We have a consortium of first-episode psychosis clinics in Massachusetts that are collecting standardized clinical data that can also be linked to other large datasets, such as electronic health records or state administrative databases. These approaches can identify patterns in disease and treatment trajectories to inform future care system design and decision-making. Early findings from this work indicate, for example, that a first episode of psychosis is almost universally preceded by episodes of medical and psychiatric care of escalating intensity as the onset of psychosis approaches (View Highlight)
Wittgenstein remarked that “classifications made by philosophers and psychologists are as if one were to classify clouds by their shape.” There are clearly different kinds of clouds; two clouds can be distinct from one another, but they can also merge. It depends on where you are in the life cycle of a cloud, many environmental parameters, and stochastic processes. So it is with psychiatric disorders: there are useful categories of disorders, but these only reflect the confluence of relevant factors in occasionally recognizable patterns and not immutable natural kinds that inexorably manifest themselves (View Highlight)
psiquiatría crítica nosología diagnóstico
our field is in what Thomas Kuhn called a pre-paradigmatic state. There is no single ruling paradigm that allows us to make sense of most scientific observations in the field, and different workers can produce good science without consensus on what to study and how to study it. This manifests itself in the journal as waves of papers using specific approaches or focusing on specific topics such as network analysis, neuroinflammation, machine learning, or mendelian randomization. The findings from these studies are often interesting and probably useful, but they come in a burst of interest where many groups in the field adopt the new focus and analyze their data but then everyone moves on to the next topic. This, to me, indicates a huge unmet need. Many in the field seem to share the hope that some new topic or method will provide a deep insight into the nature of psychopathology that we have been missing so far. When that insight fails to materialize, the field moves on to the next hope. This is what Stephan Heckers calls the “better microscopy hypothesis”—if only we had the right tool to apply to the problem, a new world of mechanisms would emerge into view. (View Highlight)
ciencia paradigma psiquiatría estado
there is a lack of imagination in our field. It was probably necessary for psychiatric science to mature by becoming institutional, developing its own dictionaries (such as the DSM), and establishing shared terms and references. But these do not amount to a scientific paradigm; they are simply a set of concepts and practices that we inculcate in each new generation of researchers. And these concepts and practices narrow the scope of questions that are asked and explored. No need to get philosophical about this; suffice it to say that it is rare for me to read a newly submitted manuscript and think, “This is clever!” That happens perhaps once or twice a year, and I feel excited that someone out there is thinking originally about our field. The constant parade of fashions without genuine creativity makes me think that our field needs, like Proust, not to seek new landscapes but to have new eyes. (View Highlight)
psiquiatría ciencia rigidez creatividad estado
I believe there is a great need for humility in our field. I cannot think of any statement in psychiatric science that is universally correct (View Highlight)
When I first started learning clinical psychiatry, I quickly noticed that the DSM system does not capture the vibrant and bewildering complexity of psychiatric disorders. It’s almost as though we tolerate the DSM, but we all know it’s not really describing reality as we find it every day. I believe most trainees who enter the field today experience this kind of cognitive dissonance: they have studied and memorized the DSM system, then they go out to the field and they learn that it is not particularly relevant. As I became older and had more discussions with others in the field, I also realized that I do not know any academic psychiatrist who respects the DSM, is proud of it, and thinks that the DSM gets psychiatric diagnosis just right. In fact, we all know intuitively that the DSM’s answer to the question “What kind of thing is a psychiatric disorder?” is plain wrong. The DSM framework is about discrete illnesses which one recognizes from lists of symptoms that are either present or absent. Symptoms don’t work that way; symptoms don’t form regular lists, and the illnesses are not discrete. But I do know many academic psychiatrists who think the DSM system was necessary to make progress and that it is better than all current alternatives. I would list some of my own mentors and others who worked on the DSM in that group—all brilliant people committed to improving our understanding of psychiatric disorders. It is instructive to talk with some of those folks who describe the chaos in the field prior to DSM-III and be reminded that the DSM enterprise played a positive role in standardizing how clinicians think and communicate (View Highlight)
diagnóstico psiquiatría crítica dsm
When surveyors ask clinicians what factors they consider in formulating the problems a patient presents with and deciding on a course of treatment, DSM diagnosis is not high on the list. Clinicians know they have to list a DSM diagnosis in their paperwork, but that’s where the DSM typically ends, and the presenting problems, course of illness, functional impairment, response to past treatments, patient and family characteristics, social determinants, cultural context, and other factors begin (View Highlight)