual (DSM-V) y el CID-10 definen y utilizan el término psicosis. La apropiación de este concepto mantiene a sí misma como una definición puramente descriptiva de la negativa a la estrategia de debate etiológico. La alucinación, uno de los criterios para la clasificación de los “trastornos psicóticos” se define empezando con un realismo ingenuo donde la realidad se toma como un hecho objetivamente. Por lo tanto, presentamos el contrapunto psicoanalítica a esa apropiación: puntos psicoanálisis a la relevancia de la estructuración simbólica de los fenómenos de percepción y la realidad como una construcción subjetiva.

Psychosis is one of the few terms in classical psychopathology and psychoanalysis that remain in the current classification systems, such as the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the ICD (International Classification of Diseases), which allows to investigate the various ways of thinking about psychological distress. We discuss how the DSM-IV-TR, its current edition (DSM-V), and the ICD-10 define and use the term psychosis. The appropriation of this concept is based on a merely descriptive definition, as a refusal strategy towards etiological discussion. Hallucination, one of the criteria for the classification of “psychotic disorders”, is defined with a naive realism in which reality is taken as an objective construction. We present the psychoanalytic counterpoint to such appropriation: psychoanalysis points to the relevance of the symbolic structuring of perceptual phenomena and reality as a subjective construction.

Sobre alucinação e realidade: a psicose na CID-10, DSM-IV-TR e DSM-V e o contraponto psicanalítico / À propos de l'hallucination et la réalité: la psychose dans la CID-10, DSM-IV-TR et DSM-V et la et le contrepoint psychanalytique / Acerca de la alucinación y la realidad: la psicosis en la CID-10, DSM-IV-TR y DSM-V y el contrapunto psicoanalítico / Regarding hallucination and reality: the psychosis in ICD-10, DSM-IV-TR, and DSM-V and the psychoanalytic counterpoint

A psicose é um dos poucos termos da psicopatologia clássica e da psicanálise que permanece nos sistemas classificatórios atuais, como o DSM (Manual Diagnóstico Estatístico de Transtornos Mentais) e a CID (Classificação Internacional de Doenças), o que nos dá condições para investigarmos as diversas maneiras de pensar o sofrimento psíquico. Desse modo, analisamos criticamente como o DSM-IV-TR, a sua atual edição (DSM-V) e a CID-10 definem e utilizam o termo 'psicose'. A apropriação desse conceito ampara-se em definição meramente descritiva como estratégia de recusa ao debate etiológico. A alucinação, um dos critérios para a classificação dos transtornos psicóticos, é definida partindo-se de realismo ingênuo em que a realidade é tomada objetivamente como um dado. Assim, apresentamos o contraponto psicanalítico para essa apropriação: a psicanálise aponta para a relevância da estruturação simbólica dos fenômenos perceptivos e para a realidade como construção subjetiva.

La psychose est l'un des rares termes de psychopathologie et de la psychanalyse classique qui restent dans les systèmes de classification actuels, tels que le Manuel diagnostique et statistique des troubles mentaux (DSM) et la Classification internationale des maladies (CID), qui nous donne les conditions pour enquêter sur les différents façons de penser la détresse psychologique. Ainsi, nous verrons comment le DSM-IV-TR, son numéro actuel (DSM-V) et la CID-10 définissent et utilisent le terme psychose. L'appropriation de ce concept se prend comme une définition purement descriptive de refus de stratégie de débat étiologique. L'hallucination, l'un des critères pour la classification des ' roubles psychotiques' est définie à partir d'un réalisme naïf où la réalité est prise comme une donnée objective. Ainsi, nous présentons le contrepoint psychanalytique de cette appropriation: les points psychanalyse à la pertinence de la structuration symbolique des phénomènes de perception et la réalité comme une construction subjective.

La psicosis es uno de los pocos términos de la psicopatología clásica y el psicoanálisis que permanecen en los sistemas de clasificación actuales, tales como el Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM) y la Clasificación Internacional de Enfermedades (CID), que nos da las condiciones para investigar las distintas formas de pensar sobre la angustia psicológica. Por lo tanto, se discute cómo el DSM-IV-TR, su edición actual (DSM-V) y el CID-10 definen y utilizan el término psicosis. La apropiación de este concepto mantiene a sí misma como una definición puramente descriptiva de la negativa a la estrategia de debate etiológico. La alucinación, uno de los criterios para la clasificación de los trastornos psicóticos se define empezando con un realismo ingenuo donde la realidad se toma como un hecho objetivamente. Por lo tanto, presentamos el contrapunto psicoanalítica a esa apropiación: puntos psicoanálisis a la relevancia de la estructuración simbólica de los fenómenos de percepción y la realidad como una construcción subjetiva.

Abstract Psychosis is one of the few terms in classical psychopathology and psychoanalysis that remain in the current classification systems, such as the DSM (Diagnostic and Statistical Manual of Mental Disorders) and the ICD (International Classification of Diseases), which allows to investigate the various ways of thinking about psychological distress. We discuss how the DSM-IV-TR, its current edition (DSM-V), and the ICD-10 define and use the term psychosis. The appropriation of this concept is based on a merely descriptive definition, as a refusal strategy towards etiological discussion. Hallucination, one of the criteria for the classification of psychotic disorders is defined with a naive realism in which reality is taken as an objective construction. We present the psychoanalytic counterpoint to such appropriation: psychoanalysis points to the relevance of the symbolic structuring of perceptual phenomena and reality as a subjective construction.

Psychosis and schizophrenia: effects of changes in psychiatric classifications on clinical and theoretical approaches to mental illness. / Psicose e esquizofrenia: efeitos das mudanças nas classificações psiquiátricas sobre a abordagem clínica e teórica das doenças mentais.

This article discusses changes in the diagnostic classification systems for mental illness, especially the conceptual weakening of the "psychosis" category while schizophrenia became the only psychosis. Current pathological classifications prioritize a physicalist approach. Consequently, conditions that previously were associated with neurosis and subjectivity are being medicalized, conditions previously recognized as psychotic are relocated under the heading of personality disorders, and psychosis has been reduced to schizophrenia and considered a deficit of psychic functions. This article indicates the clinical and operational validity of the notion of "psychosis" as a nosographic category permitting a more complex approach to "schizophrenia", which in psychiatry is the last concept that bears the symbolic weight of madness.

Psicose e esquizofrenia: efeitos das mudanças nas classificações psiquiátricas sobre a abordagem clínica e teórica das doenças mentais / Psychosis and schizophrenia: effects of changes in psychiatric classifications on clinical and theoretical approaches to mental illness

Resumo Abordam-se as mudanças nos sistemas de classificação diagnóstica das doenças mentais, em especial o enfraquecimento conceitual da categoria “psicose” e a dominância da esquizofrenia como psicose única. As classificações atuais priorizam uma abordagem fisicalista da patologia mental. Ocorrem, então, a medicalização das condições antes associadas à neurose e à subjetividade; a localização de quadros antes reconhecidos como psicóticos na rubrica dos transtornos de personalidade; e a redução da psicose à esquizofrenia, abordada como deficit das funções psíquicas. Aponta-se a validade clínica e operatória da noção de “psicose” como categoria nosográfica que permite abordagem mais complexa da “esquizofrenia”, última noção, na psiquiatria, com o peso simbólico da loucura.

Abstract This article discusses changes in the diagnostic classification systems for mental illness, especially the conceptual weakening of the “psychosis” category while schizophrenia became the only psychosis. Current pathological classifications prioritize a physicalist approach. Consequently, conditions that previously were associated with neurosis and subjectivity are being medicalized, conditions previously recognized as psychotic are relocated under the heading of personality disorders, and psychosis has been reduced to schizophrenia and considered a deficit of psychic functions. This article indicates the clinical and operational validity of the notion of “psychosis” as a nosographic category permitting a more complex approach to “schizophrenia”, which in psychiatry is the last concept that bears the symbolic weight of madness.

Values and DSM-5: looking at the debate on attenuated psychosis syndrome.

BACKGROUND: Although values have increasingly received attention in psychiatric literature over the last three decades, their role has been only partially acknowledged in psychiatric classification endeavors. The review process of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) received harsh criticism, and was even considered secretive by some authors. Also, it lacked an official discussion of values at play. In this perspective paper we briefly discuss the interplay of some values in the scientific and non-scientific debate around one of the most debated DSM-5 category proposals, the Attenuated Psychosis Syndrome (APS). Then, we point out some ethical consequences of a facts-plus-values perspective in psychiatric classification. DISCUSSION: Different stakeholders participated in the APS-debate and for analytical purposes we divided them into four groups: (i) researchers in the field of high-risk mental states; (ii) the DSM-5 Psychotic Disorders Work Group; (iii) patient, carers and advocacy groups; and (iv) external stakeholders, not related to the previous groups, but which also publicly expressed their opinions about APS inclusion in DSM-5. We found that each group differently stressed the role of values we examined in the APS-debate. These values were ethical, but also epistemic, political, economic and ontological. The prominence given to some values, and the lack of discussion about others, generated divergent positions among stakeholders in the debate. As exemplified by the APS discussion, although medicine is primarily an ethical endeavor, values of different kinds that take part in it also shape to a large extent the profession. Thus, it may be strategic to openly discuss values at play in the elaboration of diagnostic tools and classificatory systems. This task, more than scientifically or politically significant, is ethically important.

[Historical and conceptual evolution of non-schizophrenic psychotic disorders in DSM]. / Evolución histórica y conceptual de los trastornos psicóticos no esquizofrénicos en los DSM.

After firmly established the "kraepelinean dichotomy" (dementia praecox - manic-depressive insanity), classical psychiatry began to describe a group of psychotic disorders which did not fit in any of these main diagnoses. Many of these clinical pictures where incorporated to the DSM and underwent several changes throughout the successive editions of the American manual. This article aims to make a historical and conceptual overview of this group of non-schizophrenic psychotic disorders accompanying schizophrenia in the "Schizophrenia spectrum and other psychotic disorders" chapter of DSM-5.

Evolución histórica y conceptual de los trastornos psicóticos no esquizofrénicos en los DSM. / [Historical and conceptual evolution of non-schizophrenic psychotic disorders in DSM].

After firmly established the "kraepelinean dichotomy" (dementia praecox - manic-depressive insanity), classical psychiatry began to describe a group of psychotic disorders which did not fit in any of these main diagnoses. Many of these clinical pictures where incorporated to the DSM and underwent several changes throughout the successive editions of the American manual. This article aims to make a historical and conceptual overview of this group of non-schizophrenic psychotic disorders accompanying schizophrenia in the "Schizophrenia spectrum and other psychotic disorders" chapter of DSM-5.

Evolución histórica y conceptual de los trastornos psicóticos no esquizofrénicos en los DSM / [Historical and conceptual evolution of non-schizophrenic psychotic disorders in DSM].

After firmly established the "kraepelinean dichotomy" (dementia praecox - manic-depressive insanity), classical psychiatry began to describe a group of psychotic disorders which did not fit in any of these main diagnoses. Many of these clinical pictures where incorporated to the DSM and underwent several changes throughout the successive editions of the American manual. This article aims to make a historical and conceptual overview of this group of non-schizophrenic psychotic disorders accompanying schizophrenia in the "Schizophrenia spectrum and other psychotic disorders" chapter of DSM-5.

The psychosis continuum in the general population: findings from the São Paulo Epidemiologic Catchment Area Study.

The aim of the study was to examine the psychosis continuum in a Latin-American community setting. Data were from the Brazilian São Paulo Epidemiologic Catchment Area Study, a cross-sectional survey conducted in two boroughs of the city of São Paulo. The Composite International Diagnosis Interview (version 1.1) was applied to a probabilistic sample of 1,464 adults, who were interviewed in their household, in order to identify the presence of psychotic symptoms. A subsample was assessed with Schedules for Clinical Assessment in Neuropsychiatry interview. We described the occurrence of psychotic symptoms, categorized into subgroups according to their clinical impact, disability, and help-seeking behavior. The correlation of socio-demographic variables, depressive symptoms, and alcohol and substance use disorders with those psychotic subgroups was analyzed. Polychotomic logistic regression tested the associations between subgroups of psychosis (clinical and subclinical) and the correlates. Of the total sample, 38.0% presented at least one lifetime psychotic symptom, 1.9% met the criteria for an ICD-10 diagnosis of non-affective psychosis, 5.4% presented clinically relevant psychotic symptoms, and 30.7% endorsed clinically non-relevant symptoms. The most common psychotic symptom was delusion with a plausible explanation (in 18.6%). The presence of any psychiatric diagnosis was associated with the presence of psychotic symptoms (OR range, 1.9-8.9). Subclinical psychosis subgroups were found to be associated with the 18-24 year age bracket, chronic depressive mood, and alcohol use disorder. Our results support the concept of a psychosis continuum in Latin-American populations, suggesting that different risk factors influence their manifestation across the continuum.

Diagnosis of schizophrenia in latino populations: a comparison of direct interview and consensus based multi-source methods.

We determined the rates of agreement between diagnoses, using the Diagnostic Interview for Genetic Studies (DIGS) and diagnoses arrived at, using additional sources of information, to establish whether there are differences in agreement between direct interview diagnoses at US and non-US sites in comparison best estimate consensus process and to identify diagnoses that could increase diagnostic error when only the DIGS is used. DIGS diagnoses were compared with consensus diagnoses that used the same DIGS interview, plus Family Interview for Genetic Studies (FIGS) and review of medical records in 342 psychotic subjects. We found similar numbers of subjects diagnosed with schizophrenia (225 by direct interview, and 232 by consensus process). The majority of those "misdiagnosed" by direct interview had mood disorder by the consensus. Over 10% of the total subjects diagnosed by direct interview as not meeting criteria for schizophrenia had schizophrenia by consensus. There were no statistically significant differences between countries (US vs. non-US sites) in the agreement rate between direct interview diagnosis and consensus diagnosis. In conclusion, a final best-estimate process is essential to make diagnostic distinctions and to reduce diagnostic misclassifications for both research studies and in clinical practice.

The diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder and unipolar depression: interrater reliability and congruence between DSM-IV and ICD-10.

BACKGROUND: The present study investigated the interrater reliability of the diagnoses of schizophrenia (SCH), schizoaffective disorder (SAD), bipolar disorder (BPD) and unipolar depression (UPD) according to both DSM-IV and ICD-10, as well as the diagnostic congruence between the two classificatory systems. SAMPLING AND METHODS: Using the Composite International Diagnostic Interview, two trained psychiatrists simultaneously evaluated 100 inpatients and independently assessed the psychiatric diagnoses. The Cohen's kappa coefficient was employed to estimate interrater reliability and diagnostic congruence between DSM-IV and ICD-10. RESULTS: SCH was more frequent according to ICD-10 than DSM-IV criteria. Considering both diagnostic systems, all the four nosological categories, but ICD-10 SAD and DSM-IV UPD, were associated with interrater reliability coefficients above 0.50. The coefficient of the diagnostic congruence between DSM-IV and ICD-10 was inferior to 0.50 only for SAD. BPD was associated with the highest degrees of both interrater reliability and diagnostic congruence. CONCLUSIONS: The lack of an item excluding the occurrence of an affective syndrome among ICD-10 diagnostic criteria for SCH can account for: the larger frequency of SCH according to ICD-10 than DSM-IV; the unsatisfactory interrater reliability for the diagnosis of ICD-10 SAD, and the low diagnostic congruence for SAD.

Does schizoaffective disorder really exist? A systematic review of the studies that compared schizoaffective disorder with schizophrenia or mood disorders.

BACKGROUND: Since its first definition in the literature, schizoaffective disorder (SAD) has raised a considerable controversy regarding its clinical distinction from schizophrenia (SCH) and mood disorders (MD) as well as its validity as an independent nosological category. OBJECTIVE: Investigate the validity of SAD as a discrete nosological category and its relationship with SCH and MD. METHOD: A systematic literature review of clinical trial that compared SAD with SCH and/or MD patients was carried out throughout MEDLINE, psycINFO, Cochrane Library, SCIELO and LILACS databases. RESULTS: Evaluation of demographic characteristics, symptomatology, other clinical data, dexamethasone suppression test, neuroimage exams, response to treatment, evolution and family morbidity indicated that SAD occupies an intermediate position between SCH and MD. Literature review also failed to indicate a clear cut distinction between SAD and SCH or MD. DISCUSSION: Present analysis indicated that SAD cannot be interpreted as atypical forms of SCH or MD. SAD also does not appear to represent a SCH and MD comorbidity or yet an independent mental disorder. It is argued that SAD might constitute a heterogeneous group composed by both SCH and MD patients or a middle point of a continuum between SCH and MD.

Psychiatric disorders in juvenile myoclonic epilepsy: a controlled study of 100 patients.

In this controlled study we evaluated the frequency of psychiatric disorders (PDs) in 100 patients with juvenile myoclonic epilepsy (JME) and compared it with that of 100 healthy controls matched with respect to age, gender, schooling, and socioeconomic status. Our aim was to quantify the frequency of PDs and evaluate the relationship between PDs and factors related to epilepsy. Subjects were evaluated with the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) and Axis II disorders (SCID-II). Patients with JME presented with significantly more PDs (P<0.01) and psychosocial problems (P<0.01) than the controls. PDs were diagnosed in 49 patients with JME. Anxiety and mood disorders, present in 23 and 19 patients, respectively, were the most frequently observed. Twenty patients fulfilled criteria for personality disorders; 17 (85%) patients had cluster B personalities comprising the behavioral characteristics impulsivity, humor reactivity, emotional instability, and difficulty in accepting social rules, similar to those cited in the earliest mentioned description of this syndrome. PDs were more frequently observed in patients with higher seizure frequency (P<0.05).

Atendimento a pacientes dependentes de drogas: atuação conjunta do psicólogo e do psiquiatra / Attendance of drug-dependent patients: psychologists and psychiatrists in team-work

Muito se tem discutido acerca da interrelação entre psicólogos e psiquiatras quanto ao tratamento multidisciplinar de seus pacientes, e este aspecto constituiu-se no objetivo principal desta investigação. O material utilizado constou de um roteiro de entrevista com perguntas abertas, analisado segundo o método de Lefèvre e Lefèvre, tendo como amostra três psicólogos e três psiquiatras em um ambulatório de uma instituição pública de saúde do Estado de São Paulo. As conclusões resultantes desta pesquisa revelam ainda existirem pontos de divergência entre as especialidades, mas sugerem perspectivas de entrosamento no que se refere ao entendimento e expectativas entre elas.(AU)

The interrelationship amongst psychologists and psychiatrists has been an issue in terms of multidisciplinary team related to the treatment of their patients, and this aspect constituted the focus of this investigation. Three psychologists and three psychiatrists from a State Public Health Institution in Sao Paulo were interviewed and their responses to open questions were analyzed by means of the qualitative method proposed by Lefèvre and Lefèvre. The main conclusions reveal that there still are divergences amongst these specialties, but also that perspectives of mutual understanding of their professional roles can be seen.(AU)