The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

Stigma of mental illness,religious change,and explanatory models of mental illness among Jewish patients at a mental-health clinic in North Jerusalem

During 3 months in 2004, 38 recent referrals to a Community Mental Health Clinic in North Jerusalem, a substantially Ultra-Orthodox Jewish neighborhood, were evaluated by the Explanatory Model Interview Catalogue. This questionnaire, which includes a 13-item scale measuring stigma towards mental illness, was adapted and translated into Hebrew. Patients with a more religious upbringing expressed a greater sense of stigma towards mental illness; however, patients who now had a more religious affiliation did not. The 14 patients who had experienced a religious change toward a more religious affiliation reported a lower level of stigma than the 24 non-returnees. Even when controlling for religious upbringing, the partial correlation between stigma score and religious change was significant. Stigma was lower among younger but not older returnees. Findings from this study support the hypothesis that a stigma of mental illness may be a deterrent to the use of a public mental-health clinic for religious Jews in Israel. Ultra-Orthodox Jewish patients (especially non-Hasidic) used a nonreligious explanatory model (perception and understanding) of mental illness more often than a religious explanatory model. This last finding could reflect a shift in the Ultra-Orthodox Jewish communities from a religious to a more medical and psychological explanatory model.     

Countertransference and reality

The psychoanalytic situation provides many opportunities for people to observe their analysts closely. These observations are inevitably woven into the fabric of patients’ transference experience. Because the observations can be uncomfortable for the analyst, there is a constant temptation to ignore or deny the plausibility of patients’ perceptions. They can be, and often are, quickly reinterpreted as derivatives of sexual or aggressive urges. Psychoanalytic drive theory, with its emphasis on impulse rather than observation as the force behind transference experience, can encourage counter‐transferential disclaimers and lead to blind spots. Some technical suggestions are offered to avoid this tendency and are based on a relational understanding of the nature of transference.     

General Mental Ability and pay: Nonlinear effects

While many studies have examined the linear relationship between intelligence and economic success, only few, if any, examined their nonlinear relationships. The current study examines such relationships in a large, nationally representative sample, using pay as an indicator of economic success. The results show that the effect of General Mental Ability (GMA) on pay depends on occupational complexity; the greater the complexity, the stronger the effect. They also show that, by and large, there is a marginally decreasing (concave) effect of GMA on pay. Methodological and practical questions concerning the relationship between cognitive ability and pay are discussed.     

From Canon to Dialectic to Antinomy: Giving Inclinations Their Due

In a recent paper, Eckart Förster challenges interpreters to explain why in the first Critique practical reason has a canon but no dialectic, whereas in the second Critique, there is not only a dialectic, but an antinomy of practical reason. In the Groundwork, Kant claims that there is a natural dialectic with respect to morality (4:405), a different claim from those advanced in the first and second Critiques. Förster's challenge may therefore be reformulated as the problem of explaining why practical reason has a canon in the first Critique, a dialectic in the Groundwork, and an antinomy in the second Critique. In this paper, I answer this challenge. I argue that these differences are due to the different aims and scope of the works, and in particular, the different place of the inclinations in their arguments.     

There is no coherent evidence for a bilingual advantage in executive processing

Three studies compared bilinguals to monolinguals on 15 indicators of executive processing (EP). Most of the indicators compare a neutral or congruent baseline to a condition that should require EP. For each of the measures there was no main effect of group and a highly significant main effect of condition. The critical marker for a bilingual advantage, the Group × Condition interaction, was significant for only one indicator, but in a pattern indicative of a bilingual disadvantage. Tasks include antisaccade (Study 1), Simon (Studies 1–3), flanker (Study 3), and color-shape switching (Studies 1–3). The two groups performed identically on the Raven’s Advanced Matrices test (Study 3). Analyses on the combined data selecting subsets that are precisely matched on parent’s educational level or that include only highly fluent bilinguals reveal exactly the same pattern of results. A problem reconfirmed by the present study is that effects assumed to be indicators of a specific executive process in one task (e.g., inhibitory control in the flanker task) frequently do not predict individual differences in that same indicator on a related task (e.g., inhibitory control in the Simon task). The absence of consistent cross-task correlations undermines the interpretation that these are valid indicators of domain-general abilities. In a final discussion the underlying rationale for hypothesizing bilingual advantages in executive processing based on the special linguistic demands placed on bilinguals is interrogated.     

Broken mirror: The intertwining of therapist and client stories of childhood sexual abuse (CSA)

In recent years, there has been a great deal of attention given to the potential increased risk of vicarious traumatisation (VT) for clinicians with a history of childhood sexual abuse.

I am curious about whether the silencing, which has been ubiquitous within society, is also prevalent within the therapeutic profession. I wonder if therapists with a history of abuse feel they have to bracket their experience, and if this limits the potential for positive transformation.

In this paper, I draw upon my narrative study of therapists with a history of abuse. The methodology followed was narrative inquiry with two therapists in addition to an autoethnography. I used ‘narrative analysis’ to analyse the data. The findings of the study covered themes of transgenerational trauma, ‘the wounded healer’, caregivers’ responsibility in communal cultures and dissociation.

In this paper, I will consider the part dissociation plays when there is a shared history of trauma, and the ways in which dissociative enactments within the consulting room themselves may be part of the mutual healing. For this paper, only extracts from interviews with one of my participants will be included.     

Managing the death of close others: Evidence of higher valuing of ingroup identity in young adults who have experienced the death of a close other

The death of a close other (DOCO) is perhaps the most difficult experience that people endure. According to terror management theory (TMT), people manage the potentially terrorizing awareness of their mortality by immersing in cultural worldviews that allow them to feel like valuable members of a meaningful universe who may have some existence or trace after death. Although TMT has potential implications for understanding how people cope with DOCO, few studies have examined this possibility. We report results from four studies showing that, in line with TMT, students who experienced DOCO reported stronger valuing of their identification with their in-groups, which in turn was associated with higher levels of self-esteem. These findings shed new light on the social-psychological dynamics of DOCO.     

Modular cognitive-behavioral therapy for body dysmorphic disorder

This study pilot tested a newly developed modular cognitive–behavioral therapy (CBT) treatment manual for body dysmorphic disorder (BDD). We tested feasibility, acceptability, and treatment outcome in a sample of 12 adults with primary BDD. Treatment was delivered in weekly individual sessions over 18 or 22 weeks. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-month follow-ups. At posttreatment, BDD and related symptoms (e.g., mood) were significantly improved. Treatment gains were maintained at follow-up. A relatively low drop-out rate, high patient satisfaction ratings, and patient feedback indicated that the treatment was highly acceptable to patients. To our knowledge, this represents the first test of a broadly applicable, individual psychosocial treatment for BDD.