The old new theory of modern Russian psychiatry: a biopsychosocial approach (institutional discourse)

The article is discussed («Review of psychiatry and medical psychology named after V.M. Bekhterev». 2020; 2: 3-15), which examines the biopsychosocial model as the theoretical basis (scientific, clinical, preventive, therapeutic) of modern psychiatry, in particular, the biological (genetic) domain.The purpose of the discourse: from the standpoint of philosophy and methodology of science, to determine the place of the biological domain (biomedical research) of the biopsychosocial (biopsychosocial—spiritual) (BPS) approach (theory) in Russian psychiatry, in particular, from the standpoint of the subject of psychiatry and its main section-clinical psychiatry.Based on methodology and philosophy, and based on anthropological and holistic approaches, the biological domain of the BPS model, which is based on clinical psychiatry as a practice and, accordingly, theory, is discussed through the subject of psychiatry as a science. The significance and role of the subject of psychiatry (pathology, disorders, abnormalities of mental activity) in the ICD-10 and the components of the biopsychosocial (model) approach are discussed. There are differences in the domains of the model and the difficulties of clinical diagnosis (multi-axis, functional, multidimensional) and, accordingly, the study of the etiopathogenesis of mental disorders, the "bias" of diagnosis and therapy. The article deals with the neurological component of the biological domain and the "expansion" of neurologists into psychiatry, which leads to hidden antipsychiatry. The author emphasizes the independence, contiguity and two-paradigm nature of psychiatry as a science (with its own unity of subject and its own method of research—clinical and psychopathological). In addition to the interdisciplinarity of clinical neuroscience, it is proposed to be multidisciplinary (for the sections of psychiatry), but the future belongs to the transdisciplinary research methodology.

Methodological dualism considered as a heuristic paradigm for clinical psychiatry

SUMMARY Debates on dualism continue to plague psychiatry. I suggest that these debates are based on false dichotomies. According to metaphysical physicalism, reality is ultimately physical. Although this view excludes the idea of entities distinct from physical reality, it does not compel us to favour neural over psychological interventions. According to methodological dualism, both physical and mental interventions on the world can be deemed effective, and both perspectives can therefore be thought to be equally ‘real’.

Psychosis Without Meaning: Creating Modern Clinical Psychiatry, 1950 to 1980

Over the last fifty years, American psychiatrists have embraced psychotropic drugs as their primary treatment intervention. This has especially been the case in their treatment of patients suffering from psychotic disorders such as schizophrenia. This focus has led to an increasing disregard for patients’ subjective lived-experiences, life histories, and social contexts. This transformation of American psychiatry occurred abruptly beginning in the late 1960s and 1970s. My essay looks the ways these major transformations played themselves out in everyday clinical practices of state hospital psychiatrists from 1950 to 1980. Using clinical case records from California state hospitals, I chronicle the ways institutional and ideological forces shaped the clinical care of patients with psychotic disorders. I show there was an abrupt rupture in the late 1960s, where psychiatrists’ concerns about the subjective and social were replaced by a clinical vision focused on a narrow set of drug-responsive signs and symptoms. Major political, economic, and ideological shifts occurred in American life and social policy that provided the context for this increasingly pharmacocentric clinical psychiatry, a clinical perspective that has largely blinded psychiatrists to their patients’ social and psychological suffering.

Conclusion

The psychopharmacologic model has led to the prescription of the wrong drugs for the wrong indications. This chapter cites Max Fink's judgment, which describes clinical psychiatry as an extraordinarily weak discipline that is split from clinical medicine, with its roots in unfounded psychological fantasies that disregard effective diagnostic and treatment practices. It also emphasizes how clinical psychiatry as a profession is unable to identify and treat most of the complaints of patients coming to the psychiatric clinics because it has floundered in its confusion of syndromes and studies of causes. The chapter analyzes how the psychopharmacologic model that started out with a promising future has become little more than an ad copy for the pharmaceutical industry. It mentions diseases that the system offers that are now considered wrong, because drugs cannot be discovered for ailments that don't exist.

Borderline personality disorder, therapeutic privilege, integrated care: is it ethical to withhold a psychiatric diagnosis?

Once common, therapeutic privilege—the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient—is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population.

Book Review: "Titans of psychiatry of the twentieth century" by P.V. Morozov, R.A. Bekker, Yu.V. Bykov

This publication is an analysis of the book by P.V. Morozov, R.A. Becker, Yu.V. Bykov, dedicated to the four most significant persons, who had an invaluable influence on psychiatry in the XX century (Emil Kraepelin, Eugen Bleuler, Sigmund Freud, Karl Jaspers). Among the advantages of the book on the history of psychiatry, one can stress out a successful extrapolation of the ideas of the “titans” to the current state of psychiatric science and a discussion of their work with the use of the actual language of current clinical psychiatry. This makes it possible to recommend the book not only to experienced psychiatrists and researchers, but also to young specialists, as well as residents and students. Another important achievement of the book is the successful disclosure of not only ideas, but also biographies of the “titans” placed in the scientific, historical, political, cultural and personal contexts.

Understanding the Regulation of Transcription in Mental Illness

Advances in clinical psychiatry have been less than hoped for relative to the achievements in neuroscience. However, developments in neuromodulation and psychedelic therapy are promising. The efficacy of such treatments and canonical pharmacotherapies benefit from genetics and personalized medicine. Moreover, recent studies on the perturbation of transcription, including chromatin remodeling, in mental illness emphasized the importance of single-cell qPCR as an investigatory method that bolstered psychiatry. This technique demonstrated chromatin remodeling as a biomarker for addiction and the underlying mechanism of depression. If personalized medicine, along with canonical and newer therapies, can mediate and regulate transcription, epidemics in depression and addiction can be mitigated. This motivates investigators to continue to use single-cell transcription measures in models of mental illness for translational medicine.

Validating Biobehavioral Technologies for Use in Clinical Psychiatry

The last decade has witnessed the development of sophisticated biobehavioral and genetic, ambulatory, and other measures that promise unprecedented insight into psychiatric disorders. As yet, clinical sciences have struggled with implementing these objective measures and they have yet to move beyond “proof of concept.” In part, this struggle reflects a traditional, and conceptually flawed, application of traditional psychometrics (i.e., reliability and validity) for evaluating them. This paper focuses on “resolution,” concerning the degree to which changes in a signal can be detected and quantified, which is central to measurement evaluation in informatics, engineering, computational and biomedical sciences. We define and discuss resolution in terms of traditional reliability and validity evaluation for psychiatric measures, then highlight its importance in a study using acoustic features to predict self-injurious thoughts/behaviors (SITB). This study involved tracking natural language and self-reported symptoms in 124 psychiatric patients: (a) over 5–14 recording sessions, collected using a smart phone application, and (b) during a clinical interview. Importantly, the scope of these measures varied as a function of time (minutes, weeks) and spatial setting (i.e., smart phone vs. interview). Regarding reliability, acoustic features were temporally unstable until we specified the level of temporal/spatial resolution. Regarding validity, accuracy based on machine learning of acoustic features predicting SITB varied as a function of resolution. High accuracy was achieved (i.e., ~87%), but only when the acoustic and SITB measures were “temporally-matched” in resolution was the model generalizable to new data. Unlocking the potential of biobehavioral technologies for clinical psychiatry will require careful consideration of resolution.