Validez, confiabilidad y utilidad clínica de los trastornos mentales: el caso de la esquizofrenia de la CIE-11 / Validity, Reliability and Clinical Utility of Mental Disorders: The Case of ICD-11 Schizophrenia

RESUMEN Los sistemas de clasificación diagnóstica categorizan la psicopatología en trastornos mentales. Aunque estas entidades son constructos clínicos elaborados por consenso, se ha señalado que en la práctica se suele tratarlas como entidades naturales y sin valorar aspectos relacionados con su construcción nosológica. Los objetivos del estudio son revisar: a) la conceptualización de los trastornos mentales; b) los indicadores de validez, confiabilidad y utilidad clínica, y c) los valores de estos indicadores en la esquizofrenia de la CIE-11. Los resultados muestran que los trastornos mentales están conceptualizados como entidades discretas, al igual que las enfermedades de otras áreas de la medicina; sin embargo, se observan diferencias entre ambas categorías diagnósticas en la práctica clínica. La confiabilidad y la utilidad clínica de los trastornos mentales son adecuadas; no obstante, la validez aún no está esclarecida. De modo similar, la esquizofrenia de la CIE-11 presenta adecuadas confiabilidad y utilidad clínica, pero su validez permanece incierta. La conceptualización de la psicopatología mental en entidades discretas puede resultar inadecuada para su estudio, por lo que se han propuesto modelos dimensionales y mixtos. Los indicadores de validez, confiabilidad y utilidad clínica permiten tener una visión precisa del estado nosológico de los trastornos mentales al valorar distintos aspectos de su construcción nosológica.

ABSTRACT Diagnostic classification systems categorize mental psychopathology in mental disorders. Although these entities are clinical constructs developed by consensus, it has been pointed out that in practice they are usually managed as natural entities and without evaluating aspects related to their nosological construction. The objectives of the study are to review a) the conceptualization of mental disorders, b) the indicators of validity, reliability and clinical utility, and c) the values of these indicators in ICD-11 schizophrenia. The results show that mental disorders are conceptualized as discrete entities, like the diseases of other areas of medicine; however, differences are observed between these diagnostic categories in clinical practice. The reliability and clinical utility of mental disorders are adequate; however, the validity is not yet clarified. Similarly, ICD-11 schizophrenia demonstrates adequate reliability and clinical utility, but its validity remains uncertain. The conceptualization of psychopathology in discrete entities may be inadequate for its study, therefore dimensional and mixed models have been proposed. The indicators of validity, reliability and clinical utility enable us to obtain an accurate view of the nosological state of mental disorders when evaluating different aspects of their nosological construction.

A neurose como negativo da perversão: um estudo das perversões em Freud / Neurosis as negative of perversion: a study of perversions in Freud / La neurosis como negativa de la perversión: un estudio de las perversiones en Freud

Resumo Com base na afirmação freudiana de que a neurose seria o negativo da perversão, pretende-se trazer de volta ao contexto acadêmico essa entidade nosológica que paga um preço alto devido ao nome que carrega. O texto se propõe a discutir a perversão no decorrer da obra freudiana, além de desmistificar detalhes da dinâmica perversa, pouco explorada atualmente. Também são abordados os textos de Lacan, em que o psicanalista francês critica a proposta freudiana com outra expressão famosa no meio psicanalítico: a do Inconsciente a céu aberto. Realizou-se uma pesquisa minuciosa em textos nos quais as expressões freudiana e lacaniana surgem, atentando-se para a terminologia original proposta por esses autores. Isto posto e tomando como base a afirmação freudiana, verificou-se a existência de perversões negativas, constituídas por fantasias de conteúdos perversos por vezes causadoras de sintomas neuróticos, em oposição às perversões positivas - ou seja, quando essas fantasias são colocadas em prática sem a presença de sentimentos de asco, vergonha ou pudor. Buscou-se, portanto, entender a dinâmica das perversões em Freud, assim como compreender os critérios delimitadores entre traços perversos e perversões propriamente ditas que ganharam um status clínico ao decorrer de sua obra, servindo de base para o desenvolvimento das demais teorias a respeito do tema em questão.(AU)

Abstract From the Freudian claim that neurosis would be the negative of perversion, this article seeks to bring back to the academic context this nosological entity that pays such a high price because of its name. This article seeks to discuss perversion in the course of Freud's work, besides demystifying details of the perverse dynamics, little explored at present. Moreover, the texts of Lacan will be approached, from which the French psychoanalyst criticizes the Freudian proposal with another famous expression in the psychoanalytic environment: the unconscious in the open. A detailed research was conducted in texts in which the Freudian and Lacanian expressions appear, paying attention to the original terminology proposed by these authors. Having said this, and based on the Freudian assertion, negative perversions were constituted by fantasies of perverse contents, sometimes causing neurotic symptoms, as opposed to positive perversions, that is, when these fantasies are put into practice without the presence of feelings of disgust, shame or indecency. It was sought, therefore, to understand the dynamics of the perversions in Freud and understand the delimitating criteria between perverse traits and actual perversions, which gained a clinical status in the course of his work, serving as base for the development of other theories in respect theme.(AU)

Resumen Con base en la afirmación freudiana de que la neurosis sería lo negativo de la perversión, se pretende traer de vuelta al contexto académico esta entidad nosológica que tiene grandes consecuencias debido al nombre que lleva. El presente artículo intenta discutir la perversión en la obra freudiana, además de desmitificar detalles de la dinámica perversa, poco explorada actualmente. También se abordarán los textos de Lacan que hace críticas a la propuesta freudiana mediante otra expresión famosa en el medio psicoanalítico: la del Inconsciente a cielo abierto. Se realizó una investigación minuciosa en textos de ambos autores en que aparece la expresión, atentándose a la terminología original propuesta por ellos. Dicho esto, y con base en la afirmación freudiana, se encontraron perversiones negativas, constituidas por fantasías de contenido perverso por veces causando síntomas neuróticos, en contraposición a perversiones positivas, es decir, cuando estas fantasías se ponen en práctica sin la presencia de sentimientos de disgusto, vergüenza o pudor. Se buscó entender la dinámica de las perversiones en Freud, así como comprender los criterios delimitadores entre trazos perversos y perversiones propiamente dichas, que ganaron un status clínico en el curso de su obra, sirviendo de base para el desarrollo de otras teorías al respecto del tema en cuestión.(AU)

Psicoses Cicloides. Passado e futuro / Cycloid Psychosis. Past and future / Psychoses cycloïdes. Passé et future / Psicosis cicloides. Pasado y futuro

Este artigo pretende rever a origem do conceito de Psicoses Cicloides, a sua psicopatologia e a sua evolução. Através de uma análise da literatura, os autores procuram perceber a validade nosológica deste conceito, assim como o seu enquadramento atual e a sua utilidade futura na psiquiatria.

This paper intends to review the origin of the concept of cycloid psychoses, its psychopathology and its evolution. By analyzing the literature, the authors seek to delineate the nosological validity of this concept, as well as its current delimitation and its future utility in psychiatry.

Cet article a pour but de passer en revue l'origine du concept des psychoses cycloïdes, sa psychopathologie et son évolution. Une analyse de la littérature a permis aux auteurs de déterminer la validité nosologique de ce concept, ainsi que sa délimitation actuelle et son utilité future pour la psychiatrie.

Este artículo pretende revisar el origen del concepto de Psicosis Cicloides, su psicopatología y su evolución. A través de un análisis de la literatura, los autores buscan percibir la validez nosológica de este concepto, así como su actual marco y su utilidad futura en la psiquiatría.

Dieser Artikel hat zum Zweck, den Ursprung des Konzepts der Zykloiden Psychosen, seine Psychopathologie und seine Entwicklung zu untersuchen. Anhand einer Literaturanalyse versuchen die Autoren, die nosologische Gültigkeit dieses Konzepts, seine aktuelle Abgrenzung und seinen zukünftigen Nutzen für die Psychiatrie zu erörtern.

O modelo e o exemplo na nosologia psicanalítica / The model and example in psychoanalytic nosology / Le modèle et l'exemple en nosologie psychanalytique

Diversamente do modelo nosológico que opera com um saber sobre a patologia do indivíduo, o recurso ao exemplo nos auxilia a pensar a condução clínica como uma prática guiada pelo saber construído pelo próprio sujeito em sua experiência de vida. É por isso que no lugar da simplificação homogênea do modelo, valemo-nos do exemplo como chamado para fazer a mesma coisa de forma diferente, no sentido em que uma situação clínica pode ser tomada como paradigmática para se pensar o que cada caso comporta de absolutamente inédito

Unlike the nosological model that operates with a knowledge about the pathology of the individual, the use of example helps us to think about clinical conduction as a practice guided by the knowledge built by the subject himself in his life experience. That is why, instead of the homogeneous simplification of the model, we use the example as called to do something differently in the sense that a clinical situation can be taken as paradigmatic to think about what is absolutely unheard of in each case

Contrairement au modèle nosologique qui utilise une connaissance de la pathologie de l'individu, l'utilisation de l'exemple nous aide à réfléchir à la conduction clinique en tant que pratique guidée par la connaissance construite par le sujet lui-même dans son expérience de vie. C'est pourquoi, au lieu de la simplification homogène du modèle, nous utilisons l'exemple comme appel à faire la même chose différemment dans le sens où une situation clinique peut être considérée comme paradigmatique pour réfléchir à ce que chaque cas comporte d' absolument inédit

Beyond the DSM: trends in psychiatry diagnoses

Abstract Background: Although widely used in clinical practice and research, Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses have low validity: patients with different mental disorders can share similar symptoms, while those with the same diagnosis might have different symptoms. In fact, the DSM diagnostic system has been considered one of the main obstacles for further development of psychiatric research. Recently, it has been proposed that psychiatry nosology should be reframed according to a biologically-based etiology. Objectives: To review present and past endeavors of establishing an etiology-based nosology. Methods: Comprehensive review of articles on the topic. Results: From Hippocrates onwards, multiple attempts have been undertaken aiming to move etiology and nosology closer. The most recent efforts are represented by Developmental Psychopathology (DP) and the Research Domain Criteria (RDoC), which presents an operational matrix recommended to be used in clinical research instead of the DSM diagnoses. Discussion: The DSM-based nosology is faulty. RDoC and DP might be interesting alternatives for an etiology-based nosology. However, while DP has already brought promising results, RDoC is a novel proposal, whose advantages and disadvantages should gradually be identified in the upcoming years.

Estructura de la sintomatología psiquiátrica según el SRQ-18 en pacientes ambulatorios con trastornos mentales evaluados en un hospital general de Lima / Structure of psychiatric symptoms according to the SRQ-18 in outpatients with mental disorders assessed in a general hospital in Lima

Objetivos: describir la estructura de la sintomatología psiquiátrica evaluada mediante el instrumento SRQ-18 enpacientes ambulatorios con trastornos mentales de un hospital general de Lima. Métodos: Utilizando un registrode datos demográficos y clínicos de 210 pacientes de consultorio externo de psiquiatría del Hospital CayetanoHeredia (Lima, Perú), se exploraron los vínculos entre síntomas psiquiátricos del cuestionario SRQ-18 mediantecorrelaciones tetracóricas graficadas a través de redes generadas con el programa NodeXL...

Objectives: to describe the structure of psychiatric symptomatology evaluated through SRQ-18 in outpatients withmental disorders in a general hospital in Lima. Methods: Using the demographic and clinical information from filesof 210 psychiatric out-patients in the Hospital Cayetano Heredia (Lima, Peru), the connections between psychiatricsymptoms of SRQ-18 questionnaire evaluated by means of tetrachoric correlations were graphically representedin a network generated with the NodeXL program...

The classification, definition, and ontology of delusion / A classificação, definição e ontologia do delírio / Classification, définition et ontologie du délire / La clasificación, definición y ontología del delirio / Klassifizierung, Definition und Ontologie des Wahns / 谵妄症的分类，定义及其存在

Although delusion is one of the central concepts of psychopathology, it stills eludes precise conceptualization. In this paper, I present certain basic issues concerning the classification and definition of delusion, as well as its ontological status. By examining these issues, I aim to shed light on the ambiguity of the clinical term ‘delusion’ and its extension, as well as provide clues as to why philosophers are increasingly joining the ranks of psychiatrists, psychologists, and neuroscientists in the effort to come to a comprehensive understanding of delusion.

Apesar de o delírio ser um dos conceitos centrais da psicopatologia, ainda escapa à conceptualização precisa. Neste artigo, apresento alguns problemas fundamentais a respeito da classificação e definição do delírio, bem como sobre seu estatuto ontológico. Por meio do exame desses problemas, tenho como objetivo esclarecer a ambiguidade do termo clínico “delírio” e sua extensão, bem como fornecer pistas sobre o motivo de filósofos cada vez mais se juntarem a psiquiatras, psicólogos e neurocientistas na tarefa de chegar a uma compreensão global do delírio.

Bien que le délire soit l'un des concepts centraux de la psychopathologie, il échappe encore à la conceptualisation précise. Dans cet article, je présente quelques problèmes fondamentaux concernant la classification et la définition du délire, ainsi que son statut ontologique. Par le biais de l'examen de ces problèmes, je cherche à faire la lumière sur l'ambiguïté du terme clinique « délire ¼ et son ampleur, ainsi qu’à fournir des indices sur la raison pour laquelle les philosophes se joignent de plus en plus aux efforts des psychiatres, psychologues et chercheurs en neurosciences pour parvenir à une compréhension globale du délire.

Aunque el delirio sea uno de los conceptos centrales de la psicopatología, este aún se escapa de la conceptualización precisa. En este artículo, presento cuestiones fundamentales relacionadas a la clasificación y definición del delirio, así como también acerca de su estado ontológico. A través del examen de estas cuestiones, mi objetivo es dilucidar la ambigüedad del término clínico ‘delirio’ y su extensión, así como proporcionar pistas sobre por qué los filósofos se unen cada vez más a los psiquiatras, psicólogos y neurocientíficos en el esfuerzo por llegar a una comprensión global del delirio.

Obwohl der Wahn eines der zentralen Konzepte der Psychopathologie ist, konnte ein genauer Begriff bisher nicht erstellt werden. In dieser Arbeit stellen wir grundlegende Probleme bezüglich der Klassifizierung und Definition des Wahns, sowie seinen ontologischen Status dar. Unsere Problemuntersuchung hat zum Ziel, die Mehrdeutigkeit des medizinischen Begriffs „Wahn“ und seine Erweiterungen zu erläutern, sowie mögliche Antworten auf die Frage zu finden, warum Philosophen sich zunehmend Psychiatern, Psychologen und Neurowissenschaftlern anschließen, um ein umfassendes Verständnis des Wahns zu erlangen.

虽然谵妄症是精神病症的主要概念，但是它的概念依然不是很清楚。本论文对谵妄症的分类和定义方面的一些基本问题进行探讨，并且分析了它的本体论的一些问题。通过调查分析这些问题，作者尝试澄清谵妄症这个临床术语的模糊性和它的外延，了解驱使精神分析学，心理学，神经科学，众多学科的学者联合起来，试图对谵妄症进行一个全面的理解的哲学背景。.

Gender dysphoria with homosexuality and comorbid depressive disorder: complexities in concept and management.

Gender identity disorder (GID) and homosexuality are complex entities debated over decades, whether should be categorized as a disorder or not. There are a number of problems specifically related to the criteria of the GID diagnosis like differences in the terms trans-sexualism and GID, failure of the proposed criteria in conceptualizing the whole spectrum of gender variance phenomena, the potential risk of physically invasive examinations to rule out intersex conditions and the application of diagnosis even after hormonal and surgical treatment. We hereby report complexities faced in the case of a male to female transsexual with homosexuality and depressive disorder and its management.

Rutas ontológicas de la nosología psiquiátrica: ¿Cómo se llegó al DSM-5? / Ontological routes of psychiatric nosology: How did DSM-5 arrive?

Se examinan las características fundamentales de la elaboración y desarrollo de un sistema nosológico desde la perspectiva ontológica. Aplicado a la historia reciente del Manual Diagnóstico y Estadístico de Trastornos Mentales (DSM-5), de la Asociación Psiquiátrica Americana, este análisis formula, luego de un breve esbozo histórico, los planteamientos de diversos pensadores e investigadores a lo largo de los dos últimos siglos. Temas de discusiones significativas han sido, entre otros, la definición de enfermedad mental, etiopatogenia, confiabilidad y validez, justificación y propósitos de eventuales cambios, aspectos éticos y tensiones persistentes entre ciencia y humanismo, teorías heurísticas en psiquiatría y la práctica clínica concreta. Se formula la esperanza de una deseable convergencia y resultados beneficiosos del proceso para pacientes, familiares, profesionales y la sociedad en su conjunto.

The main ontological features of the elaboration and development of a nosological system, from an ontological perspective, are examined and applied to the recent publication of the fifth edition of APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). After a brief historical description, the article reviews contributions from different authors and discusses topics such as definition of mental disorder, etiopathogenesis, reliability and validity, justification and objectives of eventual changes, ethical links and tensions between science and humanism, heuristic theories in psychiatry and concrete aspects of clinical practice. The hope is to reach a desirable convergence of viewpoints and beneficial results from the process in favor of patients, families, professionals and society as a whole.

History of Schizophrenia / 신경정신의학

Fundamental difficulties in psychiatric nosology lie in the most basic fact that it deals with subjective states of the human mind. Modern instrumental diagnostic classification systems, which amount to lists of symptom inventories, could not provide accurate concepts of psychiatric disorders. This is also true for schizophrenia, a representative mental disorder. Kraepelin's dementia praecox was a collection of controversially proposed diseases, which had some critical similarities in their clinical features, i.e., the course and outcome. Despite initial debates on the adequacy of this concept, dementia praecox was recognized as a disease entity quite early, so that the concept of dementia praecox or schizophrenia proliferated, became diversified, and was then altered. We can now find large discrepancies between Kraepelin's dementia praecox and today's schizophrenia. However, the myth of disease entity was seldom challenged and psychiatrists today implicitly believe that they are dealing with what Kraepelin had proposed. In order to navigate this impasse, we thought that historical studies on the concept of dementia praecox and underlying taxonomic principles established by 19th century alienists including Kraepelin would shed some light. The aim of this article is to comprehensively review the history of concepts of dementia praecox or schizophrenia, and to question critically how much today's schizophrenia has received the conceptual inheritance from original concepts. Through this process, we expect to attain a renewed understanding of schizophrenia.

Modelo estrutural de internalização e externalização: emergência, validade e utilidade clínica / Internalizing and externalizing structural model: emergency, validity and clinical utility / El modelo estructural de internalización y externalización: emergencia, validez y utilidad clínica

Os sistemas oficiais de classificação e diagnóstico em psicopatologia apresentam limitações relacionadas à extensa heterogeneidade clínica e ao significado dos padrões de comorbidade diagnóstica. A fim de superá-las, pesquisadores têm defendido uma estrutura dimensional para as psicopatologias mais prevalentes baseada em dois fatores latentes de internalização e externalização. O presente artigo visa avaliar a validade do Modelo Estrutural de Internalização e Externalização, tendo como norte a superação das referidas limitações e sua utilidade clínica. Revisão não sistemática da literatura nas bases Scielo e PubMed. Foram selecionados artigos empíricos e teóricos que avaliavam a pertinência do modelo. Foram excluídos estudos de replicação ou que avaliam o modelo em amostras infantis. A busca de literatura resultou em um total de 536 artigos, dos quais foram mantidos 44. Esse conteúdo foi organizado em três linhas de pesquisa: estudos epidemiológicos-estruturais, psicobiológicos e psicométricos. O Modelo Estrutural de Internalização e Externalização apresenta indicadores que dão sustentabilidade aos seus pressupostos teóricos. O modelo é capaz explicar a comorbidade diagnóstica e, parcialmente, heterogeneidade clínica. Entretanto, não apresenta instrumental clínico normatizado para a operacionalização dos construtos e não há estudos com amostras clínicas graves.

The official systems of classification and diagnosis of psychopathology have limitations related to the extensive clinical heterogeneity and the meaning of patterns of diagnostic comorbidity. To overcome them, researchers have argued for a dimensional structure to the most prevalent psychopathology based on two latent factors of internalizing and externalizing vulnerability. The current study aimed to evaluate the validity of the Internalizing/Externalizing Structural Model, having as a standard its ability to overcome the aforementioned limitations and its clinical utility. A non-systematic review was performed in PubMed and SciELO databases. Theoretical and empirical articles were retrieved based and evaluated on basis of its relevance to the model. Replications and studies based on samples of children were excluded. Bibliographic search yielded a total of 536 articles, of which 44 were retrieved. The content of the articles were organized into three lines of research: structural-epidemiological, psychobiological, and psychometric. The Internalizing/Externalizing Structural Model presents indicators that support its theoretical assumptions. The model is able to explain the diagnostic comorbidity and, partially, clinical heterogeneity. However, there is no standardized clinical instrument for the operationalization of internalizing/externalizing constructs and no validation studies with inpatient samples.

Los sistemas oficiales de clasificación y diagnóstico de la psicopatología tienen limitaciones relacionadas con la amplia heterogeneidad clínica y el significado de los patrones de comorbilidad diagnóstica. Para superarlas, los investigadores han argumentado a favor de una estructura tridimensional de la psicopatología más frecuente en base a dos factores latentes de internalización y externalización vulnerabilidad. El presente estudio tuvo como objetivo evaluar la validez del modelo estructural internalización/externalización tener patrones de utilidad, la heterogeneidad y la comorbilidad clínicas como parámetros. Una revisión no sistemática fue realizada en bases de datos PubMed y SciELO. Artículos teóricos y empíricos se recuperaron basa y evaluado en función de su relevancia para el modelo. Se excluyeron réplicas y estudios basados en muestras de niños. Búsqueda bibliográfica arrojó un total de 536 artículos, de los cuales 44 fueron recuperados. El contenido de los artículos que se han organizado en tres líneas de investigación: estructural-epidemiológicos, psicobiológicos y psicométricos. El modelo estructural de internalización/externalización presenta indicadores que apoyan sus hipótesis teóricas. El modelo es capaz de explicar la comorbilidad de diagnóstico y, en parte, la heterogeneidad clínica. Sin embargo, no existe un instrumento clínico estandarizado para avaluación de internalización e externalización, ni estudios de validación con muestras de pacientes hospitalizados.

Síndrome de Marfan, mutaciones nuevas y modificadoras del gen FBN1 / Síndrome de Marfan, mutaciones nuevas y modificadoras del gen FBN1

El síndrome de Marfan (SM) es un trastorno sistémico causado por mutaciones en la proteína de la matriz extracelular fibrilina 1 (FBN1). Con un patrón de herencia autosómico dominante, los pacientes se caracterizan por presentar compromiso ocular, cardiovascular y esquelético dentro de un espectro clínico variable. Se ha sugerido que la variabilidad fenotípica intrafamiliar e interfamiliar característica del síndrome ocurre por la asociación de otras mutaciones denominadas modificadoras (driver mutations). Si bien hay claridad acerca de la causalidad genética clásica de la enfermedad, las mutaciones modificadoras descritas recientemente aún no están bien dilucidadas. Se presenta un caso de SM con una mutación no descrita previamente en el gen de la fibrilina 1; se aplica la nosología de Ghent revisada y se analiza el papel de esta mutación nueva y de las mutaciones modificadoras en la génesis de la enfermedad.

Marfan syndrome (MS) is a systemic disorder caused by mutations in the extracellular matrix protein fibrillin 1 (FBN1). With a dominant autosomal pattern, MS patients are characterized by ocular, cardiovascular and skeletal involvement, all within a variable clinical spectrum. It has been suggested that the intrafamilial and interfamilial phenotypic variability, characteristic of the syndrome, occurs by the association of other mutations called driver mutations. Even though there is a clear genetic causation, the recently described driver mutations are not yet fully elucidated. We present a MS case with a mutation not previously described in the fibrilin 1 gene, applying the revised Ghent nosology and analyzing the role of this new mutation and of the driver mutations in the genesis of the disease.

Superando a falsa dicotomia entre natureza e construção social: o caso dos transtornos mentais / Overcoming the false dichotomy between nature and social construction: the case of mental disorders / Dépasser la fausse dichotomie entre nature et construction sociale: penser autrement les maladies mentales / Superando la falsa dicotomía entre naturaleza y construcción social: el caso de los trastornos mentales

As revisões periódicas das classificações diagnósticas em psiquiatria sempre provocam intensos questionamentos que interrogam sobre a própria natureza dos objetos classificados. A pergunta recorrente é: os transtornos psiquiátricos existem de fato ou são apenas construções sociais? Neste artigo, procuramos esclarecer os pressupostos da posição essencialista e a do construtivismo social, e defender que existem alternativas conceituais, como o modelo dos tipos práticos, que nos permitem retirar o eixo central do debate nosológico da disputa natureza versus construção social.

The periodic revisions of psychiatric classificatory systems always draw sharp criticism that put at stake the very nature of the objects they classify. The recurrent question is: do psychiatric disorders in fact exist or are they merely socially constructed? In this article, our aim is to clarify the underlying assumptions of both the essentialist and the social constructionist positions. We also show that there are conceptual alternatives, such as the practical-kinds model, that move the center of gravity of the nosological discussion away from the nature-versus-social-construction argument.

Chaque révision des schèmes de classifications en psychiatrie suscite une réflexion accrue à propos de la nature des objets classés. Une question récurrente se présente: existent-ils des troubles psychiatriques ou seraient-ils la résultante d'une construction sociale? Dans cet article, nous cherchons à éclairer tantôt les thèses essentialistes, tantôt celles tributaires du constructivisme social. Nous soutenons qu'il y a des alternatives conceptuelles, tel que le modèle des types pratiques, ce qui permet de déplacer l'axe central du débat nosologique de la dispute nature contre construction sociale.

Las revisiones periódicas de las clasificaciones diagnósticas en psiquiatría siempre despiertan intensos cuestionamientos sobre la naturaleza de los objetos clasificados. La pregunta recurrente es: ¿los trastornos psiquiátricos realmente existen o son construcciones sociales? En este artículo buscamos establecer los supuestos de la posición esencialista y del construccionismo social, para luego argumentar que existen alternativas conceptuales, como el modelo de los tipos prácticos, que permiten desplazar el eje central del debate nosológico de la oposición naturaleza versus construcción social.

Obsessive-compulsive disorder for ICD-11: proposed changes to the diagnostic guidelines and specifiers

Since the approval of the ICD-10 by the World Health Organization (WHO) in 1990, global research on obsessive-compulsive disorder (OCD) has expanded dramatically. This article evaluates what changes may be needed to enhance the scientific validity, clinical utility, and global applicability of OCD diagnostic guidelines in preparation for ICD-11. Existing diagnostic guidelines for OCD were compared. Key issues pertaining to clinical description, differential diagnosis, and specifiers were identified and critically reviewed on the basis of the current literature. Specific modifications to ICD guidelines are recommended, including: clarifying the definition of obsessions (i.e., that obsessions can be thoughts, images, or impulses/urges) and compulsions (i.e., clarifying that these can be behaviors or mental acts and not calling these “stereotyped”); stating that compulsions are often associated with obsessions; and removing the ICD-10 duration requirement of at least 2 weeks. In addition, a diagnosis of OCD should no longer be excluded if comorbid with Tourette syndrome, schizophrenia, or depressive disorders. Moreover, the ICD-10 specifiers (i.e., predominantly obsessional thoughts, compulsive acts, or mixed) should be replaced with a specifier for insight. Based on new research, modifications to the ICD-10 diagnostic guidelines for OCD are recommended for ICD-11.

Hoarding disorder: a new diagnostic category in ICD-11?

Despite the long-held view that hoarding is a symptom of both obsessive-compulsive disorder and obsessive-compulsive personality disorder, increased evidence has emerged during the last 20 years suggesting that hoarding represents a distinct form of psychopathology. This study reflects the discussions on the nosological status of hoarding carried out by the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders. The distinctiveness of hoarding is based on its having core symptoms that differ from those of other disorders, as well as distinctive neurobiological correlates and treatment responses. Furthermore, data showing the clinical utility, global applicability, and appropriateness of the concept of hoarding disorder outside specialty mental health settings suggest that this condition should be included in ICD-11. Finally, given the focus of ICD-11 on primary care and public health, the Working Group suggests that poor insight and severe domestic squalor may be considered as specifiers for hoarding disorder in ICD-11.

A Historical Consideration of Psychiatric Diagnostic Systems : Focusing on the Concept of Depression / 신경정신의학

Today's diagnostic criteria are based on consensus, however, they are still incomplete and being changed. These unstable but temporarily dogmatic criteria have been constraining the thinking of individual psychiatrists, and invalidating painful scientific achievements based on previous ones. The limitation of the criteria system appears especially clear concerning depression due to the ambiguity of its definition. Therefore, the aim of this article was to review the history of various concepts of depression and to compare this to today's tendency, which attempts to consolidate diversity. In addition to all Diagnostic and Statistical Manual (DSM), Internal Classification of Diseases (ICD)-9, ICD-9-CM, and ICD-10 were centrally discussed. Classic descriptions of depression were extracted from reviews of classic literature, and some salient concepts and the process by which they had been integrated, divided, and newly proposed was traced. The descriptions of depression whose prototype had been melancholia have experienced significant conceptual changes through DSM-IV and the most recent DSM-V ; they impose tasks that are yet to be resolved. Among them, whether various depressive syndromes are diverse phenotypes of one disorder or they all represent different disorders could be regarded as the most fundamental problem. In order to conduct fruitful studies and to ensure proper treatment of every patient, more precise nosologic understanding of depression must be pursued.

A Historical Consideration of Psychiatric Diagnostic Systems : Focusing on the Concept of Depression / 신경정신의학

Today's diagnostic criteria are based on consensus, however, they are still incomplete and being changed. These unstable but temporarily dogmatic criteria have been constraining the thinking of individual psychiatrists, and invalidating painful scientific achievements based on previous ones. The limitation of the criteria system appears especially clear concerning depression due to the ambiguity of its definition. Therefore, the aim of this article was to review the history of various concepts of depression and to compare this to today's tendency, which attempts to consolidate diversity. In addition to all Diagnostic and Statistical Manual (DSM), Internal Classification of Diseases (ICD)-9, ICD-9-CM, and ICD-10 were centrally discussed. Classic descriptions of depression were extracted from reviews of classic literature, and some salient concepts and the process by which they had been integrated, divided, and newly proposed was traced. The descriptions of depression whose prototype had been melancholia have experienced significant conceptual changes through DSM-IV and the most recent DSM-V ; they impose tasks that are yet to be resolved. Among them, whether various depressive syndromes are diverse phenotypes of one disorder or they all represent different disorders could be regarded as the most fundamental problem. In order to conduct fruitful studies and to ensure proper treatment of every patient, more precise nosologic understanding of depression must be pursued.

Figuras de la depresión y figurabilidad melancólica: precisiones fenomenológicas y psicopatológicas respecto de la melancolía y la depresión / Figuras da depressão e figurabilidade melancólica: precisões fenomenológicas e psicopatológicas sobre melancolia e depressão / Figures of depression and melancholic figurability: phenomenological and psychopathological considerations on melancholia and depression / Figures de la dépression et figurabilité mélancolique: précisions phéno-ménologiques et psychopathologiques sur la mélancolie et la dépression

La generalización de la noción de melancolía acerca la melancolía de la depresión. El presente artículo precisa los límites y particularidades del discurso psiquiátrico y analiza el problema de la melancolía desde la psicopatología. Esta distinción depresión/melancolía tiene repercusiones clínicas importantes en tanto la escucha particular de la insubstancialidad del objeto propuesta pone el acento en la capacidad de regresión del analista por sobre la comprensión y la empatía, y también por el lugar que da a su aspecto somático (insomnio).

O sentido amplo da noção atualmente usada de melancolia acerca a melancolia da depressão. Este artigo especifica os limites e as características do discurso psiquiátrico e analisa o problema do objeto melancólico do ponto de vista psicopatológico. Esta distinção depressão/melancolia tem importantes implicações clínicas visto que a escuta particular da não-substancialidade do objeto aqui proposta enfatiza a capacidade de regressão do analista mais do que a compreensão e empatia, e também sobre o lugar que dá o somático (insônia).

The broad sense of the term melancholia as used today brings it close to the concept of depression. This article establishes the limits and particularities of psychiatric discourse and proposes a psychopathological analysis of melancholia. The distinction between depression and melancholia is clinically relevant since the particular listening of the non-substantiality of the object indicated here involves the analyst's capacity for regression rather than for empathy and understanding. The focus on the somatic dimension of depression (insomnia) is also clinically important.

La généralisation de la notion de mélancolie par rapport à la mélancolie de la dépression. Cet article précise les limites et les particularités du discours psychiatrique et analyse le problème de la mélancolie du point-de-vue de la psychopathologie. Cette distinction dépression/mélancolie a d'importantes répercussions cliniques, étant donné que l'écoute particulière de l'insubstantialité de l'objet proposé met plutôt en relief la capacité de régression de l'analyste que la compréhension et l'empathie, ainsi que le lieu que l'on attribue à son aspect somatique (insomnie).

Una visiíon personal de la psiquiatría actual, con ánfasis en el papel de la Psiquiatría Biológica / A personal view of psychiatry today, with emphasis on the role of Biological Psychiatry

A punto de partida de un examen A punto de partida de un examen panorámico de la psiquiatría contemporánea, se pasa revista a diversos periodos de la historia de nuestra disciplina con énfasis en su contribución epistemológica a lo largo de los últimos tres siglos. Se presta particular atención a recientes debates nosológicos, al rol del diagnóstico y clasificaciones para luego centrarse en el crucialmente dominante papel de la psiquiatría biológica en el momento actual. Los avancesde la bioquímica y fisiología cerebral y de la genética y resultados de investigaciones neurocientíficas y de neuro-imágenes abren la puerta a explicaciones causales, implicaciones terapéuticas y preventivas representadas por proyectos internacionales, uno de cuyos objetivos fundamentales es la identificación de marcadores biológicosde enfermedades mentales. Se postula, como ejemplo de estos avances, la hipótesis de que la psicoterapia misma tiene repercusiones notables en la fisiología y la genética cerebrales

After a panoramic review of contemporary psychiatry, several periods of its history are examined with emphasis on their epistemological contributions throughout the last three centuries. Particular attention is paid to recent nosological debates, to the role of diagnosis and classifications to, finally, center on the nowadays crucially dominant role of biological psychiatry at the present time. Advances in brain biochemistry and physiology, genetics and the results of neuroscientific and neuro-imaging investigations open the door to causal explanations, therapeutic and preventive implications represented by international projects, one of whose fundamental objectives is the identification of biological markers of mental disorders. As an example of these advances, the hypothesis of notable repercussions of psychotherapy on brain physiology and genetics is presented.

Prácticas contemporáneas de consumo de alcohol: Una perspectiva psicoanalítica / Contemporeary practices of alcohol consumption: A psychoanalytical perspective

El escrito recorre algunos antecedentes de las formas de considerar la relación del hombre con el alcohol; básicamente las consideraciones que de esa relación se hicieron a nivel psicopatológico y especialmente la perspectiva freudiana de la misma. Luego describe una serie de prácticas actuales de consumo de alcohol, las que manifiestan de modo patente algunos de los efectos más destacados de la configuración cultural contemporánea. El trabajo concluye con el planteo de la diferencia que la respuesta del psicoanálisis ofrece a dichos efectos, en contraste con otras respuestas de la época.

The text covers some background on the ways of looking at man's relationship with alcohol; basically the considerations of this relationship made at psychopathology and especially the Freudian perspective of it. It then describes a series of current practices of alcohol consumption, which points out some of the more prominent effects of the contemporary cultural setting. The paper ends exposing the difference that psychoanalytical response offers to such effects.