DSM-5. ¿La incorporación definitiva de la psiquiatría en la medicina? / DSM-5: the definitive inclusion of psychiatry in medicine?

DSM-5 is a significant factor in promoting the "remedicalization" of psychiatry as the focus of psychiatric knowledge, developed by the evidence-based medicine movement, shifted from the clinically-based biopsychosocial model to a research-based medical model. DSM-5 purposes are 1]clinical: diagnosis, prevention, early identification, management, outcome, assessment of improvement; 2] clinical research: etiology, course, effective treatments, cost-effective treatments, reliability and validity and utility of diagnosis; 3] a worldwide common language of diagnostic criteria used by mental health professionals; and 4] to improve communication with users of services, caregivers, and society in general. In the absence of a "gold standard" there are two basic questions still without answers 1] what kind of entities are psychiatric disorders?; and 2] How to integrate the multiple explanatory perspectives of psychiatric illness?.

Transtornos psiquiátricos na medicina estética: a importância do reconhecimento de sinais e sintomas / Psychiatric disorders in aesthetic medicine: the importance of recognizing signs and symptoms

Transtornos psiquiátricos são amplamente evidenciados em pacientes que buscam tratamentos estéticos. Apesar de não configurarem necessariamente uma contraindicação para a realização de procedimentos, o reconhecimento desses sintomas pelo profissional tende a contribuir para o fortalecimento da relação profissional-paciente e para um melhor prognóstico, reduzindo as chances de insatisfação, complicações e agravos nos sintomas psiquiátricos, além de evitar complicações legais. No presente artigo, os transtornos psiquiátricos mais comuns no domínio cosmético e estético foram apresentados e discutidos, assim como as orientações para o reconhecimento de sintomas e de manuseio destes pacientes por profissionais de saúde.

Psychiatric disorders are widely reported in patients seeking aesthetic treatments. Although they are not necessarily a contraindication for procedures, the recognition of these symptoms by the professional tends to strengthen the professional-patient relationship, thus leading to a better prognosis. This reduces the chances of dissatisfaction, complications, and aggravation of psychiatric symptoms, in addition to avoiding legal complications. In this article, the most common psychiatric disorders arising in cosmetic and aesthetic treatment are presented and discussed, as well as guidelines for recognizing the symptoms and managing these patients.

Research Domain Criteria (RDoC). Marco político y contenido / [Research Domain Criteria (RDoC). Political framework and content].

The Research Domain Criteria (RDoC) is an initiative of the National Institute of Mental Health of the United States of America, which based on research purposes consists of a new way of classifying mental disorders. His raison d’Ûtre is based on the conclusion that the knowledge progress of neurosciences does not seem to confirm the validity of the conventional psychiatric diagnoses. Furthermore, researching based on such diagnoses would weaken the progress in Psychiatry. Besides these scientific reasons, the Research Domain Criteria project is born within a political framework, giving raise to economic tensions. The objective of this paper is to discuss the first issue without avoiding the second one.

Aproximándose al DSM-5: ¿un avance en psiquiatría? / [An approach to DSM-5: a breakthrough in psychiatry?].

One of the main problems of current psychiatry is that its diagnostic classification systems are not precise and reliable, they do not help to identify with certainty a specific type of mental disorder and they frequently overlap two or more diagnoses. This may conduce to over diagnosis and overtreatment, which is the main criticism of the DSM system. The American Psychiatric Association (APA) launched recently the DSM-5, the fifth edition of its diagnostic manual, which provides diagnostic criteria for thousands of psychiatrist, psychologist and researchers and who will be using it in the next coming years. DSM-5, like the preceding editions, placed disorders in discrete categories such as bipolar disorder or schizophrenia. The problem is that scientists have been unable to find yet a genetic or neurobiological evidence to support the theory of mental disorders as separate categories. Several authors wanted the latest DSM to move away from the category model towards a new "dimensional approach", where disorders can be measured and mental illnesses overlapping can be reduced. Recent findings supports this new dimensional strategy, suggesting that the disorders are a product of shared risk factors that lead to abnormalities in specific drives, which can be measured and used to place persons on one of several spectra. In some parts the DSM-5 entered changes aiming to achieve a greater objectivity. The door for new changes in each category, dimension or criteria has been opened, favoring an evidence-based development of the future versions. DSM-5 is presented as a "living document" that can be updated easily. However, the category model still remains for many disorders. The future research in psychiatric diagnostic systems requires more genetic-molecular and neurophysiological evidence and more objective multinational field trials, in order to confirm the existence of the new diagnostic entities, spectrums or dimensions. This approach may provide us reliable information about the pathogenesis, psychopathology, adequate taxonomy and treatment of mental disorders.

Aún lo social: crisis en la práctica clínica / [Still the social factor: crisis in the clinical practice].

Consultations in our hospital center are problematic, mainly due to the poor living situation which patients come from (the suburbs of Buenos Aires). The housing situation, the environment and the economic or political conditions of these patients frame "the social" emergency that sets the context and the impact in the different psychopathological symptoms that they present. These conditions should also be reviewed from our theoretical assessment together with the clinical approach that our assistance practice studies. From a perception viewpoint we observe that "self-perception is far from any ideals. The perception of their environment is threatening and has no future". We constantly note the loss of the value of words and speech, when we hear our patients, wo have turned language into just an abject joy, as in the word of the addict. These issues must be studied from a theoretical point of view to be applied clinically. Such analysis reveals that our practice takes place in a context of failure. However, we cannot move backwards in "potential treatment" as Lacan states in the ethics as regards psychosis.

Palabras que no se lleva el viento. Identidad y diagnóstico en psiquiatría / [Words that won’t fade off in the wind: identity and diagnosis in psychiatry].

The main focus of this paper is to analyze the role of the word pronounced by members of the health staff as it is constitutive of identity in the patient recepting the word. How is identity constructed? How does the word spoken by a significant Other impinge on this process? In particular, what about the influence of words denoting medical diagnoses? Regarding such queries we also look, on a preliminary basis, at each of the two main currents in Western medicine (biomedicine and medical anthropology), to find out if and how it addresses the relation between the word as an element of identity and the same word as a therapeutic tool.

Detecção do risco de suicídio nos serviços de emergência psiquiátrica / Detecting suicide risk at psychiatric emergency services

OBJETIVO: Auxiliar o profissional de saúde na identificação dos fatores de risco e de proteção, e no manejo de pacientes com risco de suicídio, por meio de entrevista clinica, no contexto de emergência médica. MÉTODO: Revisão seletiva da literatura para identificar achados clínicos relevantes e ilustrativos. RESULTADO: A entrevista clinica é o melhor método para avaliar o risco suicida e tem dois objetivos: 1) apoio emocional e de estabelecimento de vínculo; 2) coleta de informações. Existe um número considerável de informações a serem coletadas durante a entrevista: fatores de risco e proteção (predisponentes e precipitantes), dados epidemiológicos, caracterização do ato, aspectos psicodinâmicos, antecedentes pessoais e familiares, modelos de identificação, dados sobre saúde física e rede de apoio social. Dificuldades ao longo da entrevista serão encontradas, mas com conhecimento e treinamento adequado, o profissional poderá abordar e ajudar adequadamente o paciente. Embora várias escalas tenham sido propostas, nenhuma delas demonstrou eficiência para a detecção de risco de suicídio. CONCLUSÃO: Não há como prever quem cometerá suicídio, mas é possível avaliar o risco individual que cada paciente apresenta, tendo em vista a investigação detalhada e empática da entrevista clinica. Impedir que o paciente venha a se matar é regra preliminar e fundamental.

OBJECTIVE: Guide the health professional to identify risk factors and forms of protection, together with handling such patient throughout a clinical interview within the emergency service context. METHOD: Selected literature revision so as to identify relevant and illustrative key cases. RESULTS: The clinical interview is the best method to evaluate the suicidal risk and has two different aims: 1) emotional support and creation of a bond; 2) collecting information. There is a substantial amount of information to be collected during the clinical interview, such as: risk factors and protection, epidemiologic data, act characterization, psychical dynamics aspects, personal and familial historic patterns, identification models, data on physical wealth and social net support. Difficulties are to emerge throughout the clinical interview, but a trained and informed professional will be able to approach and adequately add the patient. Although several scales have been proposed, none of them have been efficient to deter the suicidal risk. CONCLUSION: There is no method to predict who is to commit suicide, nevertheless, it is possible to evaluate the individual risk of each patient with regards to a detailed and empathic clinical interview. Prevent the patient to commit suicide is the preliminary and fundamental rule.

Is there an elephant in the room? Boundary violations in the doctor-patient relationship in India.

An anonymous postal survey on the awareness of the occurrence of nonsexual and sexual boundary violations (NSBV and SBV) in the doctor-patient relationship in India was conducted with psychiatrists and psychologists working in the state of Karnataka in India (n=51). Though this was not designed to be a prevalence study on violations, the results suggest that both NSBV and SBV do occur and, more importantly, respondents felt that this is an area which needs urgent attention in India. There was disagreement on whether some behaviours in certain situations could be construed as NSBV in the Indian culture. Though several respondents agreed that there was a need to develop guidelines on this issue in India, there was a perception that the problem was not in the availability of guidelines but in their implementation. The ethical implications of the study are discussed.

Diagnóstico em psiquiatria e relaçäo médico-paciente / Psychiatric diagnosis and physician-patient relationship

A autora salienta a importância do diagnóstico, como procedimento médico. Em seguida, apresenta um breve histórico do desenvolvimento da Psiquiatria e do diagnóstico psiquiátrico para, entao, caracterizá-lo como pluridimensional e comentar sua sistematizaçao, privilegiando a sistemática de Leme Lopes. Chama a atençao para a atual tendência de sistemas classificatórios ateóricos em relaçao à etiologia. E, paradoxalmente, de recursos cada vez mais sofisticados, no campo do diagnóstico causal. Alerta para o reconhecimento das tensoes geradas pelo curso médico, as quais podem contribuir para a complexidade dos procedimentos diagnósticos, com prejuízo do aperfeiçoamento da relaçao médico-paciente e da finalidade terapêutica da Medicina e da Psiquiatria.

A reforma psiquiátrica no Município do Rio de Janeiro: perspectivas e impasses / The psychiatric reform in the Rio de Janeiro city: perspectives and impasses

Compreende a organizaçäo da assistência à saúde mental no município do Rio de Janeiro e as perspectivas que se colocam para a mesma, a partir do contexto apresentado pelo processo de Reforma Psiquiátrica no Brasil no presente momento. O Rio de Janeiro, como outros municípios brasileiros, está passando por uma reorganizaçäo de sua rede de assistência em saúde. No entanto, por sua história de ex-capital federal, e capital estadual, o município apresenta uma organizaçäo de saúde muito peculiar, única no país. No caso da assistência psiquiátrica, é a cidade onde estäo localizadas todas as unidades hospitalares do Ministério da Saúde, e onde foi inaugurado o primeiro hospício do Brasil. E, até hoje, a administraçäo municipal näo conseguiu implementar nenhuma proposta alternativa ao modelo asilar, apesar da sua Lei Orgânica, que prevê esta implantaçäo, e das portarias do Ministério da Saúde, que remuneram essas formas de assistência. Foi realizada a revisäo bibliográfica e documental, e observaçäo participante nas unidades de saúde e nos fóruns de discussäo sobre a saúde mental no Município. Conclui que a sua grande rede manicomial, de grande autonomia em relaçäo ao poder local, reflete uma cultura centenária que vê a internaçäo como destino natural do louco. O fortalecimento da instância municipal, enquanto gerente do sistema de saúde, como consequência da efetiva implantaçäo do Sistema Unico de Saúde na cidade, aliada a vontade política de se reverter um modelo há tanto tempo instituido, é a possibilidade que se coloca de uma reversäo do atual quadro de abandono dos usuários de serviços de saúde mental do município.