Formación en investigación durante el mir / Training in research as part of the specialist training programme

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¿Es científica la psiquiatría? Carta al residente de psiquiatría del siglo XXI / Is psychiatry scientific? A letter to a 21st century psychiatry resident

Durante el desarrollo del DSM-5 incluso la prensa ha cuestionado la validez científica de la psiquiatría. Esta revisión proporciona a los residentes de psiquiatría del s. XXI maneras de responder a estas críticas a través de la definición de los conceptos y la historia de la psiquiatría (una rama de la medicina), la medicina y la ciencia. El lenguaje psiquiátrico tiene 2 niveles: primero, describir los síntomas y signos (la psicopatología descriptiva del s. XIX , desarrollada en Francia y Alemania), y, segundo, describir los trastornos (la nosología psiquiátrica fue desarrollada a principios del s. XX por Kraepelin y resucitada por la revolución americana neo-kraepeliniana, llevando finalmente al DSM- III ). La ciencia es un proceso histórico complejo de ensayo y error que puede verse amenazada por aquellos que creen demasiado en ella e ignoran sus limitaciones. Los avances psiquiátricos más importantes (la terapia electroconvulsiva y los principales agentes psicofarmacológicos) fueron descubiertos por «casualidad», no gracias a la planificación científica. La Psicopatología general, escrita por Jaspers, es un complejo libro de 100 años de antigüedad que describe: 1) los trastornos psiquiátricos como heterogéneos y 2) la psiquiatría como una disciplina científica híbrida que requiere una combinación de comprensión (un método del campo de las ciencias sociales) y explicación (un método del campo de las ciencias naturales). En el s. XXI Berrios nos recuerda los aspectos relacionados con la poco afortunada metodología de la psiquiatría debido a la heterogeneidad de sus síntomas y trastornos, algunos de los cuales resultan más comprensibles si son considerados problemas de comunicación fruto de la interacción entre seres humanos; en estas situaciones, los métodos neurocientíficos como las pruebas de neuroimagen no tienen sentido. Se necesita un nuevo lenguaje en la psiquiatría. Los residentes de psiquiatría del este de Asia, que no están particularmente apegados al lenguaje anticuado utilizado actualmente, pueden resultar especialmente preparados para la tarea de recrear el lenguaje psiquiátrico utilizando el conocimiento del s. XXI (AU)

During the development of the DSM-5, even the lay press questioned psychiatry’s scientific validity. This review provides 21st century psychiatry residents with ways of answering these attacks by defining the concepts and history of psychiatry (a branch of medicine), medicine and science. Psychiatric language has two levels: first, describing symptoms and signs (19th century descriptive psychopathology developed in France and Germany), and second, describing disorders (psychiatric nosology was developed in the early 20th century by Kraepelin and resuscitated by the US neo-Kraepelinian revolution leading to the DSM-III I ). Science is a complex trial-and-error historical process that can be threatened by those who believe too much in it and disregard its limitations. The most important Psychiatric advances, electroconvulsive therapy and major psychopharmacological agents, were discovered by « chance » , not by scientific planning. Jaspers’s General Psychopathology is a complex 100-year-old book that describes: 1) psychiatric disorders as heterogeneous and 2) psychiatry as a hybrid scientific discipline requiring a combination of understanding (a social science method) and explanation (a natural science method). In the 21st century Berrios reminds us of psychiatry’s unfortunate methodological issues due to hybrid symptoms and disorders, some of which are better understood as problems in communication between interacting human beings; in those situations neuroscience methods such as brain imaging make no sense. A new language is needed in psychiatry. East Asian psychiatry residents, who are not particularly attached to the antiquated language currently used, may be particularly equipped for the task of recreating psychiatric language using 21st century knowledge (AU)

Visión de un residente español de la psiquiatría del siglo XXI / A Spanish resident's vision of 21 st century psychiatry

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[Mind the gap: towards integrative perspectives of psychiatry].

In this century, marked advances in human genetics and brain imaging technology have finally allowed us to approach fundamental questions in psychiatry, even those in clinical psychiatry, by utilizing biological science. As of 2014, discussion on the advantages and limitations in operational diagnostic criteria, such as DSM (Diagnostic and Statistical Manual of Mental Disorders), in clinical psychiatry is becoming even more important. In contrast to most of the medical areas in which multi-disciplinal approaches are successful, factionalism augmented by mind-brain problem or mind-body problem has hampered the progress of psychiatry. Here I discuss the importance of building integrative perspectives of psychiatry.

Psiquiatría Biológica: nuevas etapas, nuevos objetivos / Biological Psychiatry: new phases, new goals

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Perspectivas hacia la psiquiatría de los estudiantes de medicina. Ocho años después / Views of psychiatry among medical students. Eight years after

Introducción. El objetivo de este estudio es observar si existen cambios en las opiniones de los estudiantes de medicina de la UAB hacia la psiquiatría en un período de ocho años. Sujetos y método. Mediante un diseño transversal, se administró el cuestionario de Balon et al (1999) a 90 estudiantes de medicina después de cursar la asignatura de psiquiatría en el año 2005. Los resultados de esta muestra se han comparado con un estudio previo llevado a cabo bajo las mismas condiciones con 91 estudiantes de 1997. Resultados. En comparación con el año 1997, los estudiantes de 2005 tienen una mayor percepción de avance y rigor científico de la psiquiatría y de claridad de las funciones del psiquiatra. Además los estudiantes de 2005 tienen una menor percepción de presión social si muestran interés por la especialidad. Estos cambios coinciden con una mayor percepción de calidad de la enseñanza y un aumento en el porcentaje de estudiantes que muestran interés por escoger psiquiatría como futuro profesional (un 2,2% en 1997 y un 5,6% en 2005). Conclusiones. La mejoría en la percepción de la calidad de la enseñanza puede haber influido en el aumento de las vocaciones hacia la psiquiatría (AU)

Introduction. The aim of the study is to assess changes in the opinions of medical students from UAB towards psychiatry in an 8-year period. Subjects and method. With a cross-sectional design, we administered the Balon et al (1999) questionnaire to 90 medical students after the psychiatry rotation in 2005. The results of this sample have been compared with a previous study carried out under the same conditions with 91 students in 1997. Results. Compared to 1997, the students of 2005 have a greater perception of advance and scientific rigor of psychiatry and of clarity of the psychiatrist's functions. In addition, the students of 2005 have a lower perception of social pressure if they show interest in the specialty. These changes co-occur with a greater perception of the teaching quality and an increase in the rate of students who show interest in choosing psychiatry as a professional future (2.2% in 1997 vs. 5.6% in 2005). Conclusions. This better perception of the teaching quality could have influenced the increase of vocational tendencies towards psychiatry (AU)

Neuroscience, power and culture: an introduction.

In line with their vast expansion over the last few decades, the brain sciences -- including neurobiology, psychopharmacology, biological psychiatry, and brain imaging -- are becoming increasingly prominent in a variety of cultural formations, from self-help guides and the arts to advertising and public health programmes. This article, which introduces the special issue of "History of the Human Science" on "Neuroscience, Power and Culture," considers the ways that social and historical research can, through empirical investigations grounded in the observation of what is actually happening and has already happened in the sciences of mind and brain, complement speculative discussions of the possible social implications of neuroscience that now appear regularly in the media and in philosophical bioethics. It suggests that the neurosciences are best understood in terms of their lineage within the "psy"-disciplines, and that, accordingly, our analyses of them will be strengthened by drawing on existing literatures on the history and politics of psychology -- particularly those that analyze formations of knowledge, power and subjectivity associated with the discipline and its practical applications. Additionally, it argues against taking today's neuroscientific facts and brain-targetting technologies as starting points for analysis, and for greater recognition of the ways that these are shaped by historical, cultural and political-economic forces.

Brainhood, anthropological figure of modernity.

If personhood is the quality or condition of being an individual person, "brainhood" could name the quality or condition of being a brain. This ontological quality would define the "cerebral subject" that has, at least in industrialized and highly medicalized societies, gained numerous social inscriptions since the mid-20th century. This article explores the historical development of brainhood. It suggests that the brain is necessarily the location of the "modern self," and that, consequently, the cerebral subject is the anthropological figure inherent to modernity (at least insofar as modernity gives supreme value to the individual as autonomous agent of choice and initiative). It further argues that the ideology of brainhood impelled neuroscientific investigation much more than it resulted from it, and sketches how an expanding constellation of neurocultural discourses and practices embodies and sustains that ideology.

Cajal y la Psiquiatría Biológica. El legado psiquiátrico de Ramón y Cajal (una teoría y una escuela) / Cajal and biological psychiatry: the psychiatric legacy of Cajal (a theory and a school)

El legado de Santiago Ramón y Cajal a la historia de la psiquiatría es doble; por un lado aportó una teoría que cambió la forma de entender el sistema nervioso, la teoría neuronal, y por otro, creó una escuela de psiquiatría que transformó definitivamente esta especialidad en España. La doctrina neuronal, postulada en 1888, supone la «piedra angular» sobre la que se han construido, a lo largo del siglo XX, todas las disciplinas neurocientíficas, incluida la psiquiatría biológica. Sin ella sería imposible, en la actualidad, tratar de explicar las bases etiopatogénicas de los trastornos mentales o el mecanismo de acción de los psicofármacos. Tras la concesión del Premio Nobel, en 1906, surgió en torno a su figura científica una generación de discípulos psiquiatras que renovaron la psiquiatría española (generación de Archivos de Neurobiología), pero cuya consolidación no fue posible por el desastre de la Guerra Civil. Cabe distinguir un grupo de discípulos directos (Achúcarro, Lafora, Sacristán, Gayarre, Villaverde, Fortún y Prados) y una segunda generación de discípulos diferidos, formados con los anteriores (López Aydillo, Rodríguez Somoza, Llavero). Entre todos, destacaron especialmente Achúcarro, maestro a su vez de la mayor parte de ellos y considerado como el sustituto natural de Cajal por sus extraordinarias dotes científicas, y Lafora, el más reconocido internacionalmente (baste recordar la «enfermedad de Lafora», o epilepsia mioclónica familiar progresiva con presencia intraneuronal de cuerpos amieloides). El mérito de Cajal también hay que circunscribirlo a su capacidad para promover las medidas políticas necesarias para implementar un sistema de formación internacional para profesionales aventajados (la Junta para Ampliación de Estudios, de la que fue presidente). Becados por esta institución, numerosos neuropsiquiatras españoles se formaron en los mejores centros europeos, con figuras de la talla de Kraepelin o Alzheimer (AU)

The legacy of Santiago Ramon y Cajal for the history of psychiatry is two-fold; he postulated a theory that changed the way we understand the nervous system, the neuron theory; and he also created a psychiatry school that definitively transformed this subject in Spain. The neuron doctrine, formulated in 1888, forms the cornerstone on which all the neurosciences, including biological psychiatry, have been constructed throughout the 20th century. Without it, it would be impossible, now, to try to explain the aetio-pathogenic bases of mental disorders or how psychotropic drugs work. After he was granted the Nobel Prize in 1906, a generation of psychiatrist disciples grew up around this scientific figure, who renewed Spanish psychiatry («the generation of Archivos of Neurobiology») but were prevented from consolidating their work by the Spanish Civil War. It is possible to distinguish a group of direct disciples (Achúcarro, Lafora, Sacristán, Gayarre, Villaverde, Fortín, and Prados) and a second generation trained by the former (López Aydillo, Rodríguez Somoza, Llavero). Of these, Achúcarro stands out as the teacher of most of the rest, considered to be Cajal’s natural successor for his extraordinary scientific talent. Lafora won the most international renown (think of Lafora’s Disease, or progressive familial myoclonic epilepsy with intra-neuronal presence of amyloid bodies). Cajal’s merit also lay in promoting the necessary political measures to implement an international training scheme for outstanding professionals (the Council for the Broadening of Studies, of which he was President). On scholarships from this institution, numerous Spanish neuro-psychiatrists studied at top European centres, with such great men as Kraepelin and Alzheimer (AU)

Neurobiological formulations: integrating clinical and biological psychiatry.

OBJECTIVE: The authors describe a pilot program allowing psychiatric residents to participate in neurobiological evaluations of patients with Axis I disorders. The program aimed to familiarize residents with available tools for assessing cognitive and neuroanatomical abnormalities in psychiatric patients and to foster greater interest among residents in correlating psychiatric symptoms with abnormalities in neural structures and pathways. METHODS: Residents meet weekly with a faculty mentor to plan and construct a neurobiological formulation. Residents review the salient literature on the Axis I condition present in a patient of their choosing. The patient undergoes neuroanatomical, physiological, and cognitive testing relevant to his disorder. The resident then integrates the findings from this testing with the patient's clinical presentation. Using a questionnaire, the authors obtain feedback from residents based on residents' experiences with this didactic program. RESULTS: Residents felt they obtained a greater appreciation and understanding of the relevance of neuroanatomical and neurophysiological abnormalities and testing in clinical psychiatry. The project was well received and residents rated it highly for its educational value. CONCLUSION: Neurobiological formulations offer a new educational method to foster knowledge and interest among psychiatric residents about the importance of neuroscience in clinical practice.

Psychotherapy in psychiatry.

The relationship between psychotherapy and psychiatry has become a beleagured one in recent years. The swing of the pendulum in the direction of biological psychiatry has led to a marginalization of psychotherapy within the discipline of psychiatry as a whole. However, psychotherapy continues to be a basic science of psychiatry with application in all clinical settings. It must be regarded as a biological treatment that works by changing the brain and is therefore just as important as pharmacotherapy in terms of overall treatment planning. The combined treatment of medication and psychotherapy has become the most common mode of psychiatric treatment planning in current practice. Both the two-treater model and the single-treater model have a set of advantages and disadvantages that are explicated. Further research is needed to identify clinical situations in which psychotherapy is essential, whether alone or in combination with medication. Moreover, as greater insights are gained into the brain mechanisms responsible for therapeutic changes, more specifically targeted psychotherapies can be developed.

[An integrative research model for child and adolescent psychiatry bringing together biological, psychological and social research approaches]. / Ein integratives Forschungsmodell für die Kinder- und Jugendpsychiatrie: die Zusammenführung von biologischen, psychologischen und sozialen Untersuchungsansätzen.

After some general remarks on the current situation of child and adolescent psychiatric research in Germany, a research concept is presented which in the course of 30 years of testing and further development has proven to be successful both in the inauguration of scientific projects, as well as in the qualification of trainees and co-workers. The nucleus of this concept is a research unit that is to a large extent independent of the daily health care routine. Some of the unit staff members are natural scientists holding permanent positions, complemented by a secondary labour force of young doctors and psychologists aspiring to a scientific career. This research unit provides supply for scientific projects and basic research, as well as for the development of new methods. The unit was endorsed by a Clinical Research Group funded by the German Research Foundation (DFG) that proved of value as power supply for research (e.g. by raising substantial third-party funds) and as an instrument for the qualification of young scientists. The article describes some results of four research projects derived from this approach (schizophrenia research, dyslexia research, research on Asperger syndrome, quality assurance, and therapy evaluation research).

Diagnóstico de la depresión / Diagnosis of depression

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The use of standardized patients for mock oral board exams in neurology: a pilot study.

BACKGROUND: Mock oral board exams, fashioned after the live patient hour of the American Board of Psychiatry and Neurology exam, are commonly part of resident assessment during residency training. Exams using real patients selected from clinics or hospitals are not standardized and do not allow comparisons of resident performance across the residency program. We sought to create a standardized patient mock oral board exam that would allow comparison of residents' clinical performance. METHODS: Three cases were created and then used for this mock oral boards exercise utilizing trained standardized patients. Residents from the University of Cincinnati and Indiana University participated in the exam. Residents were scored by attending physician examiners who directly observed the encounter with the standardized patient. The standardized patient also assessed each resident. A post-test survey was administered to ascertain participant's satisfaction with the examination process. RESULTS: Resident scores were grouped within one standard deviation of the mean, with the exception of one resident who was also subjectively felt to "fail" the exam. In exams with two faculty "evaluators", scores were highly correlated. The survey showed satisfaction with the examination process in general. CONCLUSION: Standardized patients can be used for mock oral boards in the live patient format. Our initial experience with this examination process was positive. Further testing is needed to determine if this examination format is more reliable and valid than traditional methods of assessing resident competency.

Genetic susceptibility to psychiatric disorders.

Genetics contributes susceptibility to most psychiatric conditions and the understanding of these genetic factors is increasing rapidly. Because of such breakthroughs and their implications for patient care, professional nursing organizations support the incorporation of genetics into nursing curricula and the attainment of a working knowledge of genetics by all nurses. In this article, the basics of psychiatric genetics are presented to provide a foundation for the understanding of current and future findings in the field as well as information about family history assessment and appropriate references that the practitioner may find helpful.

Integrar, integrar / Integrate, integrate

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