Conceptual reviews in psychiatry

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The mesolimbic hypothesis has been a central dogma of schizophrenia for decades, positing that aberrant functioning of midbrain dopamine projections to limbic regions causes psychotic symptoms. Recently, however, advances in neuroimaging techniques have led to the unanticipated finding that dopaminergic dysfunction in schizophrenia is greatest within nigrostriatal pathways, implicating the dorsal striatum in the pathophysiology and calling into question the mesolimbic theory. At the same time our knowledge of striatal anatomy and function has progressed, suggesting new mechanisms via which striatal dysfunction may contribute to the symptoms of schizophrenia...

The concept of schizophrenia only covers the 30% poor outcome fraction of a much broader multidimensional psychotic syndrome, yet paradoxically has become the dominant prism through which everything 'psychotic' is observed, even affective states with mild psychosis labelled 'ultra-high risk' (for schizophrenia). The inability of psychiatry to frame psychosis as multidimensional syndromal variation of largely unpredictable course and outcome - within and between individuals - hampers research and recovery-oriented practice...

IMPORTANCE: This article aims to determine the degree to which modern operationalized diagnostic criteria for schizophrenia reflect the main clinical features of the disorder as described historically by diagnostic experts. OBSERVATIONS: Amazon.com, the National Library of Medicine, and Forgottenbooks.com were searched for articles written or translated into English from 1900 to 1960. Clinical descriptions of schizophrenia or dementia praecox appearing in 16 textbooks or review articles published between 1899 and 1956 were reviewed and compared with the criteria for schizophrenia from 6 modern US operationalized diagnostic systems...

How should DSM criteria relate to the disorders they are designed to assess? To address this question empirically, the author examines how well DSM-5 symptomatic criteria for major depression capture the descriptions of clinical depression in the post-Kraepelin Western psychiatric tradition as described in textbooks published between 1900 and 1960. Eighteen symptoms and signs of depression were described, 10 of which are covered by the DSM criteria for major depression or melancholia. For two symptoms (mood and cognitive content), DSM criteria are considerably narrower than those described in the textbooks...

In the last third of the 20th century, the German psychiatrist Emil Kraepelin (1856-1926) became an icon of postpsychoanalytic medical-model psychiatry in the United States. His name became synonymous with a proto-biological, antipsychological, brain-based, and hard-nosed nosologic approach to psychiatry. This article argues that this contemporary image of Kraepelin fails to appreciate the historical contexts in which he worked and misrepresents his own understanding of his clinical practice and research. A careful rereading and contextualization of his inaugural lecture on becoming chair of psychiatry at the University of Tartu (known at the time as the University of Dorpat) in 1886 and of the numerous editions of his famous textbook reveals that Kraepelin was, compared with our current view of him, 1) far more psychologically inclined and stimulated by the exciting early developments of scientific psychology, 2) considerably less brain-centric, and 3) nosologically more skeptical and less doctrinaire...

Sensory processing deficits, first investigated by Kraepelin and Bleuler as possible pathophysiological mechanisms in schizophrenia, are now being recharacterized in the context of our current understanding of the molecular and neurobiological brain mechanisms involved. The National Institute of Mental Health Research Domain Criteria position these deficits as intermediaries between molecular and cellular mechanisms and clinical symptoms of schizophrenia, such as hallucinations. The prepulse inhibition of startle responses by a weaker preceding tone, the inhibitory gating of response to paired sensory stimuli characterized using the auditory P50 evoked response, and the detection of slight deviations in patterns of sensory stimulation eliciting the cortical mismatch negativity potential demonstrate deficits in early sensory processing mechanisms, whose molecular and neurobiological bases are increasingly well understood...

Two-polarities models of personality propose that personality development evolves through a dialectic synergistic interaction between two fundamental developmental psychological processes across the life span-the development of interpersonal relatedness on the one hand and of self-definition on the other. This article offers a broad review of extant research concerning these models, discusses their implications for psychology and psychiatry, and addresses future research perspectives deriving from these models...

Clinically significant separation anxiety disorder in childhood leads to adult panic disorder and other anxiety disorders. The prevailing pathophysiological model of anxiety disorders, which emphasizes extinction deficits of fear-conditioned responses, does not fully consider the role of separation anxiety. Pathological early childhood attachments have far-reaching consequences for the later adult ability to experience and internalize positive relationships in order to develop mental capacities for self-soothing, anxiety tolerance, affect modulation, and individuation...

Affective neuroscience addresses the brain mechanisms underlying emotional behaviour. In psychiatry, affective neuroscience finds application not only in understanding the neurobiology of mood disorders, but also by providing a framework for understanding the neural control of interpersonal and social behaviour and processes that underlie psychopathology. By providing a coherent conceptual framework, affective neuroscience is increasingly able to provide a mechanistic explanatory understanding of current therapies and is driving the development of novel therapeutic approaches...

The classification of mood disorders lacks precision and consequently there has been no recent meaningful advance in their treatment. By virtue of its therapeutic specificity, lithium responsivity offers an opportunity to diagnose a definitive subtype of mood disorders that may provide a platform for the development of targeted therapy.

Emil Kraepelin's nosology has been reinvented, for better or worse. In the United States, the rise of the neo-Kraepelinian nosology of DSM-III resuscitated Kraepelin's work but also differed from many of his ideas, especially his overtly biological ontology. This neo-Kraepelinian system has led to concerns regarding overdiagnosis of psychiatric syndromes ("nosologomania") and perhaps scientifically ill-founded psychopharmacological treatment for presumed neo-Kraepelinian syndromes. In the early 20th century, Karl Jaspers provided unique insights into Kraepelin's work, and Jaspers even proposed an alternate nosology which, though influenced by Kraepelin, also introduced the concept of ideal types...

OBJECTIVE: This review aims to address concerns about the potential overinclusiveness and vagueness of bipolar spectrum concepts, and also, concerns about the overlap between bipolar illness and borderline personality. METHOD: Narrative review based on historical and empirical studies. RESULTS: Bipolar disorder (BD) and major depressive disorder (MDD) came to be separate entities with the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM III), in contrast to the Kraepelinian manic-depressive insanity (MDI) concept, which included both...

This essay addresses two interrelated questions: What is the structure of current psychiatric science and what should its goals be? The author analyzed all studies addressing the etiology of psychiatric disorders in the first four 2013 issues of 12 psychiatry and psychology journals. He classified the resulting 197 articles by the risk factors examined using five biological, four psychological, and three environmental levels. The risk factors were widely dispersed across levels, suggesting that our field is inherently multilevel and already practicing empirically based pluralism...

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Questions concerning both the ontology and epistemology of the "psychiatric object" (symptoms and signs) should be at the forefront of current concerns of psychiatry as a clinical neuroscience. We argue that neglect of these issues is a crucial source of the stagnation of psychiatric research. In honor of the centenary of Karl Jaspers' book, General Psychopathology, we offer a critique of the contemporary "operationalist" epistemology, a critique that is consistent with Jaspers' views. Symptoms and signs cannot be properly understood or identified apart from an appreciation of the nature of consciousness or subjectivity, which in turn cannot be treated as a collection of thing-like, mutually independent objects, accessible to context-free, "atheoretical" definitions or unproblematic forms of measurement (as is often assumed in structured interviewing)...

This essay explores four answers to the question 'What kinds of things are psychiatric disorders?' Essentialist kinds are classes whose members share an essence from which their defining features arise. Although elegant and appropriate for some physical (e.g. atomic elements) and medical (e.g. Mendelian disorders) phenomena, this model is inappropriate for psychiatric disorders, which are multi-factorial and 'fuzzy'. Socially constructed kinds are classes whose members are defined by the cultural context in which they arise...

Diagnostic systems, phenotype models, and theories of etiology incorporate propositions on the underlying nature of psychosis and schizophrenia phenotypes. These propositions, whether implicit or explicit, are that the distributions of the phenotypes, or the phenotype experiences themselves, are dimensional or categorical. On one hand, evidence on the epidemiology of schizophrenia phenotypes suggests symptom phenotypes may not be bound by conventional diagnostic thresholds but instead may blend imperceptibly with subclinical, statistically frequent experience, supporting continuum viewpoints...

OBJECTIVE: Japan was the first country to abandon the 19th century term of 'mind-splitting disease' (schizophrenia). Revisions of DSM and ICD are forthcoming. Should the rest of the world follow Japan's example? METHOD: A comprehensive literature search was carried out in order to review the scientific evidence for the validity, usefulness and acceptability of current concepts of psychotic disorder. RESULTS: The discussion about re-classifying and renaming schizophrenia and other psychotic disorders is clouded by conceptual confusion...

The widely held clinical view of 'antidepressants' as highly effective and specific for the treatment of all types of depressive disorders is exaggerated. This sobering conclusion is supported by recent findings from the NIMH-sponsored STEP-BD and STAR*D projects. Antidepressants have limited short-term efficacy in unipolar depressive disorders and less in acute bipolar depression; their long-term prophylactic effectiveness in recurrent unipolar major depression remains uncertain, and is doubtful in recurrent bipolar depression...