John Z. Sadler

What is a mental/psychiatric disorder? From DSM-IV to DSM-V

The distinction between normality and psychopathology has long been subject to debate. DSM-III and DSM-IV provided a definition of mental disorder to help clinicians address this distinction. As part of the process of developing DSM-V, researchers have reviewed the concept of mental disorder and emphasized the need for additional work in this area. Here we review the DSM-IV definition of mental disorder and propose some changes. The approach taken here arguably takes a middle course through some of the relevant conceptual debates. We agree with the view that no definition perfectly specifies precise boundaries for the concept of mental/psychiatric disorder, but in line with a view that the nomenclature can improve over time, we aim here for a more scientifically valid and more clinically useful definition.

VALUES AND PSYCHIATRIC DIAGNOSIS

PART 1: INTRODUCTION PART 2: METHODS PART 3: SCIENCE PART 4: PATIENTS, PROFESSIONS AND GUILD PART 5: SPACE, TIME AND BEING PART 6: SEX AND GENDER PART 7: CULTURE PART 8: GENETIC NOSOLOGY PART 9: TECHNOLOGY PART 10: POLITICS PART 11: VALUES AND PSYCHIATRIC DIAGNOSIS

Validity and utility of bipolar spectrum models

The bipolar spectrum model suggests that several patient presentations not currently recognized by the DSM warrant consideration as part of a mood disorders continuum. These include hypomania or mania associated with antidepressants; manic symptoms which fall short of the current DSM threshold for hypomania; and depression attended by multiple non-manic markers that are associated with bipolar course. Evidence supporting the inclusion of these groups within the realm of bipolar disorder (BP) is examined. Several diagnostic tools for detecting and characterizing these patient groups are described. Finally, options for altering DSM-IV criteria to allow some of the above patient presentations to be recognized as bipolar are considered. More data on the validity and utility of these alterations would be useful, but limited changes appear warranted now. We describe an additional BP Not Otherwise Specified (BP NOS) example which creates a subthreshold hypomanic analogue to cyclothymia, consistent with existing BP NOS criteria. This change should be accompanied by additional requirements for the assessment and reporting of non-manic bipolar markers.

History and philosophy.

Antipsychiatry is dead ± long live antipsychiatry! Dramatic advances in the neurosciences in the ®nal decade of the twentieth century have led many in psychiatry to believe that the ®nal triumph of the biological model of mental disorder, which was the target of so much antipsychiatric sentiment in the debate about mental illness in the 1960s and 1970s, is just around the corner. This years articles in the history and philosophy of psychiatry show, to the contrary, that the debate between psychiatry and antipsychiatry is far from over.

The virtuous psychiatrist : character ethics in psychiatric practice

The context for this interdisciplinary work by a philosopher and a clinician is the psychiatric care provided to those with severe mental disorders. Such a setting makes distinctive moral demands on the very character of the practitioner, it is shown, calling for special virtues and greater virtue than many other practice settings. In a practice so attentive to the patients self identity, the authors promote a heightened awareness of cultural and particularly gender issues. By elucidating the nature of the moral psychology and character of the good psychiatrist, this work provides a sustained application of virtue theory to clinical practice. With its roots in Aristotelian writing, The Virtuous Psychiatrist presents virtue traits as habits, able to be cultivated and enhanced through training. The book describes these traits, and how they can be habituated in clinical training. A turn towards virtue theory within philosophy during the last several decades has resulted in important research on professional ethics. By approaching the ethics of psychiatric professionals in these virtue terms, Radden and Sadlers work provides an original application of this theorizing to practice. Of interest to both theorists and practitioners, the book explores the tension between the model of enduring character implicit in virtue theory and the segmented personae of role-specific moral responses. Clinical examples are provided, based upon dramaturgical vignettes (caseplays) which illustrate both the interactions of the case participants as well as the inner monologue of the clinician protagonist.

Can medicalization be good? Situating medicalization within bioethics

Medicalization has been a process articulated primarily by social scientists, historians, and cultural critics. Comparatively little is written about the role of bioethics in appraising medicalization as a social process. The authors consider what medicalization means, its definition, functions, and criteria for assessment. A series of brief case sketches illustrate how bioethics can contribute to the analysis and public policy discussion of medicalization.

Knowing, valuing, acting : clues to revising the biopsychosocial model

While remaining influential in education and research in psychiatry and medicine, the biopsychosocial (BPS) model has been criticized for ambiguity in conceptualizing everyday clinical problems. As a multilevel general systems approach, it leaves obscure which system level (cellular, person, family, community, and so on) is most clinically important at any point in time. As a model for psychiatry and medicine, it does not address the practical and moral dimensions of clinical work. This report reviews criticisms and concerns about the BPS model. These criticisms are used to begin a more practicable revision of the model.

Horsefeathers: a commentary on "evolutionary versus prototype analyses of the concept of disorder".

J. C. Wakefields (1999) article further develops his harmful dysfunction (HD) model for disorder concepts. This commentary focuses on three areas. The first notes the imbalance in the debate between the Lilienfeld and Marino (1995) Roschian model and the HD model for disorder concepts. The second claims that Wakefields purposes for the HD model have changed over the years and progressed toward irrelevance to psychopathology in general and toward irrelevance to actual nosologic, reimbursement, and sociopolitical controversies about disorder status. Further discussion is on how certain structural elements in Wakefields arguments and current limitations of evolutionary theory permit a superficially attractive model for psychopathology. These arguments and limitations, however, harbor serious problems when confronted with actual disputes about disorders. The conclusion notes some virtues to Wakefields inquiry, in style and substance.

The cognitive context of examinations in psychiatry using Bloom's taxonomy

Summary. Psychiatric practice involves complex thinking patterns. In addition to commanding a huge number of facts, the student must learn to manipulate factual knowledge to solve diagnostic problems, develop treatment plans, and critically evaluate those plans. This study demonstrates an empirical method for evaluating the level of cognitive processes tested in multiple choice examinations. Use of Blooms taxonomy in evaluating test items demonstrated the majority of test items on a psychiatry clerkship examination and a resident in‐training examination fell into the most basic cognitive level, that of simple recall. The utility of Blooms taxonomy is discussed along with implications for medical education.

Professional identity formation: creating a longitudinal framework through TIME (Transformation in Medical Education).

The University of Texas System established the Transformation in Medical Education (TIME) initiative to reconfigure and shorten medical education from college matriculation through medical school graduation. One of the key changes proposed as part of the TIME initiative was to begin emphasizing professional identity formation (PIF) at the premedical level. The TIME Steering Committee appointed an interdisciplinary task force to explore the fundamentals of PIF and to formulate strategies that would help students develop their professional identity as they transform into physicians. In this article, the authors describe the task force’s process for defining PIF and developing a framework, which includes 10 key aspects, 6 domains, and 30 subdomains to characterize the complexity of physician identity. The task force mapped this framework onto three developmental phases of medical education typified by the undergraduate student, the clerkship-level medical student, and the graduating medical student. The task force provided strategies for the promotion and assessment of PIF for each subdomain at each of the three phases, in addition to references and resources. Assessments were suggested for student feedback, curriculum evaluation, and theoretical development. The authors emphasize the importance of longitudinal, formative assessment using a combination of existing assessment methods. Though not unique to the medical profession, PIF is critical to the practice of exemplary medicine and the well-being of patients and physicians.