Posts Tagged ‘DSM’

Exibição do filme: ‘A céu aberto, entrevistas. Le Courtil, a invenção no dia a dia’  de Mariana Otero

Após a axibição do filme, haverá um debate conduzido pelas psicanalistas:

Monica Nezan (Master Profissional em Psicologia e Psicopatologia na Universidade Paris V – Sorbone e Especialista em transtornos globais do desenvolvimento pelo Lugar de Vida)

Camille Gavioli (Mestre em Educação e Psicologia pela FEUSP, Especialista em transtornos globais do desenvolvimento pelo Lugar de Vida, Psicóloga nos Centros de Excelência em Especialidades Pediátricas no Hospital Sabará)

Data: 31 de março de 2016 ; Horário: das 18h30 às 21h30

 

Mais informações: http://www.lugardevida.com.br/home_not00.php?id=156

Anúncios

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Dia 19 de setembro, evento em Cuiabá, com o filme “O silêncio que fala” de Miriam Chnaiderman

Inscrições debateosilencioquefalacba@gmail.com

silencio

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topo_inicio

CFP e OAB promovem seminário sobre manicômios no Brasil

Durante o evento, que acontece em setembro, será lançado relatório com resultados de inspeções realizadas por Conselhos Regionais de Psicologia em manicômios judiciários de 17 estados

O Conselho Federal de Psicologia (CFP) e a Ordem dos Advogados do Brasil (OAB) promovem, nos próximos dias 15 e 16 de setembro, em Brasília, o Seminário “A desconstrução da lógica manicomial – construindo alternativas”. Durante dois dias de atividades serão debatidos temas, impasses e desafios para a questão das pessoas em sofrimento mental em conflito com a lei, os pacientes judiciários, a segregação e a urgência de se discutir alternativas, como o Programa de Atenção Integral ao Paciente Judiciário (PAI-PJ-MG) e o Programa de Atenção ao Louco Infrator (PAILI-GO).

“Queremos evidenciar esta problemática dos manicômios, da prisão perpétua das medidas de segurança, o mito da periculosidade, a falta de direitos e garantir o que faz a Psicologia nesses espaços. Assim, apresentaremos a necessidade de desconstrução dos manicômios, da lógica que segrega e não trata. Os desafios estão postos, construir alternativas ao modelo manicomial, como PAI-PJ do Tribunal de Justiça de MG e o PAILI e outras formas de assistência, tratamento e, sobretudo, responsabilização”, afirma Rodrigo Tôrres Oliveira, coordenador da Comissão de Psicologia Jurídica do CFP.

Publicação
Na ocasião, será lançado também o Relatório Brasil 2015, com resultados de Inspeções aos manicômios, feitas por Conselhos Regionais de Psicologia em instituições judiciários deste perfil em 17 estados mais o Distrito Federal. A proposta da publicação é dar visibilidade ao que acontece nestas instituições e discutir as práticas excludentes, punitivas e o cuidado das pessoas que hoje ainda se encontram nesses ambientes, muitas sob condições adversas e contrárias ao modelo assistencial.

Inscrições
O Seminário acontece na sede do Conselho Federal da Ordem dos Advogados do Brasil (SAUS Quadra 5 Lote 1 Bloco M – Brasília), é aberto ao público e gratuito. As inscrições devem ser feitas antecipadamente por meio do linkhttp://www2.pol.org.br/inscricoesonline/seminarioim/

PROGRAMAÇÃO 

15/09/2015 (Terça-feira)

Abertura – 9h30 às 10h15

· Marcus Vinicius Furtado Coêlho – Presidente do Conselho Federal da Ordem dos Advogados do Brasil (OAB)
· Mariza Monteiro Borges – Presidente do Conselho Federal de Psicologia (CFP)
· Oswaldo José Barbosa Silva – Representando Associação Nacional do Ministério Público de Defesa da Saúde (AMPASA) e o Ministério Público Federal (MPF)
· Dirceu Ditmar Klitzke – Coordenador-geral de gestão da atenção básica do Ministério da Saúde
· Marden Marques Soares Filho – Coordenador de Apoio à Assistência Jurídica, Social e à Saúde do Ministério da Justiça

Lançamento do Relatório Nacional das Inspeções a Manicômios Judiciários – 10h15 às 10h30

Conferência de Abertura – 11h00 às 12h00

· Ernesto Venturini – Psiquiatra italiano, colaborador de Franco Basaglia

Almoço – 12h00 às 13h45

Mesa “Por quê ainda existem manicômios?” – 13h45 às 15h

· Mediadora: Fátima França – Coordenadora do curso de Especialização em Psicologia Jurídica do Instituto Sedes Sapientiae
· Virgílio de Mattos – Professor e Coordenador do Curso de Direito do Centro de Ensino Superior de São Gotardo (CESG)
· Cristina Mair Barros Rauter – Professora da Universidade Federal Fluminense (UFF)

Mesa Relatos da Inspeção: por que a negação da cidadania? – 15h15 às 16h30

· Rodrigo Tôrres Oliveira – Coordenador da Comissão de Psicologia Jurídica do CFP
· Janne Calhau Mourão– Coordenadora da Comissão de Direitos Humanos do Conselho Regional de Psicologia do Rio de Janeiro (CRP-05)
· Natália de Souza Silva – Conselheira-secretária do Conselho Regional de Psicologia do Piauí (CRP-21)
· Rodrigo Silveira da Rosa– Advogado. Integrante da Comissão de Direitos Humanos da OAB/RS

Mesa Relatos da Inspeção: por que a negação da cidadania? – 16h30 às 17h45

· Caroline Martini Kraid Pereira –
· Nelma Pereira da Silva – Presidente do Conselho Regional de Psicologia do Maranhão (CRP-22)
· Mayk Diego da Glória – Coordenador da Comissão de Direitos Humanos (CDH) do Conselho Regional de Psicologia de Goiás (CRP-09)
· Luiz Romano da Motta Araújo Neto – Vice-Presidente do Conselho Regional de Psicologia do Pará/Amapá (CRP-10)

16/09/15 (Quarta-feira)

O Mito da periculosidade e as medidas de segurança – 9h15 às 10h30

· José Luiz Quadros de Magalhães – Professor Titular da Universidade Federal de Minas Gerais (UFMG)
· Nasser Haidar Barbosa – Coordenador do Centro dos Direitos Humanos de Joinville (CDH – Joinville)

Os danos da política proibicionista antidrogas e os reflexos manicomiais – 10h30 às 12h00

· Mediador: Ileno Izídio Da Costa – Professor da Universidade de Brasília (UnB)
· Carlos Magalhães – Autor e professor do Centro Universitário Newton Paiva
· Vladimir Andrade Stempliuk – Integrante da Comissão de Direitos Humanos (CDH) do CFP

Almoço – 12h às 14h

O que pode a Psicologia? Avaliação, Tratamento e Orientação pela reforma psiquiátrica e pela luta antimanicomial – 14h às 15h30

· Mediador: Rogério de Oliveira Silva – Vice-Presidente do CFP
· Tânia Kolker – Pesquisadora do Observatório Nacional de Saúde Mental e Justiça Criminal da UFF
· Silvia Helena Tedesco – Professora do Instituto de Psicologia da UFF

Alternativas possíveis: a experiência de Minas Gerais e Goiás e os desafios da inclusão nos serviços substitutivos residenciais terapêuticos – 15h30 às 17h30

· Mediador: Rodrigo Tôrres Oliveira – Coordenador da Comissão de Psicologia Jurídica do CFP
· Maria Aparecida Diniz – Programa de Atenção Integral ao Louco Infrator de Goiás (PAILI-GO)
· Pedro Gabriel Godinho Delgado – Professor da Universidade Federal do Rio de Janeiro (UFRJ)

Mais informações aqui

Para inscrever-se clique aqui

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peste

Data: 26 de junho de 2015 (6ª feira)

Conferência: 20:00h

Lançamento: 21:30 às 22:30 horas

Local: PUC-SP, R. Ministro Godoy 969 (Perdizes, São Paulo – SP)

Auditório 239, 2º andar (prédio novo)

 

ENTRADA FRANCA

 

EDITORES

Raul Albino Pacheco Filho (Editor Responsável)

Christian Ingo Lenz Dunker (Editor Associado)

Vladimir Safatle (Editor Associado)

Fuad Kyrillos Neto (Editor Adjunto)

Leandro Alves Rodrigues dos Santos (Editor Adjunto)

Luis Guilherme Coelho Mola (Editor Gerente do Site)

 

 

A Peste: Revista de Psicanálise e Sociedade e Filosofia  é um periódico científico semestral temático, com o objetivo de publicar investigações/ desenvolvimentos teóricos, relatos de pesquisas, debates, entrevistas e resenhas que contenham análises, críticas e reflexões sobre temas, fatos e questões sociais, a partir do referencial psicanalítico. Publica também artigos voltados à interlocução entre a Psicanálise e outros campos do saber, como a Filosofia e as Ciências Sociais, igualmente dedicados ao pensamento sobre a sociedade e a cultura.

 

A Peste: Revista de Psicanálise e Sociedade e Filosofia  é uma publicação do Núcleo de Pesquisa Psicanálise e Sociedade do Programa de Estudos Pós-Graduados em Psicologia Social da PUCSP (instituição responsável), em parceria com o Laboratório de Estudos em Teoria Social, Filosofia e Psicanálise – LATESFIP/USP  –, vinculado ao Departamento de Filosofia e ao Instituto de Psicologia da USP (instituição parceira).

 


Pontifícia Universidade Católica de São Paulo
Programa de Estudos Pós-Graduados em Psicologia Social
Núcleo de Pesquisa Psicanálise e Sociedade
 

Universidade de São Paulo

Departamento de Filosofia e Instituto de Psicologia
LATESFIP – USP

 

 

Conselho Editorial-Científico

 

Alberto Olavo Advincula Reis

Universidade de São Paulo

 

Alenka Zupancic

Slovene Academy of Sciences and Arts

 

Ana Cristina Figueiredo

Universidade Federal do Rio de Janeiro

 

Ana Laura Prates Pacheco

Escola de Psicanálise dos Fóruns do Campo Lacaniano

 

Ángel Gordo-López

Universidad Complutense de Madrid

 

Antonio Quinet

Universidade Veiga de Almeida

 

Antonio Teixeira

Universidade Federal de Minas Gerais

 

Carlo Viganò

Association Mondiale de Psychanalyse

 

Caterina Koltai

Pontifícia Universidade Católica de São Paulo

 

Charles Shepherdson

State University of New York

 

Cláudio Oliveira

Universidade Federal Fluminense

 

Conrado Ramos

Escola de Psicanálise dos Fóruns do Campo Lacaniano

 

Dominique Fingermann

Escola de Psicanálise dos Fóruns do Campo Lacaniano

 

Edson Luiz André de Sousa

Universidade Federal do Rio Grande do Sul

 

Ernani Chaves

Universidade Federal do Pará

 

Gabriel Lombardi

Universidad de Buenos Aires

 

Graciela Haydée Barbero

Universidade Federal de Mato Grosso

 

Ian Parker

Manchester Metropolitan University

 

Jean Christophe Goddard

Université Toulouse 2 Le Mirail

 

Jeferson Machado Pinto

Universidade Federal de Minas Gerais 

 

Laurent Jeanpierre

Université Paris VIII

 

Luis Guilherme Mola

Universidade São Judas Tadeu

 

Maria Rita Bicalho Kehl

Associação Psicanalítica de Porto Alegre

 

Mário Eduardo Costa Pereira

Universidade Estadual de Campinas

 

Monique David-Ménard

Université Paris VII

 

Nelson Silva Junior

Universidade de São Paulo

 

Néstor A. Braunstein

Universidad Nacional Autónoma de México

 

Oscar Angel Cesarotto

Pontifícia Universidade Católica de São Paulo

 

Osvaldo Giacoia

Universidade Estadual de Campinas

 

Patrice Maniglier

University of Essex

 

Paulo Arantes

Universidade de São Paulo

 

Peter Dews

University of Essex

 

Philippe Van Haute

Radboud Universiteit Nijmegen

 

Renato Lessa

Universidade Candido Mendes

 

Richard Simanke

Universidade Federal de São Carlos

 

Rodrigo Duarte

Universidade Federal de Minas Gerais

 

Sandra Dias

Pontifícia Universidade Católica de São Paulo

 

Sidi Askofaré

Université Toulouse 2 Le Mirail

 

Sonia Alberti

Universidade do Estado do Rio de Janeiro

 

 

 

Correspondência e assinaturas

A Peste: Revista de Psicanálise e Sociedade e Filosofia  

Rua Ministro Godói, 969, sala 4E-10 (4º andar)

05015-901 – São Paulo – SP

Fone: (11) 3670-8520

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VideoClube CRP SP – Ciclo Antimanicomial

Próxima sessão:
Imagens do Inconsciente I – Em Busca do Espaço Cotidiano

Data: 03/07/2014
Horário: 19h00 às 22h30
Local: Auditório do CRP SP
Endereço: Rua Arruda Alvim, 89, Jd. América, São Paulo, SP

Sinopse:
Fernando Diniz, filho de uma empregada doméstica baiana, busca recuperar um espaço cotidiano sob a forma de um quadro – é a pintura em luta constante contra o caos, um caos vivenciado numa questão de amor, uma questão de paixão. Fernando submerge como uma autodefesa para viver no inconsciente, mas não é um grande mergulho, é algo mais no nível do cotidiano.

Duração: 80 minutos.
Gênero: Documentário
Direção: Leon Hirszman
Ano de produção: 1989
País de produção: Brasil

Coordenação:
Guilherme Luz Fenerich
– Conselheiro do Conselho Regional de Psicologia da 6ª Região – CRP 06.

Debatedores:
Augusto Sergio Callile – Psicólogo. Mestrado em Pós-Graduação em Saúde Coletiva pela Faculdade de Medicina de Botucatu – UNESP.

Gustavo Henrique Dionisio – Psicanalista. Mestre e doutor pelo IP-USP. Professor de Graduação e Pós-Graduação do Departamento de Psicologia Clínica da Unesp-Assis. Autor de “O antídoto do mal. Crítica de arte e loucura na modernidade brasileira” (Ed. Fiocruz) e “Pede-se abrir os olhos: psicanálise e reflexão estética hoje” (Ed. Annablume/Fapesp).

Entrada gratuita
Não há necessidade de inscrições prévias! Compareça!

Mais informações: www.crpsp.org.br/videoclube

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Por Sergio Telles, Estadão, 26 de maio de 2012.

Excluindo as doenças mentais mais graves – nas quais as perturbações das funções psíquicas são facilmente reconhecíveis através de sintomas como delírios, alucinações ou crises de agitação psicomotora -, é difícil estabelecer um diagnóstico em psiquiatria. Não há parâmetros unívocos para detectar com precisão as alterações na estrutura do pensamento, na produção das ideias, na intensidade da atenção, nas nuances da senso-percepção. As fronteiras entre a chamada normalidade e a psicopatologia não são bem delimitadas e mudam em função das circunstâncias socioculturais.

O psiquiatra conta apenas com a capacidade de observação e a subjetividade para avaliar este imponderável material que é a vida psíquica. Isso faz com que os diagnósticos em psiquiatria muitas vezes oscilem, não tenham a firmeza desejada.

Em 1952, a Associação Psiquiátrica Americana (APA) lançou a primeira versão do Manual de Diagnóstico e Estatística dos Distúrbios Mentais, que passou a ser mundialmente conhecido como DSM. Suas três primeiras versões não diferiam muitos dos grandes compêndios de psiquiatria, com suas densas descrições da psicopatologia, na maioria das vezes baseadas em pressupostos psicanalíticos. Em 1980, saiu sua terceira edição, o DSM3, com um enfoque diferente, procurando uniformizar e padronizar os dados observados, com o objetivo de deixar os diagnósticos psiquiátricos menos vagos e imprecisos. Grosso modo, ao invés de atentar para os meandros do psiquismo e as profundezas da psicopatologia ou da psicodinâmica psicanalítica, o DSM3 se centrou no registro dos sintomas observáveis no pragmatismo e na conduta do paciente, mais fáceis de quantificar e avaliar estatisticamente. Os motivos conscientes ou inconscientes que poderiam estar ligados a estes sintomas não são valorizados, não é feita uma relação de causa e efeito entre vivências existenciais traumáticas e a sintomatologia. O exame psiquiátrico não se interessa pela vida do paciente.

Esse enfoque reflete uma mudança na própria abordagem e compreensão da doença mental. Abandonou-se a visão analítica psicogênica e se defende a ideia de que o funcionamento normal do psiquismo resulta do equilíbrio dos neurotransmissores cerebrais, substâncias existentes entre os neurônios a facilitarem a circulação dos impulsos e sinais. Os sintomas seriam evidências do desequilíbrio dos neurotransmissores. Em sendo assim, não importam as vivências atuais e passadas do paciente e sim o repertório de sintomas que exibe e que será eliminado com uma medicação que devolve aos neurotransmissores o equilíbrio perdido. As psicoterapias são desvalorizadas e quando indicadas, devem seguir a linha cognitivista, que ensina o paciente a lidar com o sintoma através de treinamentos e condicionamentos conscientes. Não pode ser ignorado que este panorama se instala dentro de dois grandes referenciais econômicos – a indústria farmacêutica e os seguros-saúde, ambos beneficiados pela ênfase quase exclusiva na medicação. O primeiro, pelo incremento nas vendas, pois das medicações prescritas nos Estados Unidos, as psicotrópicas são as mais vendidas, tendo movimentado mais de US$ 14 bilhões em 2008. O segundo, que passa a impor para os segurados um modelo cognitivo de terapia com poucas sessões, que lhes é bem mais barato do que as longas terapias que antes tinham de pagar.

Largo debate se estabeleceu desde então. Os aspectos positivos deste enfoque são a tentativa de uniformização dos critérios diagnósticos, compartilhados facilmente por psiquiatras de várias culturas e formações diversas, o que deu novo alento à pesquisa e epidemiologia em psiquiatria. Como pontos negativos, ressalta-se a proliferação desenfreada de diagnósticos, a patologização e medicalização de modos de ser, a expansão para a infância de diagnósticos antes restritos a outras faixas etárias, como o transtorno bipolar.

A própria psiquiatria sofre uma certa desumanização, na medida em que o paciente fica despojado de sua singularidade, em que sua história é ignorada. Descarta-se o saber psicanalítico e a consulta psiquiatra fica rebaixada a um mero check-list de sintomas, na qual o paciente não tem oportunidade de falar de sua angústia e sofrimentos. Ao relegar sua vertente psicoterápica a um segundo plano e enfatizar excessivamente o lado medicamentoso, cuja importância não pode ser diminuída, a prática psiquiátrica fica empobrecida. Além do mais, se a psicopatologia fica reduzida a um mero desequilíbrio dos neurotransmissores, qualquer médico não psiquiatra se sente autorizado a passar antidepressivos e tranquilizantes, como ocorre atualmente.

Este é o pano de fundo que se instalou progressivamente desde os anos 80. Agora se aguarda com expectativa o DSM5, a quinta edição do manual, a ser lançada em maio do próximo ano. No último dia 11, o dr. Allen Frances, que liderou uma das forças-tarefa do DSM4, escreveu um artigo no New York Times fazendo pesadas críticas ao modo como os trabalhos estão sendo encaminhados.

Allen teme que o DSM5 seja um “desastre”, pois insiste em ampliar cada vez mais os critérios diagnósticos, invadindo a infância e procurando transformar as preocupações, angústias e tristezas inerentes à vida em sintomas a serem medicados. Com isso, “introduzirá muitos diagnósticos novos e não comprovados que irão medicalizar a normalidade”, resultando numa “fartura desnecessária e prejudicial de prescrição medicamentosa”.

Allen diz que a fabricação de diagnósticos – desvio no qual as DSM são pródigas – é mais danosa do que a proliferação de medicação, embora uma coisa leve à outra. Apesar de afastar a acusação mais comum de que o grupo do DSM5 está atrelado à indústria farmacêutica, sabe-se que mais de 70 % dele declarou ter algum tipo de vínculo com ela. Allen vai mais longe ao propor que a própria APA abdique da função de estabelecer o que é mentalmente são ou doente, pois acredita que o mundo mudou e que essa atribuição não pode mais ficar restrita a uma associação de psiquiatria e, sim, a um leque muito mais vasto de representantes da sociedade.

Vê-se que o DSM tentou resolver um problema – a excessiva subjetividade na formulação do diagnóstico – e caiu noutro, a produção excessiva de diagnósticos “objetivos”. É um impasse, que não deve ser entendido como uma prova da insuficiência da psiquiatria e, sim, como evidência da complexidade do fenômeno do qual ela trata.

Não é fácil medir e pesar a loucura dos homens, como tão bem sabia Machado de Assis. Em O Alienista, o Dr. Simão Bacamarte também oscilava em firmar o diagnóstico – serão todos loucos em Itaguaí, ou não há louco nenhum? Sem chegar a uma conclusão, termina por se internar sozinho no Hospício de Casa Verde, numa decisão mais filosófica do que clínica.

http://www.estadao.com.br/noticias/impresso,dificil-diagnostico-,878252,0.htm

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DSM in Philosophyland: Curiouser and Curiouser, Allen Frances *

*  é um dos organizadores da última versão do Manual Diagnóstico e Estatísticos de Transtornos Mentais (DSM-IV) .

      First off, thanks to James Phillips for inviting these stimulating commentaries. Second, a confession. My last (and only) formal training in philosophy was a freshman course in college that went well over my head. Now I have been invited to share my (probably sophomoric) speculations on the meanings that swirl below the surface of psychiatric classification. I do so without any confidence they can survive rigorous analysis by  those more expert than I in the tools of philosophic inquiry. Much of what I say below may be simple minded or simply wrong. What I do understand (perhaps better than anyone) are the practical issues of creating a psychiatric manual and the many good and bad (intended, unintended) consequences it can have. My views on deeper meanings are given, and should be taken, with a large grain of salt.

The Epistemologic Game

        First Umpire: “There are balls and there are strikes and I call them as they are.”

Second Umpire: “There are balls and there are strikes and I call them as I see them.”

Third Umpire: “There are no balls and there are no strikes until I call them.”

As I recall it, the three umpires are replaying a marathon epistemological game that: 1) began with Plato; 2) continued in the medieval joust between the realists and Occam’s nominalists; 3)was revived in the post-renaissance debate between Descartes and Vico on the power and limits of rational thought; 4)was refined by Kant; 5)churned up by Freud; and 6)finally settled by quantum physicists who have sharply downgraded the capacity of the human mind to ever fully intuit (much less understand) reality. Closer to my turf, I like to think of Bob Spitzer as umpire #1,  me as umpire #2, and Tom Szasz as umpire #3.

Spitzer’s achieved a paradigmatic revolution in psychiatric diagnosis and nosology. He introduced the method of diagnostic criteria (originally developed for research purposes) into a tool for general clinical practice. For the first time, psychiatrists could agree on diagnoses and make interpretive judgments across the research/ clinical interface. Certainly, the level of reliability achieved by DSM- III was over sold, especially when it was used by the average clinician. But DSM III was a huge leap forward from the useless and neglected guidance offered by DSM-I and DSM-II. It gave hope that psychiatry could become scientific and join in the advances that were being made in the rest of medicine.

DSM-III resulted from and promoted the victory of biological psychiatry over the psychological and social models that until then were its serious competitors. In the early dawn of its triumph, the biological model was presented with a realist, reductionist flourish that would have done umpire #1 proud. Mental disorders were real entities that existed  “out there.” The process of scientific discovery would elucidate their etiology and pathogenesis using the powerful new methods of neuroscience, imaging, and genetics.

The next section will focus on the disappointing fate of this ambitious program, but one  central point belongs here. Biological psychiatry has failed to produce quick, convincing  explanations for any of the mental disorders. This is because it has been unable to circumvent the fundamental and inherent flaw in the biological, “realist” approach – mental disorders don’t really live “out there” waiting to be explained. They are constructs we have made up – and often not very compelling ones at that. It has, for example, become clear that there is no one prototype “schizophrenia” waiting to be explained with one incisive and sweeping biological model. There is no gene, or small subset of genes, for “schizophrenia.” As Bleuler intuited, “schizophrenia” is rather a group of disorders, or perhaps better a mob. There may eventually turn out to be twenty or fifty or two hundred kinds of “schizophrenia.” As it stands now the definition and boundaries of “schizophrenia” are necessaarily arbitrary. There is no clear right way to diagnose this gang and not even much agreement on what the validators should be and how they should be applied. The first umpire was called out on strikes when the holy grail of finding the cause of “schizophrenia” turned out to be a wild goose chase.

Szasz is the third umpire. He quickly saw through the epistemological “no clothes” of umpire #1 and led the fight against simple minded biological reductionism (even well before the biologists had discovered their own voice and began making their overly ambitious and naïve claims). Szasz vigorously presented the view that mental illness is a medical “myth.”  Mental disorders were no more than social constructs that in some cases served a useful purpose, but in many others could be misused to exert a noxious social control, reducing freedom and personal responsibility. The biological “realists” reacted predictably to Szasz’ “nominalist” attack. They dismissed it. “If schizophrenia is a myth, they crowed, it is a myth that responds to medication and has a genetic pattern.” But their triumphalism was premature and based on both weak philosophic and weak scientific grounds. It turned out that the neuroscience, genetics, and treatment response of “schizophrenia” follow anything but a simple reductionist pattern. The more we learn about “schizophrenia” the more it resembles a heuristic, the less it resembles a disease.

This brings us to me (a call’um as I see’um) second umpire. In preparing DSM-IV, I had no grand illusions of seeing reality straight on or of reconstructing it whole clothe from my own pet theories. I just wanted to get the job done – i.e., produce a useful document that would make the fewest possible mistakes, and create the fewest problems for patients. Following Vico, I accepted that much in real life ( and almost everything in psychiatric classification) is overlapping, fuzzy, and heterogeneous – anything but Cartesian and amenable to overarching rationalist principles or mathematical precision. Psychiatric classification is necessarily a sloppy business. The desirable goal of having a classification consisting of mutually exhaustive, non-overlapping mental disorders is simply impossible to meet.

Instead, the second umpire follows a down-to-earth brand of Bentham utilitarian pragmatism. His umpire’s eye is fixed on the end result of getting to what works best – not distracted by biological reductionism or rationalist models of how things should be constructed. A diagnosis is a call to action with huge and unpredictable results. No decision can be right on narrow scientific grounds if it winds up hurting people.

Descriptive Psychiatry Gets Long of Tooth

The Dodo: “Everyone has run and everone has won and all must have prizes”.

      Modern descriptive psychiatry just passed its 200 birthday – if we measure it from the milestone of Pinel’s creation of the first psychiatric classification that resembles our own. His work was born from the Enlightenment belief in a rational world – some underlying order could be imposed even on the obvious irrationality of mental illness. The premise was that any domain receiving systematic observation and classification would eventually display causal patterns.

This approach was enormously successful in each of the major paradigm shifts in science. Always a careful description preceded a causal model. Kepler’s astronomical observations led toNewton’s gravity. Linnaeus’ classification of plants and animals led toDarwin’s  evolution. Mendeleyev’s periodic table led to Bohr’s structure of the atom. There have been dozens of descriptive systems vieing to describe things so brilliantly that their truth would shine forth. “All have run, but none has won prizes.” Descriptive classification in psychiatry has so far been singularly unsuccessful in promoting a breakthrough discovery of the causes of mental disorder.

This is doubly disappointing given the miraculous advances in our understanding of  normal  brain functioning. The advances in molecular biology, brain imaging, and genetics are spectacular – their impact on understanding psychopatholgy almost nil. Why the disconnect? The answer lies in a paraphrase of the opening lines of Anna Karenina. All normal brain functioning is normal in more or less the same way, but any given type of pathological functioning can have many different causes.

This is also true for all the complex diseases in medicine. A genetics company using  the Icelandic registry had tremendous success in finding gene markers for a dozen diseases, including schizophrenia. It recently went bankrupt because, in each instance, the particular candidate marker explained fewer than three per cent of the cases of the particular disease. There appear to be no common genes even for the common illnesses. Psychopathology is heterogeneous and overlapping not only in its presentation but also in its pathogenesis. There will likely be hundreds of paths to schizophrenia, not one or just a few and perhaps no final common pathway. Where does that leave the descriptive system of psychiatry? Fairly high and dry. Nature has obviously chosen to deprive us of clear joints, ripe for carving. There is little indication of any imminent and sweeping etiological breakthrough. Everything points towards a slow and painstaking retail accumulation of explanatory power. It is not even clear that the DSM categorical approach is the best research tool. The NIMH is embarking on a project to correlate an integrated exploration of neural networks with psychopathology. They chose to study dimensions of behavior (e.g. anxiety, pleasure seeking, executive functioning)  – not with the standard psychiatric disorders which are deemed too complex to have any simple relationship with a given neural network. Our DSM categories may not lead the future charge in understanding psychopathology.

Our descriptive classification of disorders is old and tired. It has worked hard for us and  continues to have many valuable and irreplaceable functions (which we will discuss in the last section). Fiddling needlessly with the labels will not advance science and may actually do more harm than good in its effect on clinical care.

The Elusive Definition of Mental Disorder

Humpty Dumpty: “When I choose a word it means just what I choose it to mean.”

      When it comes to defining the term “mental disorder” or figuring out which conditions qualify, we enter Humpty’s world of shifting, ambiguous, and idiosyncratic word usages. This is a fundamental weakness of our field. Many crucial problems would be much less problematic if only it were possible to frame an operational definition of mental disorder that really worked.

Nosologists could use it to guide decisions on which aspects of human distress and malfunction should be considered psychiatric – and which should not. Clinicians could use it when deciding whether to diagnose and treat a patient on the border with normality. A meaningful definition would clear up the great confusion in the legal system where matters of great consequence often rest on whether a mental disorder is present or absent.

Alas, I have read dozens of definitions of mental disorder (and helped to write one) and I can’t say that any have the slightest value whatever. Historically, conditions have become mental disorders by accretion and practical necessity, not because they met some independent set of operationalized definitional criteria. Indeed, the concept of mental disorder is so amorphous, protean, and heterogeneous that it inherently defies definition. This is a hole at the center of psychiatric classification.  And the specific mental disorders certainly constitute a hodge podge. Some describe short term states, others lifelong personality. Some reflect inner misery, others bad behavior. Some represent problems rarely or never seen in normals, others are just slight accentuations of the everyday. Some reflect too little control, others too much. Some are quite intrinsic to the individual, others are defined against varying and changing cultural mores and stressors. Some begin in infancy, others in old age. Some affect primarily thought, others emotions, yet others behaviors, others interpersonal relations, and there are complex combinations of all of these. Some seem more biological, others more psychological or social. If there is a common theme it is distress and disability, but these are very imprecise and nonspecific markers on which to hang a definition.

Ironically, the one definition of mental disorder that does have great and abiding practical meaning is never given formal status because it is tautological and potentially highly self serving. It would go something like “Mental disorder is what clinicians treat and researchers research and educators teach and insurance companies pay for.” In effect, this is historically how the individual mental disorders made their way into the system.

The definition of mental disorder has been elastic and follows practice rather than guides it. The greater the number of mental health clinicians, the greater the number of life conditions that work their way into becoming disorders. There were only five disorders listed in the initial census of mental patients in the mid nineteenth century, now there are close to three hundred. Society also has a seemingly insatiable capacity (even hunger) to accept and endorse newly defined mental disorders that help to define and explain away its emerging concerns. As a result, psychiatry is subject to recurring diagnostic fads. Were DSM-V to have its way we would have a wholesale medicalization of everyday incapacity (mild memory loss with aging); distress (grief, mixed anxiety depression); defects in self control (binge eating); eccentricity(psychotic risk); irresponsibility (hypersexuality); and even criminality (rape, statutory rape).

Remarkably, none of these newly proposes diagnoses even remotely pass the standard loose definition of “what clinician’s treat.” None of these “mental disorders” has an established treatment with proven efficacy. Each is so early in development as to be no more than “what researchers research” – a concoction of highly specialized research interests.

We must accept that our diagnostic classification is the result of historical accretion and accident without any real underlying system or scientific necessity. The rules for entry have varied over time and have rarely been very rigorous. Our mental disorders are no more than fallible social constructs (but nonetheless useful ones if understood and applied properly).

The Conservative/Innovation Debate or Where Have All the Normals Gone?

Alice: “But I don’t want to go among mad people

Cheshire Cat: Oh, you can’t help it,we’re all mad here”

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DSM-IV would have been a very different document if I had adopted Humpty Dumpty’s confident attitude and used my authority to shape it to my personal taste. Bob Spitzer, who had led the efforts to create DSM-III and DSM-IIIR is a “splitter” whose preference is to divide the diagnostic pie into small manageable pieces. This enhances reliability, but creates many new diagnoses and artificial comorbidity (as complex syndromes are divided into their component parts). I joke that Spitzer never met a new diagnosis he didn’t like.

I am more of a lumper and also very wary of diagnostic fads and the unintended consequences of introducing new diagnoses. Given my druthers, DSM-IV would have had fewer, lumped categories and tighter criteria sets to make it harder to get a diagnosis. Instead, I chose not to impose this view on DSM-IV. We would apply a conservative standard for all changes – equally not add new things or take out old ones unless there was substantial evidence to support the change. Many decisions were thus grand-fathered  into DSM-IV that would not have had nearly enough support to meet the new higher evidentiary standard.

I am not a particularly risk averse or conservative person in my everyday life. So why the conservative tilt in setting ground rules for DSM-V?

1) The system had previously been in great flux with the rapid fire appearance within

seven years of DSM-III and DSM-IIIR. It needed a period of stability;

2) The two previous DSM’s were the product of an innovative and charismatic figure who singlehandedly moved the field by dint of his energy, determination, and grit. Now that  his accomplishments were realized, it was time for a less personalized leadership and for the field at large to reclaim responsibility for its diagnostic system;

3) My experience working on DSM-III and DSM-IIIR was that most decisions were fairly arbitrary – with plausible supporting arguments that could have gone either way. Making more arbitrary changes didn’t make much sense;

4) The scientific evidence supporting proposed changes was usually meager. Requiring that all changes be based on substantial evidence usually shut up even the most passionate advocates;

5) The literatures are not only thin but also mostly derived from highly specialized research settings that have questionable generalizability to the real world.

One’s position on the conservative/innovation continuum is influenced by reactions to the epistemological question raised previously. If you regard the categories in DSM as descriptions of “real entities,” you will be eager to change definitions in accord with evidence that they can be better described in a way that captures their real natures. On the other hand, if you believe as I do, that the DSM is necessarily more an exercise in forging a common language than in finding a truth, you need a strong reason to change the syntax. And it turns out that such strong evidence is usually lacking. This is why the reliability and utility goals are so important (and for all the discussion about it, validation is not yet particularly meaningful).

The second divide in the conservative/liberal split relates to how worried one is by real world consequences. As a pragmatist, I was acutely conscious that every change made by DSM-IV could have enormous practical consequences: 1) determining who got medicines that could greatly help or greatly harm; 2)deciding insurance and disability claims; and 3)influencing life and death forensic issues. Those of a more pure research world, innovation orientation would argue for “following the data” and damn the consequences. In my view, data sets that are thin and selective are never sufficient

support for changes that can cause considerable mischief. So there are two contrasting attitudes. Mine, the conservative view, is “Do no harm – revise the system with a light and cautious touch only when you are sure of what you are doing after a thorough risk/ benefit analysis.” The conservative approach assumes that things are there for a reason and are imbricated in a complex set of relations. I have had the painful experience of changing a word or two in a seemingly harmless way and then later learning that we had helped trigger an “epidemic” of false positives (as in Attention Deficit Disorder) or a forensic nightmare (e.g., the misuse of Paraphilia NOS in the extended civil commitment of sexual offenders).

One of the commentaries presents quite the opposite view – that the existing system is so bad that even the aggressively innovative DSM-V is suggesting far too little change, not too much. I believe this to be a naïve Cartesian rationalist view that neglects the deep roots and far flung branches of the diagnostic system. Most of the suggested DSM-V changes are such really bad ideas that they do not even represent a meaningful test of the conservative/innovator divide. I believe that most sensible people informed of their risks and benefits would veto them (this leaves out the Work Group members who are otherwise sensible but too attached to their pet suggestions to be objective about their risks).

The new suggestions all share the common problem of greatly expanding the reach of “mental disorders” at the expense of normality. Armies of millions (perhaps tens of millions) false positive “patients” would receive unnecessary and harmful treatments. I have covered this problem extensively elsewhere and won’t repeat the details here. A better, because much tougher, test case of the conservative/innovator debate comes from the DSM IV introduction of Bipolar II disorder. Here there are strong arguments on both sides and no clear right answer.

We knew that adding Bipolar II would be one of the most consequential changes in DSM-IV but went ahead (despite our conservative bias) because of what seemed to be compelling enough research evidence (descriptive, course, family history, treatment response) that it sorted better with bipolar than with unipolar mood disorders. We recognized the risks that some unipolar patients would be mislabeled and receive unnecessary and potentially harmful, mood stabilizing and antipsychotic medication. But this risk seemed more than counterbalanced by the opposing risk posed by uncovered antidepressants for those whose bipolar tendencies were previously missed by the diagnostic system.

Several facts are incontestable about trends since DSM-IV: 1) with a huge push from the pharmaceutical industry, Bipolar II has become an enormously popular diagnosis;  2) so that the ratio of bipolar to unipolar patients increased dramatically; 3) and prescriptions jumped for mood stabilizers and antipsychotics (which can cause huge and dangerous weight gains),and 4) for different reasons  rates of childhood Bipolar Disorder have increased forty fold. Some patients are undoubtedly better off for being diagnosed as Bipolar II. Others have gained a lot of weight (and risk diabetes and a potentially shortened lifespan) taking a medication that was unnecessary.

A conservative might prefer that such public health experiments be based on more evidence than was available to us when we made the decision to include Bipolar II. We also had no way of anticipating how aggressive and successful were the pharmaceutical industry marketting efforts to move product. Bipolar II also illustrates the exquisite and dangerous sensitivity of the diagnostic system to small changes. The hugely consequential decision regarding the need for potentially very harmful medication rests on the most fragile and unreliable of distinctions – the decision whether or not a hypomanic episode is present. If the minimum duration of the episode is set at a week (or even longer), people at risk for antidepressant worsening will be missed; if the requirement is 4 days (or even less), many people will receive unnecessary medication. The symptom thresholds for defining a hypomanic episode are similarly arbitrary and subject to wide swings in sensitivity and specificity, based on very minor adjustments. Making this even more complicated are the difficulties distinguishing hypomania from normal mood in someone who is chronically depressed or hypomania from substance induced mood elevation in someone using drugs.

The point here is that tiny changes in definition can (and often do) result in large, unpredictable (and usually unwarranted) swings in diagnostic and treatment habits, especially when amplified by drug companies, advocacy groups, and the media. Such potentially dangerous fads are enough to turn a lifelong, risk-taking liberal like me into a conservative nosologist. First, last, and always – DO NO HARM.

Afterword

The Talmud: “We don’t see things as they are, We see things as we are”.

      Many people are troubled by the relativism implied in this penetrating insight – but I find it liberating. We will never have the perfect diagnostic system. Our classification of mental disorders will always necessarily be no more than a collection of fallible and limited constructs that seek but never find an elusive truth. But this is our best current  way of seeing and communicating about mental disorders. And despite all its epistemological, scientific, and even clinical failings, the DSM does its job reasonably well if it is applied properly and its limitations are understood.

The concern about comorbidity across disorders arises from the misconception that each is a “real” and independent psychiatric illness and that clear boundaries should or could be created to separate them. If instead, one accepts that each disorder is just a description (not a disease), then the combined descriptions  become modular building blocks each of which adds precision and information.

The concerns about heterogeneity within diagnoses also reflect a longing for well defined psychiatric “illnesses.” Instead, we are dealing with descriptive prototypes (“schizophrenia,” “panic disorder,” “mood disorder,” etc., through the manual) that are inherently heterogeneous and will hopefullly with time be divided into many true etiologically defined illnesses.

The greatest misuse of the DSM occurs in diagnosing conditions at the border of normality and criminality. Clinicians should hold themselves to the most rigorous standards when applying criteria sets in these dangerous boundary territories. The DSM incorporates a great deal of practical knowledge in a convenient and useful format.

To not know it castes one outside the community of common language speakers – the language being clinical psychiatry. But it should always be used with pragmatism and clinical common sense.

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