Epistemology of psychopathology

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Values And Dsm-5: Looking At The Debate On Attenuated Psychosis Syndrome.

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. 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.17

Avaliação da resposta terapêutica ao tratamento de manutenção com lítio em pacientes com transtorno afetivo bipolar

Objetive To identify potential clinical and epidemiological predictors of long-term response to lithium treatment. Methods A total of 40 adult outpatients followed in an university hospital, with confirmed diagnosis of bipolar disorder and with history of lithium use for at least a six months period, had their response to this medication assessed through the use of a standardized instrument. The ALDA scale is based on retrospective clinical data, in our study assessed through a thoroughly reviewed of the medical charts, and is used to evaluate the clinical improvement with the treatment (Criterion A), corrected by the acknowledgement of possible confounding factors, such as duration of the treatment, compliance and concomitant use of additional medications (Criterion B), in order to estimate the response that can be specifically attributable to lithium. Results Our study found an inverse relation between the number of mood episodes with psychotic symptoms and lithium treatment outcome. Conclusion The results reinforce the hypothesis that lithium seems to be less efficacious in patients with bipolar disorder who present psychotic symptoms.Objetivo Identificar potenciais preditores clínicos e epidemiológicos de resposta terapêutica ao uso prolongado de lítio. Métodos Um total de 40 pacientes adultos em tratamento ambulatorial em um hospital universitário, com diagnóstico confirmado de transtorno afetivo bipolar e história de pelo menos seis meses de uso de lítio, teve sua resposta a essa medicação avaliada com a utilização de um instrumento padronizado. A escala ALDA leva em consideração informações clínicas obtidas de forma retrospectiva, em nosso estudo, por meio de minuciosa revisão dos prontuários médicos, para julgar a melhora clínica obtida com o tratamento (Critério A), corrigida pela identificação de possíveis fatores confundidores, tais como duração do tratamento, adesão e uso concomitante de outras drogas (Critério B), de forma a estimar a resposta que pode ser atribuída especificamente ao uso do lítio. Resultados Nosso estudo encontrou uma relação inversa entre o número de episódios de humor com a presença de sintomas psicóticos e o desfecho no tratamento com lítio. Conclusão Esses resultados reforçam a hipótese de que o lítio parece ser menos eficaz em pacientes com transtorno afetivo bipolar que manifestam sintomas psicóticos.To identify potential clinical and epidemiological predictors of long-term response to lithium treatment. A total of 40 adult outpatients followed in an university hospital, with confirmed diagnosis of bipolar disorder and with history of lithium use for651916sem informaçãosem informaçãoIdentificar potenciais preditores clínicos e epidemiológicos de resposta terapêutica ao uso prolongado de lítio. Métodos Um total de 40 pacientes adultos em tratamento ambulatorial em um hospital universitário, com diagnóstico confirmado de transtorno af

Concepts of liberty and value pluralism: Implications for psychiatry

Isaiah Berlin’s distinction between the ideas of ‘positive’ and ‘negative’ liberty is examined within the context of his value pluralism, in which goods, evils and forms of life are ultimately incommensurable (or incomparable through reasoning). Adopting this pluralist stance as to values, I try to answer the following question: does psychiatry need to/is it able to reach an explicit agreement as what is the best way to live? Given the precedence of practical reasoning in psychiatry, I suggest that, when confronted with certain kinds of human suffering (pathos), often associated with a clash between values, the last word (however tentative and always individual) should come from the clinical realm

Critical evaluation of current diagnostic systems

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Raising awareness of values in the recognition of negative symptoms of schizophrenia

What we call today negative symptoms are thought to descend from the very deficits that the earliest scholars of schizophrenia (such as Kraepelin and Bleuler) considered to be the key, fundamental symptoms of the disorder. In the latter half of the 20th century, delusions and hallucinations received greater prominence, which eventually changed both the concept of schizophrenia and its diagnostic criteria by placing positive symptoms at the forefront. The first decade of the 21st century witnessed a resurgence of interest in negative symptoms of schizophrenia. Persistent and clinically significant negative symptoms were declared an unmet therapeutic need in a large proportion of cases by several schizophrenia experts, who, with the support of the NIMH, held a consensus development conference in 2005 to discuss negative symptoms and how to proceed in this area. The Consensus Statement read that improved recognition and awareness of negative symptoms are the fi rst step to improving function in patients with negative symptoms of schizophrenia. According to the principles of Values-Based Practice that also means improving recognition and awareness of the diverse values involved in the conceptualization and practical assessment of negative symptoms. By analyzing selected conceptual papers on negative symptoms, instruments developed for the assessment of this area of psychopathology, and clinical vignettes, we intend to point out some values-related issues in the diagnosis of negative symptoms as well as to make the case that these symptoms may be a particularly complex aspect of schizophrenia, vis-à- vis understanding the role played by values

A logical-pragmatic perspective on validity

Background: Despite being often taken as the benchmark of quality for diagnostic and classificatory tools, 'validity' is admitted as a poorly worked out notion in psychiatric nosology. Objective: Here we aim at presenting a view that we believe to do better justice to the significance of the notion of validity, as well as at explaining away some misconceptions and inappropriate expectations regarding this attribute in the aforementioned context. Method: The notion of validity is addressed taking into account its role, the framework according to which it should be assessed and the specific contents to which it refers within psychiatric nosology. Results and Conclusions: The notion of validity has an epistemological thrust and its foremost role is distinguishing correct reasoning and truth from what is irrational or false. From it follows not only that 'validity' always refers to elements of knowledge and rationality such as arguments, inferences and propositions, but also that the appropriate frameworks to assess 'validity' are logics and scientific methodology. When the validity of a psychiatric diagnostic category is at stake, the contents to which it refers are those relevantly related to the notion of 'diagnostic concept'. The consequences of our reading on the notion of 'validity' are discussed vis-à-vis the challenges faced by psychiatric nosology in order to have its diagnostic categories validated

A pragmatic meta-conception of validity for diagnostic concepts in psychiatry: a step prior to utility, theories and methods of validation

Dear Editor, in a previous paper we have tried to delve into what validity means in the context of psychiatric nosology, arguing for a pragmatic view of it. Here we want to briefly reassert the basic points of our analysis, make a few clarifications and address some issues raised by commentators