How evolutionary psychiatry can advance psychopharmacology

The prevailing paradigm for psychopharmacology focuses on understanding brain mechanisms as the key to finding new medications and improving clinical outcomes, but frustration with slow progress has inspired many pleas for new approaches. Evolutionary psychiatry brings in an additional basic science that poses new questions about why natural selection left us vulnerable to so many mental disorders, and new insights about how drugs work. The integration of neuroscience with evolutionary psychiatry is synergistic, going beyond reductionism to provide a model like the one used by the rest of medicine. It recognizes negative emotions as symptoms, that are, like pain and cough, useful defenses whose presence should initiate a search for causes. An integrative evolutionary approach explains why agents that block useful aversive responses are usually safe, and how to anticipate when they may cause harm. More generally, an evolutionary framework suggests novel practical strategies for finding and testing new drugs.


Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental)

BACKGROUND

Recommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking.

METHOD

The French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments.

RESULTS

The expert guidelines combine scientific evidence and expert clinician's opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression.

CONCLUSION

These guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

The use of well controls: an unhealthy practice in psychiatric research

BACKGROUND

Studies comparing cases with controls to uncover the causes of psychiatric disorders are common in biological research. The validity of these studies depends upon adherence to the methodological principles underlying the case-control design. However, these principles are often violated. One common practice that violates these principles is the use of well controls. In this paper we describe the bias that it can cause and discuss why the use of well controls leads to invalidity in case-control studies.

METHOD

Using hypothetical numerical examples we illustrate the consequences of using well controls.

RESULTS

The results illustrate that the use of well controls can cause substantial bias. In no instance does the use of well controls improve validity.

CONCLUSIONS

We conclude that the use of well controls is an unhealthy practice in psychiatric research.

[The birth of convulsive therapy]

The history of the first convulsive treatment is summarized here in commemoration of its 75th anniversary. The neuropathological and clinical findings underlying the theoretical basis of the method are reviewed, together with the case histories of the first batch of patients who underwent convulsive therapy. The early indications and effectiveness of convulsive therapy are also discussed. Finally, in a broader context, the role of convulsive treatment in the development of modern biological psychiatry and Laszlo Meduna's contribution to this development touched upon.

The beginnings of modern psychiatric treatment in Europe. Lessons from an early account of convulsive therapy

Convulsive therapy (COT) is a major European contribution to the psychiatric armamentarium and biological psychiatry. COT was introduced in psychiatry by László Meduna, a Hungarian neuropsychiatrist. All subsequent publications about the first patient treated with COT, Zoltán L (ZL), were based on Meduna's papers and autobiography. After 4 years of catatonic stupor, ZL received camphor-induced COT which resulted in full remission and discharge from the institution. The aim of this paper is to reconstruct ZL's case history from the original case notes--partly written by Meduna himself--which were recovered from the archives of the National Institute of Psychiatry and Neurology. The case notes show that ZL repeatedly received COT between 1934 and 1937, first with camphor and then with cardiazol induction. After the first course of COT the catatonic stupor was resolved and the psychotic symptoms subsided. However, the remission lasted for only a few months and was followed by a relapse. Despite repeated courses of COT, ZL never became symptom free again, was never discharged and died in the Institute in 1945. This historical case is discussed from both the diagnostic and therapeutic points of view, and an attempt is made to explain the possible reasons for the discrepancies found between Meduna's account and ZL's case notes.

Transdisciplinary holistic integrative psychiatry - a wishfull thinking or reality?

Modern psychiatry in the last century proposed several aggregative biopsychosocial models as an opposition to prevailing fragmentary, reductionistic and dogmatic approaches. Although the biopsychosocial approach has become the mainstream concept of the present-day psychiatry, it is not fruitful enough because it is excessively broad and provides no real complex field integration and guidance to clinicians and researchers. The postmodern psychiatry alternatives have been appeared as pluralism and integrationism. Holistic and integrative approach in medicine and psychiatry is built on the premise that human beings in health and disease are complex systems of dinamically interacting biological, psychological, social, energetic, informational and spiritual processes. Emerging as a transdisciplinary holistic, complementary and integrative psychiatry implies widely accepted general systems theory on psychopathology, novel integrating interpretative models, new integrative understanding of etiopathogenesis or meanings of symptoms, and novel integrative assessment and treatment approaches addressing those etiopathogenesis and meanings.

Integrative treatment in psychiatry

Psychiatry is a medical discipline addressing the study, diagnosis, treatment and prevention of mental disorders. Psychiatric disorders, which may be seen in people of all ages, involve the emotions, the will, and intellectual processes, verbal and non-verbal behaviour. According to current knowledge we cannot speak about only one cause but of the interaction of several etiological factors, mutually pervading and causing the mental illness. Because of this the treatment of mental disorders involves the complex implementation of biological, psycho-therapeutic, and socio-therapeutic methods of treatment. The contemporary principle of integrative psychiatry immanently requires simultaneous treatment of three human components: body, mind, and spirit. The holistic approach emphasizes the importance of the wholeness of the human person, and the inter-dependence of his components.

[The birth of biological therapy in Hungary: the story of László Meduna's first patient receiving convulsive therapy]

Convulsive treatment was introduced to psychiatry by László Meduna, a Hungarian neuropsychiatrist. In his autobiography, Meduna gave a detailed description of his first patient who underwent convulsive therapy. According to Meduna's recollections, this patient was L. Zoltán, who after 4 years of fluctuating catatonic stupor received several sessions of camphor-induced convulsive therapy resulting in full remission and discharge from the institution. In this communication, the authors reconstruct L Zoltán's case history from the original case notes, which were recovered from the Archives of the National Institute of Psychiatry and Neurology, Budapest. The case notes show that L. Zoltán received courses of convulsive treatment between 1934 and 1937, first induced with camphor and then with cardiazol. After the first course of treatment the catatonic stupor was resolved and the psychotic symptoms subsided. However, this incomplete remission lasted only for a few months and was followed by a relapse. Despite further courses of convulsive therapy, L. Zoltán never became symptom free again, could never be discharged and died in the institute in 1945. The authors attempt to explain possible reasons for the discrepancies found between Meduna's account and L. Zoltán's case notes.

Conceptual issues in psychiatric neuroimaging

PURPOSE OF REVIEW

Psychiatric neuroimaging has made a dramatic impact on the understanding of the brain in mental illness in a relatively brief period of time and continues to be evolving in terms of methodology, analysis and utilization of the combination of techniques. Given the level of sophistication of the techniques and the importance of imaging in current academic psychiatry, it is timely to review its conceptual influence on psychopathology.

RECENT FINDINGS

The study will review scientific advances in psychiatric neuromaging, around the themes of functional connectivity, diffusion tensor imaging, magnetoencephalography, modality integration, meta-analyses and mega-analyses of data and discuss recent influential findings in contemporary research. We then focus on more conceptual issues relating to biological psychiatry and its relationship with cognitive neuroscience. We discuss the dominant paradigm of scientific psychopathology, namely cognitive neuropsychiatry and how it relates more broadly to imaging and cognitive science and elaborate on the philosophical positions of the paradigm and how it views abnormal mental states.

SUMMARY

We conclude that despite the advances in biological psychiatry and the power of the cognitive neuropsychiatry paradigm, its findings are logically contingent upon psychopathology and the normatively defined terms employed therein.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: long-term treatment of schizophrenia

These guidelines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This second part of the guidelines covers the long-term treatment as well as the management of relevant side effects. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

[Chapters from the history of biological psychiatry: efforts made to increase the efficacy of electroconvulsive therapy]

Efforts to increase the efficacy of electroconvulsive therapy are reviewed from a historical perspective. The 'intensive' method, the 'regressive technique' and the 'de-patterning' method are discussed in more detail based on available publications. Side effects and complications of these methods are also dealt with in detail. Finally, an attempt is made to critically evaluate these methods in the context of contemporary ethical standards.

Interactive dualism as a partial solution to the mind–brain problem for psychiatry

With the collapse of the psychoanalytic and the behaviorist models, and the failure of reductive biologism to account for mental life, psychiatry has been searching for a broad, integrative theory on which to base daily practice. The most recent attempt at such a model, Engel's 'biopsychosocial model', has been shown to be devoid of any scientific content, meaning that psychiatry, alone among the medical disciplines, has no recognised scientific basis. It is no coincidence that psychiatry is constantly under attack from all quarters. In order to develop, the discipline requires an integrative and interactive model which can take account of both the mental and the physical dimensions of human life, yet still remain within the materialist scientific ethos. This paper proposes an entirely new model of mind based in Chalmers' 'interactive dualism' which satisfies those needs. It attributes the causation of all behaviour to mental life, but proposes a split in the nature of mentality such that mind becomes a composite function with two, profoundly different aspects. Causation is assigned to a fast, inaccessible cognitive realm operating within the brain machinery while conscious experience is seen as the outcome of a higher order level of brain processing. The particular value of this model is that it immediately offers a practical solution to the mind-brain problem in that, while all information-processing takes place in the mental realm, it is not in the same order of abstraction as perception. This leads to a model of rational interaction which acknowledges both psyche and soma. It can fill the gap left by the demise of Engel's empty 'biopsychosocial model'.

Cognitive neuropsychiatry: conceptual, methodological and philosophical perspectives

Cognitive neuropsychiatry attempts to understand psychiatric disorders as disturbances to the normal function of human cognitive organisation, and it attempts to link this functional framework to relevant brain structures and their pathology. This recent scientific discipline is the natural extension of cognitive neuroscience into the domain of psychiatry. We present two examples of recent research in cognitive neuropsychiatry: delusions of control in schizophrenia, and affective disorders. The examples demonstrate how the cognitive approach is a fruitful and necessary supplement to the otherwise successful biological psychiatry paradigm, which tend to bypass the cognitive level. Philosophy concerns some of the core concepts involved in psychiatric illness, particularly concerning rationality, thought and action, reality testing, and the self. We present concrete examples that illustrate how philosophical conceptual tools can be particularly important for the construction and interpretation of the cognitive models relevant to the understanding of psychiatric illness. We conclude that cognitive neuropsychiatry is a fruitful and necessary supplement to biological psychiatry. Furthermore, cognitive neuropsychiatry itself may benefit significantly from employing philosophical conceptual tools in the interpretation and construction of its cognitive models. The cognitive and philosophical approaches may thus be further steps towards a scientific psychopathology.

Psychiatric genetics: a methodologic critique

Psychiatric genetics, which is growing in size and influence within psychiatry, employs four major research paradigms: 1) basic genetic epidemiology, 2) advanced genetic epidemiology, 3) gene finding methods, and 4) molecular genetics. Paradigms 1 and 2 study aggregate genetic risk factors inferred from patterns of resemblance in relatives. Paradigms 3 and 4 study individual susceptibility genes localized on the human genome. Paradigms 1, 2, and 3 are statistical in nature, while paradigm 4 is biological. Genetic risk factors reflect the statistical signals from susceptibility genes. Whether it will be possible to identify all the susceptibility genes that underlie genetic risk factors is uncertain. Furthermore, given current research methods, the inability to detect susceptibility genes cannot disconfirm evidence for genetic risk factors. While paradigms 3 and 4 can provide great explanatory power by tracing etiologic pathways back to basic biological mechanisms, genetic epidemiology can also provide important etiologic insights, albeit of a less basic nature. While paradigms 3 and 4 may eventually replace paradigms 1 and 2, this shift is unlikely to occur quickly. Therefore, the field of psychiatric genetics would do best to integrate these four paradigms, stressing their relative strengths and limitations. This integration can be best done within an overall framework of explanatory pluralism that values a range of reductive explanations across varying levels of biological and psychological complexity.

International Congress of Biological Psychiatry. 8-13 February 2004, Sydney, Australia

Approximately 1500 psychiatrists, psychologists and basic scientists attended the International Congress of Biological Psychiatry with a specialist interest in the biological aspects of psychiatry. There was relatively little information on new medications for the treatment of psychiatric disorders but the congress emphasized approaches to treatment based on medications and physical therapies, as well as advances in the understanding of the biological basis of psychiatric illnesses. Around 800 abstracts were presented in symposia, sponsored satellite sessions, free communications and poster sessions. The poster sessions were particularly well attended and provided many lively discussions. Of particular interest were sessions devoted to new antipsychotics for the treatment of schizophrenia, management of mood and anxiety disorder, Alzheimer's disease and bipolar disorder. This report describes information on the new antipsychotic drug aripiprazole, novel targets for the treatment of mood disorders and psychoses, GABAA receptors in the treatment of panic disorder, and poster presentations on bipolar disorder.

Can 'differential display' methodologies make an impact on biological psychiatry?

The past decade has been marked by a dramatic increase in the availability of techniques to identify and clone genes that are differentially expressed in disease states and by drug treatments. The applications of such techniques to problems in biological psychiatry are manifold and the implications of discovering novel and/or known genes that are perturbed in neuropsychiatric disorders profound. While there are success stories, it is becoming ever more apparent that each of these techniques has its limitations, particularly when applied to the central nervous system. Given that these methods (e.g. differential display, RNA fingerprinting, suppression-subtractive hybridization, microarrays) are labour-intensive and potentially time-consuming, it is important to understand these limitations. For example, differential display is capable of detecting very small changes in the expression of mRNA species. Methods like suppression-subtractive hybridization are better suited to examine potential differences in rare transcripts, but only when their expression is changed substantially (currently ? 5-fold). Moreover, both the functional and morphological organization of the central nervous system present challenges that may not be encountered in other systems. In this overview, we will discuss the advantages and disadvantages of some of these approaches and their application to research in biological psychiatry.

[Body-mediated therapies in geriatric psychiatry]

The use of body mediated therapies at the Clinical geriatric psychiatry became possible due to the convergence between multi, inter and transdisciplinary approaches and the clinical experience in this application of various therapeutic technics. This approach at the aged clinic must take into consideration the specificity of the correlation to the body of the aged person beside the advantages and the needs that resent this approaches to both the patient and his therapist.

Magnetic resonance imaging in biological psychiatry

1. Although clinicians have been quick to adopt magnetic resonance imaging (MRI) in the search for brain pathology in psychiatric disorders, the clinical utility of MRI is only now being well defined. 2. Numerous past computerized tomography or post-mortem tissue reports in patients with schizophrenia, affective disorders, dementia, autism, and many other psychiatric illnesses have suggested neuroanatomical substrates for these disorders. However, these techniques have several limitations. 3. The advent of MRI has allowed a high resolution method for examining the brain in vivo. It is important for psychiatrists to know the clinical utility, and the advantages/disadvantages of MR compared with CT. 4. In this article, the authors review the relevant MR literature with some illustrative cases where MRI provided clinically useful information. Recent advances in MRI technology that will have future applications in psychiatry are also discussed.

A critique of the scientific status of biological psychiatry

Biological psychiatry has four principal modes of investigation but each has been flawed by errors in procedure and inference such that the bulk of existing findings must be called into question. Pedigree studies are ruined by selective adoption, the use of "throw-away kids" to demonstrate so-called genetic effects, lack of case history data, and lapses in "blind" diagnosis. In particular, the Danish adoption studies are challenged, despite the field's insistence that this research has settled the nature-nurture controversy in schizophrenia. Pharmacological-response studies are the next line of methodology and these are marred by a spurious assumption that drugs which work must be correcting a biochemical imbalance that causes the condition. Thirdly, neuropsychological-neurophysiological studies are "heuristic" fishing-expeditions to find a presumed abnormality to account for psychopathology, without doing the prospective longitudinal research necessary to validate such theory. Lastly, biochemical correlates of emotion are treated as if each emotion must have a distinct neuronal substrate rather than possibly representing a general visceral arousal where cognition defines the feeling. All told, biological psychiatry is often more reductionist than acknowledged, does not come up to current scientific standards, and uncritically cites work which is, or should be, discredited. At the heart of the problem is an implicit ideology within biological psychiatry, with insufficient awareness of its social ramifications: "blaming the victim's body" protects the status quo by holding protoplasm at fault for maladjustment rather than the person, family, or community.

Denosologization of biological psychiatry or the specificity of 5-HT disturbances in psychiatric disorders

5-Hydroxytryptamine (5-HT) disorders have been reported to occur in a variety of psychiatric disorders. The situation has been called chaotic, the disturbances non-specific. We reject this viewpoint. 5-HT disturbances are non-specific only from a nosological/categorical viewpoint; they seem rather specific from a functional/dimensional point of view, correlating as they do with particular psychopathological dimensions, i.e. aggression-, anxiety- and possibly mood-disregulation, across diagnosis. The evolution of 5-HT research in psychiatry illustrates the importance of what we have called the functional approach, implying dissection of a given psychopathological syndrome in its component parts, i.e., the psychological dysfunctions, and searching for correlations between biological and psychological dysfunctions. The rigid preoccupation of biological psychiatry with the search for markers of disease entities has hampered progress. The functional approach should be incorporated in biological psychiatry, not as an alternative for the nosological approach but as its complement.