¿Qué aportan a la Psiquiatría los estudios en cerebro post mórtem? / Do post-mortem brain studies provide useful information for Psychiatry?

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[Biologism controversy: ethical implications for psychiatry]. / Biologismus-Kontroversen: Ethische Implikationen für die Psychiatrie.

Current biological psychiatry, it is frequently claimed by its opponents, is "biologistic" and unduly narrows psychological disorders to neurobiology and molecular biology. They deem a complete neuroscientific reduction of the mental phenomena to be impossible because of the impossibility of reducing certain phenomena, such as the individual subjective experience. If such a reduction is nevertheless undertaken it is ultimately to the disadvantage of the patients. We argue in this article that the very term "biologism" has to be put under scrutiny in the first place. As a result it becomes obvious that "biologism", as a subclass of "philosophical naturalism", is ultimately quite unproblematic. Biologism is dangerous only if it implies an eliminative rejection or an inappropriate underestimation of the relevance of the psyche. On closer examination it gets evident that such implications do not follow necessarily from biologism but cannot be precluded either. To better identify and possibly prevent such dangers, a more differentiated terminology seems helpful.

A emergência da categoria “fobia social” no contexto da rebiologização da psiquiatria / The emergence of the category

Este trabalho expõe um estudo de caso da entidade clínica “fobia social”, como exemplar da ampliação numérica do espectro de diagnósticos psiquiátricos, e identifica alguns dos elementos constituintes da construção da psiquiatria biológica nos últimos 26 anos, destacando aspectos que conduziram à sua hegemonia. Buscou-se refletir sobre o aumento do número das categorias diagnósticas psiquiátricas a partir da descrição da emergência da categoria nosológica “fobia social”, bem como das transformações nos critérios classificatórios que propiciaram tal ampliação. A dissertação tem como objetivo descrever historicamente a construção de um novo diagnóstico na psiquiatria com alvo no tratamento farmacológico, a “fobia social”, com características até então pertinentes à esfera da personalidade ou abordada através das psicoterapias, comparando a abordagem das fobias em situações sociais nas diferentes versões do DSM. Através da reconstrução do surgimento da “fobia social” como entidade distinta, pesquisou-se a produção científica sobre “fobia social”, através de revisão bibliográfica em periódicos científicos internacionais de 1966 a 1988 sobre o tema. Realizou-se, ainda, estudo comparativo entre as mudanças classificatórias acerca das fobias nas edições do DSM, culminando com a introdução da “fobia social” a partir do DSM-III. Conclui-se que a psiquiatria biológica tornou-se a principal vertente na psiquiatria a partir de 1980, sendo a inclusão da fobia social no DSM-III exemplar dessa transformação, com conseqüente mudança de abordagem, de “psicologizada” para “farmacologizada”.

This work presents a case study on the clinical entity “social phobia”, as example of the numerical amplification of the range of psychiatric diagnoses, identifying some elements which build the biological psychiatrics in the past 26 years, highlighting some aspects that led to its hegemony. It tried to reflect on the growing number of psychiatric diagnostic categories, based on the description of the emergence of the nosological category “social phobia”, as well as the changes in the classification criteria which made this amplification possible. The dissertation aims to describe the history of the construction of a new diagnosis in Psychiatrics, targeted at the pharmacological treatment, the “social phobia”, whose features, until then pertaining to the sphere of personality or approached by psychotherapies, as compared to the approach of phobias in social situations in the several versions of the DSM. Through the reconstruction of the emergence of the “social phobia” as distinct entity, the author assessed the scientific production on “social phobia”, through a bibliographical review of international scientific journals, published from 1966 to 1988. The author also carried out a comparative study between classification changes on phobias in DSM, ending with the inclusion of “social phobia” in DSM-III. The work concludes that biological psychiatrics became the main trend in Psychiatrics from 1980 on, and the inclusion of social phobia in DSM-III was an example of this, and consequently changed the approach from “psychologized” to “pharmacologized”.

Principios éticos y legales en la práctica pericial psiquiátrica / Ethical and legal principles at the psychiatric expert practice

Se plantea un análisis ético de la práctica pericial psiquiátrica, realizando una reflexión crítica a partir de las referencias clásicas de la bioética y la deontología, aplicadas a la relación clínica convencional. Se concluye con una selección de los principios éticos que, adaptados a la especificidad de la psiquiatría forense, podrían servir de referencia para la excelencia en la práctica de esta rama de la medicina legal

An ethical analysis of psychiatric expert practice has been raised, carrying a critical thought out from classic references of bioethics and deontology, applied to conventional clinical relation. Concluding with a selection of the ethical principles which, adapted to the specifity of forensic psychiatry, could make use of reference superbly to the practice of this subspeciality of legal medicine

Forthcoming ethical issues in biological psychiatry.

Ethical issues in biological psychiatry are framed by (i) progress in the neurosciences, and (ii) a changing socio-cultural context. With regard to forthcoming neurotechniques to modify specifically defined brain functions by pharmacological substances with selective effects, by activating neuroplasticity including neurogenesis, or by implantation of neuronal tissues or computer-brain interfaces, etc., ethical problems will develop (i) at the border between therapy of diseases and enhancement of abilities in healthy people with regard to effects on society (e.g., social justice: equal access, loss of societal diversity) as well as on human value systems (e.g., personality, efforts, conditio humana), and (ii) at the border between the medical system and the wellness market with regard to financing what by whom? Ethical dilemmas in psychiatry develop (i) between the individual's best and the common good (demanded from outside medicine), (ii) among different ethical principles (inside medicine), iii) if solutions are influenced by personal reasons without observing ethical principles. Ethical guidelines are necessary for ethical orientation, but may protect against misconduct only (i) if psychiatrists are educated in ethics and (ii) if psychiatric acting is under continuous debate (by ethical review boards or the public). Thus, if we psychiatrists will become ethically sensitive by reflecting and perhaps solving our current ethical dilemmas we will be prepared to deal with forthcoming ethical issues in biological psychiatry.

Ethical issues of cost effectiveness analysis and guideline setting in mental health care.

This article discusses ethical issues which are raised as a result of the introduction of economic evidence in mental health care in order to rationalise clinical practice. Cost effectiveness studies and guidelines based on such studies are often seen as impartial, neutral instruments which try to reduce the influence of non-scientific factors. However, such rationalising instruments often hide normative assumptions about the goals of treatment, the selection of treatments, the role of the patient, and the just distribution of scarce resources. These issues are dealt with in the context of increased control over clinical practice by third parties. In particular, health insurers have a great interest in economic evidence in clinical care settings in order to control access to and quality of (mental) health care. The authors conclude that guideline setting and cost effectiveness analysis may be seen as important instruments for making choices in health care, including mental health care, but that such an approach should always go hand in hand with a social and political debate about the goals of medicine and (mental) health care. This article is partly based on the results of a research project on the normative aspects of guideline setting in psychiatry and cardiology which was conducted under the guidance of the Royal Dutch Medical Association.

Past, present and future of biological psychiatry.

These excerpts from the Presidential Address at the 7th World Congress of Biological Psychiatry, Berlin, 2001 attempt to define the term "biological psychiatry", the principle relevance of diagnostic systems for biological psychiatry and the relevance of biological psychiatry in the past and future for the development of psychiatry in general. They also cover the problem of misuse of biological psychiatry and the need for the rigorous observation of ethical standards.

Ethical problems in psychiatric research.

This article raises questions about the morality and value of experiments conducted mainly on psychiatric patient-subjects whose mental capacity and judgment are often impaired, making them incapable of giving informed consent. Its focus is on experimental studies in which psychotic symptoms in patients with schizophrenia have been knowingly exacerbated by suddenly withdrawing medications that they needed, administering known psychosis-producing substances such as L-dopa and apomorphine, and ignoring the treatment needs of those serving as experimental controls in placebo studies. Concerns are raised about the draft "Statement of Principles for Ethical Conduct" by the American College of Neuropsychopharmacology. Questions are also raised about the adequacy of current safeguards, including federal regulations, peer review, and the trivialization of "informed consent" by institutional review boards that operate under veils of secrecy. Implications for mental health policy are discussed, and suggestions are made for improving safeguards and reducing risks.