What is a mental/psychiatric disorder? From DSM-IV to DSM-V.

The distinction between normality and psychopathology has long been subject to debate. DSM-III and DSM-IV provided a definition of mental disorder to help clinicians address this distinction. As part of the process of developing DSM-V, researchers have reviewed the concept of mental disorder and emphasized the need for additional work in this area. Here we review the DSM-IV definition of mental disorder and propose some changes. The approach taken here arguably takes a middle course through some of the relevant conceptual debates. We agree with the view that no definition perfectly specifies precise boundaries for the concept of mental/psychiatric disorder, but in line with a view that the nomenclature can improve over time, we aim here for a more scientifically valid and more clinically useful definition.

Hindsight, foresight, and having it both ways: a rejoinder to R. L. Spitzer.

Using the methods of philosophical analysis, we provide a rejoinder to R. L. Spitzer's (2001) response to our own consideration of the DSMs first published in 1994. Then as now, our major contention has been that the DSM contents and process have been insufficiently explicit in their various value commitments, choices, and decisions. Spitzer raises four major points in his commentary, concerning our claims about the "value naivete" of past DSMs, his contention that the goals of DSM-III and III-R were not "inherently" in conflict, about our allegations of the DSM architects preferring reliability over validity, and various DSM critics' failure to offer a viable alternative to the DSMs. We address each of Spitzer's main points in turn, appealing to Spitzer's own work while acknowledging his leadership role in addressing value issues in mental disorder classification.

Horsefeathers: a commentary on "evolutionary versus prototype analyses of the concept of disorder".

J. C. Wakefield's (1999) article further develops his harmful dysfunction (HD) model for disorder concepts. This commentary focuses on three areas. The first notes the imbalance in the debate between the Lilienfeld and Marino (1995) Roschian model and the HD model for disorder concepts. The second claims that Wakefield's purposes for the HD model have changed over the years and progressed toward irrelevance to psychopathology in general and toward irrelevance to actual nosologic, reimbursement, and sociopolitical controversies about disorder status. Further discussion is on how certain structural elements in Wakefield's arguments and current limitations of evolutionary theory permit a superficially attractive model for psychopathology. These arguments and limitations, however, harbor serious problems when confronted with actual disputes about disorders. The conclusion notes some virtues to Wakefield's inquiry, in style and substance.

Teaching ethics using small-group, problem-based learning.

Ethics is the emphasis of our first-year Introduction to Clinical Medicine-1 course. Introduction to Clinical Medicine-1 uses problem-based learning to involve groups of seven to nine students and two facilitators in realistic clinical cases. The cases emphasize ethics, but also include human behaviour, basic science, clinical medicine, and prevention learning issues. Three cases use written vignettes, while the other three cases feature standardized patients. Groups meet twice for each case. In session one, students read the case introduction, obtain data from the written case or standardized patient, identify the case's ethical problems, formulate learning issues, discuss ways to resolve the moral conflicts, and assign research responsibilities. In session two, students discuss their assigned learning issues and specify and justify clinical actions to address the case's ethical dilemmas. Following three cases, groups write an essay discussing what they learned and describing how they would approach and resolve the case's learning issues.

The philosophy of psychiatry: who needs it?

Many a psychiatrist has said that he did not want to burden himself with a philosophy and that this science had nothing to do with philosophy. But the exclusion of philosophy would nevertheless be disastrous for psychiatry: firstly, if we are not clearly conscious of our philosophy we shall mix it up with our scientific thinking quite unawares and bring about a scientific and philosophic confusion. Secondly, since in psychopathology in particular the scientific knowledge is not all of one kind, we have to distinguish the different modes of knowing and clarify our methods, the meaning and validity of our statements and the criteria of tests- and all this calls for philosophic logic ... To sum up: If anyone thinks he can exclude philosophy and leave it aside as useless, he will be eventually defeated by it in some obscure form or another.

Recognizing values: a descriptive-causal method for medical/scientific discourses.

While much discussion in bioethics, philosophy of science, and philosophy of medicine concerns the proper handling and uses of value considerations, there has been little discussion about how to identify or recognize values in medical/scientific discourse. This article presents a heuristic method for identifying values in such discourses. Values are defined as descriptions or conditions that guide human action and are praise- or blameworthy. Values manifest themselves in discourses in one or more of three dimensions: linguistic, causal, and descriptive; each with distinctive "subtypes". By recognizing the various ways that values manifest in discourses, a "values scholar" can ask relevant questions of the discourse and thereby come to recognize potential evaluative meanings in the discourse. Numerous examples are provided from the author's own research program. Strengths, limitations, and paths to developing the model are briefly discussed.

Rationales, values, and DSM-IV: the case of "medication-induced movement disorders".

The DSM-IV has improved psychiatric diagnostic classification through initiating, among other things, the open disclosure of rationales for nosologic changes. It will be argued that a consideration of values is necessary in justifying nosologic changes, considerations missing from the DSM-IV rationales. In illustration of this, I examine the reasons for including the medication-induced movement disorders (MIMDs) on axis I by using a literature review, then compare the published rationales for including the MIMDs with the DSM-IV Task Force's own guidelines for including categories. Discrepancies are found between the Task Force's guidelines for including categories and the published rationales for including MIMDs. Strict adherence to the Task Force guidelines more strongly supports placing MIMDs in axis III. Discussion emphasizes the importance of value commitments in nosology development.

Self-directed learning in a psychopathology course.

Self-directed learning has been identified as an essential element of professional development. In this approach, students receive in advance a complete set of objectives and didactic knowledge (cognitive) learning materials, are provided opportunities to develop skills with actual or simulated clinical experiences, and adapt a broad and flexible array of educational media to their individual learning styles. In the development of a self-directed psychopa-thology course for second-year medical students, the authors incorporated four modifications to the traditional lecture and small group (faculty-directed) approach: 1) independent (self-directed) learning with no prescribed study times or sequence to the material, 2) use of student and facult y-directed interviews of patients, 3) greater freedom for selecting teaching methods in small groups, and 4) elimination of formal lectures. The authors describe the educational results with such an approach.

On values in recent American psychiatric classification.

The DSM-IV, like its predecessors, will be a major influence on American psychiatry. As a consequence, continuing analysis of its assumptions is essential. Review of the manuals as well as conceptually-oriented literature on DSM-III, DSM-III-R, and DSM-IV reveals that the authors of these classifications have paid little attention to the explicit and implicit value commitments made by the classifications. The response to DSM criticisms and controversy has often been to incorporate more scientific diversity into the classification, instead of careful inquiry and assessment of the principal values that drive the nosologic process. Implications for psychiatric science and future DSM classifications are discussed.

What components should be evaluated in a psychiatry residency.

In this pilot study, the authors examined faculty responses to a proposed new evaluation form for residents. Because past research on priorities for psychiatric residency curricula have depended on direct surveys, previous findings may represent auricular ideals instead of what faculty actually evaluate. The goal of the study was to draw inferences about priorities in psychiatric education by studying what components (knowledge, skills, and attitudes) of a psychiatry residency that faculty are willing to spend their time evaluating. The responses were grouped by agreement about whether the item 1) could be evaluated on their site, 2) could be evaluated during psychotherapy supervision, 3) should be combined with other items, and 4) should be eliminated. The results showed much agreement about which items to include and little agreement about which ones to exclude. Fundamental psychiatric skills and attitudes were rated as most important, and there was widespread interest in a diversity of knowledge, skills, and attitudes that psychiatric residents should possess. The authors found this method, which could be easily applied to other programs, useful in setting auricular priorities.

Critical thinking in preclinical course examinations.

PURPOSE: To examine the relationship between preclinical medical school course examinations and critical-thinking skills by correlating examination results with the Watson-Glaser Critical Thinking Appraisal (WGCTA), an 80-item critical-thinking inventory. METHOD: The 196 students in the class of 1993 at the University of Texas Southwestern Medical Center at Dallas Southwestern Medical School were given the WGCTA during the second half of their freshman year. A composite WGCTA score and five subtest scores were calculated for each student. The course examinations were 25 tests, each with a majority of multiple-choice items, from courses given during the first two years of the school curriculum. The students' undergraduate grade-point average (GPAs), medical school GPAs, and Medical College Admission Test (MCAT) scores were also included in the analysis. Pearson product-moment correlations were calculated between the students' WGCTA scores and their examination scores, MCAT scores, and GPAs. RESULTS: Sixteen of the examinations--in the behavioral sciences, psychiatry, ethics, pathology, introduction to clinical medicine, genetics, endocrinology, and cell biology--had significant positive correlations with the WGCTA, as did MCAT scores and first-year GPAs. Correlations were more robust with the WGCTA subscales for interpretation (18 examinations), evaluation of arguments (15), and deduction (13), and less robust with the subscales for inference (7) and recognition of assumptions (3). CONCLUSIONS: The results suggest that objective multiple-choice examinations can at least partially reflect critical-thinking skills.

The Parkland approach to demands for "futile" treatment.

Recent literature in medical ethics has emphasized disputes concerning the relative usefulness or uselessness (futility) of medical treatments. In our institution, these disputes typically arise in the context of critical care, with patients or families requesting or demanding a treatment (such as cardiopulmonary resuscitation) that in the treating physician's view holds no promise of benefit. In the context of revising our general treatment refusal/withdrawal/withholding guidelines, we provided a structure for resolving such disputes in a manner that balances the often conflicting goods of patient/family autonomy, physician autonomy, and institutional responsibility.

A value-added methodology for assessing the effectiveness of psychiatric residency training.

Educators often find it difficult to identify variables that accurately assess the knowledge that residents have gained due to their training. Recently in professional education circles, attention has shifted from process to outcome variables, with more emphasis being placed on student gains rather than on program resources. A methodology used extensively to assess undergraduate education is the value-added approach. This methodology is often demonstrated by a change in scores from two administrations of a test instrument that measures students' specific knowledge or aptitudes. Residency training programs that offer standardized examinations to their residents are in a good position to utilize this evaluation technique. This article will demonstrate how the value-added technique can be used to demonstrate cognitive growth in psychiatric residents by using the Psychiatry Resident In-Training Examination.

Clinical problem solving and the biopsychosocial model.

Engel's biopsychosocial model, while unifying the sciences relevant to medicine under general systems theory, is of limited utility in organizing bedside clinical problem solving. The authors consider this issue in light of the structure and goals of the clinical encounter. The biopsychosocial model is a model for organizing the sciences relevant to medicine; however, medical/psychiatric practice poses problems both within and outside the scientific realm. Since the biopsychosocial model cannot account for clinical problems to which the methods of science do not apply, the authors seek to facilitate biopsychosocial problem solving by proposing a clinical decision-making model that complements the biopsychosocial model. Their model directs the clinician's attention to three core aspects of the clinical encounter: problems of knowledge, ethics, and pragmatics. The authors reconsider Engel's case of Mr. Glover to demonstrate the anticipatory emphasis of the model. Other clinical examples are used to demonstrate the difficulties arising from mistaking one kind of aspect of medicine for another. When these three aspects of medicine are respected equally, a biopsychosocial practice is unavoidable.

The cognitive context of examinations in psychiatry using Bloom's taxonomy.

Psychiatric practice involves complex thinking patterns. In addition to commanding a huge number of facts, the student must learn to manipulate factual knowledge to solve diagnostic problems, develop treatment plans, and critically evaluate those plans. This study demonstrates an empirical method for evaluating the level of cognitive processes tested in multiple choice examinations. Use of Bloom's taxonomy in evaluating test items demonstrated the majority of test items on a psychiatry clerkship examination and a resident in-training examination fell into the most basic cognitive level, that of simple recall. The utility of Bloom's taxonomy is discussed along with implications for medical education.

Clinical controversy and the domains of scientific evidence.

The diversity of mental health care "schools" or therapeutic perspectives poses problems in selecting and using any single therapeutic perspective. This article describes the genesis of clinical controversy--that is, how two or more therapeutic perspectives of the same clinical situation can be so different yet not necessarily differ in outcome. Ideas drawn from contemporary philosophy of science show how different "schools" derive separate, incompatible sets of scientific evidence from the same clinical situation. The school or theory determines (in part) not just what evidence is used, but what evidence is actually perceived. The authors conclude by recommending a pluralistic approach to mental health care; they map out some consequences of this pluralism and suggest some strategies for minimizing the disadvantages of "mixing and matching" therapeutic perspectives.

Knowing, valuing, acting: clues to revising the biopsychosocial model.

While remaining influential in education and research in psychiatry and medicine, the biopsychosocial (BPS) model has been criticized for ambiguity in conceptualizing everyday clinical problems. As a multilevel general systems approach, it leaves obscure which system level (cellular, person, family, community, and so on) is most clinically important at any point in time. As a model for psychiatry and medicine, it does not address the practical and moral dimensions of clinical work. This report reviews criticisms and concerns about the BPS model. These criticisms are used to begin a more practicable revision of the model.