In the context of the history of psychology, which of the following is true of philippe pinel?

The asylum and moral therapy

The history of ‘psychiatry’ began with the custodial asylum – an institution to confine raging individuals who were dangerous or a nuisance. The discovery that the institution itself could have a therapeutic function led to the birth of psychiatry as a medical speciality. This notion can be traced to clinicians such as William Battie (St Luke's, 1751), Chiarugi (Florence, 1785) and Pinel (Paris, 1795), and lay people such as William Tuke (1796), a Quaker tea merchant who founded the Retreat in York. Such a development was in keeping with the style of thinking of the Age of Enlightenment (that ended with the French Revolution in 1789), with its religious scepticism and its quest for understanding. Pinel (at the Salpêtrière for women and the Bicêtre for men), in particular, anticipated several trends, abolishing the use of restraining chains and recognizing a group of ‘curable lunatics’ (mainly with melancholia or mania without delusions), for whom a more humanitarian approach in an ‘institution morale’ seemed to be therapeutic.

The term ‘psychiatry’ was first used in 1808 by Reil, a professor of medicine in Germany, to describe the evolving discipline, although its practitioners were known as alienists (those who treated mental alienation) until the twentieth century.

During the eighteenth century, there had been a growing trade in lunacy throughout Europe. In Britain, for example, the insane were confined to private madhouses, to which physicians had limited access and input. In 1788, King George III suffered a bout of mental illness for which eventually he received attention from Francis Willis, a ‘mad-doctor’ renowned for his piercing stare. The constitutional implications were considerable, and parliament subsequently instituted a committee to enquire into this and into the care of the mentally ill in general.

The therapeutic asylums, which sprang up in the nineteenth century, had in common a routine of work and activity and an approach by the staff encompassed in the term ‘moral therapy’ and variously described as ‘a mildness of manner and expression, an attention to their narrative and seeming acquiescence in its truth’ (Haslam, Bedlam, 1809), ‘the soothing voice of friendship’ (Burrows, London, 1828) and ‘encouraging esteem … conducive to a salutary habit of self-restraint’ (Samuel Tuke, York, 1813). Uplifting architecture, as well as access to sunlight and the opportunity to work in the open air, were also valued.

Many of these institutions had charismatic directors and employed attendants who could be trusted not to beat the patients. Reil (1803) described the qualities of a good psychiatrist as having ‘perspicacity, a talent for observation, intelligence, goodwill, persistence, patience, experience, an imposing physique and a countenance that commands respect’. These are recognizable ingredients contributing to a placebo effect, and most of the physical treatments at their disposal were largely that: purgatives, enemas, blood letting (advocated, e.g. for mania by Benjamin Rush, the founding father of American psychiatry, 1812) and emetics, aimed to ‘draw out’ nervous irritants (‘catharsis’).

During the nineteenth century, the confining of patients to an asylum passed from an unusual procedure born of grave necessity to society's first response when dealing with psychotic illness. Therapeutic asylums were built on a vast scale as politicians responded to the claims of the early enthusiasts. Unfortunately, while the doctors had no effective treatments, the asylums were destined to accumulate more and more incurable patients, leaving the staff overwhelmed, demoralized, and with insufficient time or conviction to sustain their ‘moral’ approach. The situation was exacerbated by an increase in the numbers of mentally ill people, especially through neurosyphilis and alcoholism, and by the increasing reluctance of families in industrialized society to tolerate their mentally ill relatives.

In 1894, the American neurologist Silas Weir Mitchell told asylum physicians that they had lost contact with the rest of medicine, and that their treatments were ‘a sham’. In Britain, apart from the Maudsley Hospital, which opened in 1923 for teaching and research and for the treatment of recently ill patients, asylum psychiatry remained virtually divorced from the rest of medicine until the 1930s.

9.13.4.3 The Outcomes of Psychiatric Rehabilitation

The scientific evidence that psychiatric rehabilitation is cost-effective for helping people with SMI gain freedom from inpatient settings has been accumulating for 4 decades now. The first and most important landmark was publication in 1977 of a 10-year controlled outcome trial conducted by Gordon Paul, an academic clinical psychologist at the University of Illinois, and his students (Paul and Lentz, 1977). Paul designed a comprehensive treatment program that today would be classified as “secure residential,” serving the same patients as secure state hospital inpatient units. The program was based on the emerging principles of behavior therapy at the time, most notably token economy, an early form of what is now the broad rubric of contingency management, and social skills training. Paul's experiment had two control conditions, one a secure residential program that used a different theoretical model based on therapeutic milieu, a humanistic approach not directly influenced by social learning theory, and a traditional but unusually well-funded state hospital using a conventional medical institutional model consisting of medication and assistance and support of activities of daily living (hygiene, occupational activities, etc). Patients coming through the normal state hospital admission process were randomized to the three conditions. The superiority of the social learning program over the therapeutic milieu program was substantial, and its superiority over the traditional state hospital medical model was overwhelming. It produced greater reductions in ambient psychotic behavior, less continuing dependence on medication to control behavior, more effective personal and social functioning, a higher rate of discharge, and lower rates of hospital recidivism. The quicker discharge (95% of the social learning patients were successfully discharged within 1 year of treatment) and lower recidivism rate produced enormous system-wide cost savings.

With multiple levels of experimental control, including randomization, blinds, time-sample behavioral observation, and a 10-year study period, the Paul and Lentz (1977) trial achieved an unprecedented level of experimental rigor. It was described at the time as the largest controlled treatment trial in the history of psychiatry. It was the largest and most elaborate of many related studies of social learning-based practices for schizophrenia spectrum disorders, all showing superiority for specific purposes. Beyond demonstration of improved outcomes upon introduction of psychiatric rehabilitation modalities, research has also documented catastrophic effects of discontinuing it (Tarasenko et al., 2013). This is a fairly rare level of outcome data in mental health services. It would be logical to expect that these findings would have a definitive impact on institutional practices for schizophrenia. They did not. Residential and inpatient treatment with a social learning-based therapeutic milieu continued to evolve, arguably to the present day, but almost exclusively in university research centers or settings affiliated with academic researchers. There are several interrelated reasons for this.

First, numerous national study groups charged with monitoring the quality of services for people with SMI repeatedly find that dissemination of new healthcare methods and practices is especially slow in the mental health domain, compared to general healthcare. This applies even to development and dissemination of new pharmaceuticals, but it is especially true for psychosocial treatments. This is usually interpreted as a manifestation of lingering public stigmatization and apathy, and a general lack of political will to protect society's most vulnerable and disenfranchized members.

Second, the social learning model identifies the direct care staff, the people who spend the most time with the patient, as the key agents for behavior change. It is they who selectively reinforce adaptive behavior and strategically withhold responding to maladaptive behavior, and prompt the patients to use new behavioral skills in the ambient social environment. They are directed not by a nurse supervisor, but by a manual that specifies how to interact with patients under what conditions. This is inconsistent with traditional medical model hierarchies, and consequently nursing administrators are incentivized to resist development of social learning programs in inpatient settings (in contrast, line nurses generally appreciate the superior effectiveness of the social learning model, and their training and background are well-suited to the treatment coordinating function that usually falls to them in hospital-based social learning programs). Also, extensive training of the direct care staff is necessary to achieve fidelity to the treatment model, and most of this training is outside the traditional scope and practice of inpatient psychiatric nursing. Similarly, in the social learning model the physician/psychiatrist has a consulting role mostly limited to managing medication, and serving as liaison to general healthcare professionals when necessary (e.g., when a patient's physical/medical condition complicates psychopharmacotherapy). This is a direct affront to the traditional professional hegemony enjoyed by psychiatrists in inpatient settings, and strongly opposed by guild interests.

Medical professionals are not the only ones whose traditional roles are challenged. Psychologists in social learning programs are generally responsible for the overall formulation and treatment plan required by regulation, and they must exercise well-developed expertize in behavioral contingency management to maintain patients' adherence to treatment, and address the high-risk behaviors that put them in the inpatient setting. Also, they must involve themselves in the myriad legal processes in which the patients are usually entangled. Although these abilities are generally within the scope of well-trained psychologists, they are more demanding than the traditional psychologist's role of administering tests and conducting individual psychotherapy in their office. Social workers are called upon to lead therapy and skill training groups, less preferred by some than their usual role of liaison to community agencies and families. Occupational and recreational therapists and others are called upon to participate on interdisciplinary treatment teams and adhere to a particular treatment model more than is generally expected in mental health settings, and this is interpreted by some as an infringement on their professional prerogatives and autonomy.

Psychological Factors

There was a time when clinicians thought they knew the causes of BPD. Many believed that early childhood trauma was the main risk factor, and if one expressed doubt about that relationship, one might be accused of being “in denial” about the reality of child abuse. Research articles (e.g., Herman, Perry, & van der Kolk, 1989) presented statistics about the frequency of childhood sexual abuse (CSA) in BPD, and assumed that the relationship is direct and causal. Some still hold on this idea (van der Kolk, 2014).

This naive view of cause and effect fails to consider differences between risk factors and causes, and does not consider the complex interactions that lead to psychopathology. Unfortunately, therapists picked up on these simple ideas. Some pressed their patients to remember childhood traumas (McNally, 2003). This approach revived Freud’s early ideas that trauma causes repression, requiring special methods to “recover” lost memories (McHugh, 2005). The results were that highly suggestible patients became convinced—by their therapists, by the media, and by best-selling books, that they must have been abused.

This “epidemic” of recovered memories had many resemblances to other types of epidemic hysteria, such as the Salem Witch Trials. Fortunately, this sad episode in the history of psychiatry and clinical psychology is now, for the most part, history. Researchers on memory have concluded that there is no scientific evidence for repression, and that the most common response to trauma is to have trouble stopping intrusive memories (McNally, 2003).

Another problem was that these ideas failed to distinguish between mild and severe trauma. Although these studies were conducted many years ago, research since then has produced nothing to challenge the conclusion that there are many pathways to BPD (Paris, 2005). Childhood trauma is a risk factor, but is more important in some patients than in others. This is probably why a metaanalysis (Fossati, Madeddu, & Maffei, 1999) showed that the effect size of CSA on a BPD outcome is small.

Our research group conducted a large-scale study in which we compared BPD patients to a cohort with other categories of personality disorders (Paris et al., 1994a, 1994b). We took careful histories from patients to measure what are called the parameters of CSA. The most important parameter was the identity of the perpetrator. It is well established that father–daughter incest is the most damaging form of CSA (Fergusson & Mullen, 1999). CSA by a stepfather or by an older brother is more common, but less likely to produce long-term symptoms. Sexual abuse by a nonrelative, such as a neighbor, or the mother’s boyfriend, is even more common, and even less damaging. The second important parameter is the nature of the abuse—being touched inappropriately is not as damaging as being subjected to full intercourse. Duration is also important, since single incidents will not lead to the same outcomes as long-term abuse.

We found that about a third of our sample had experienced forms of CSA severe enough to make was long-term consequences likely. Another third had experienced only single incidents of molestation, mostly by strangers, which we considered to be incidental rather than pathogenic. A final third had no such history. Our conclusion was that CSA, if severe, is indeed a risk factor for BPD. But childhood adversity has to be seen as part of a larger story.

Widom, Cjaza, and Paris (2009) conducted a long-term follow-up of 500 children with well documented child abuse (all these cases had gone to court). The results did show that sexual and physical abuse increased the risk for BPD in adulthood. However, there were many exceptions—the relationship, while statistically significant, was by no means strong enough to make predictions.

The adversities experienced by many BPD patients are broader in range. Many report physical abuse, and most report emotional abuse (i.e., hurtful and hostile comments) from family members (Zanarini, 2000). However, it is doubtful to describe these patients as having “complex PTSD,” i.e., a condition resulting from chronic and repeated trauma (Herman, 1992). Moreover, the effects of CSA are largely accounted for by the severe family dysfunction that so often accompanies it (Nash, Hulsely, Sexton, Harrison, & Lambert, 1993). In addition, children who are sexually abused are vulnerable because they are lonely and unable to confide in their parents.

All these life events, however adverse, do not provide a full explanation. The problems in BPD are embedded in complex interactions between temperamental vulnerability and life experience.

Linehan (1993), whose therapy for BPD patients was a landmark in personality disorder research, developed a much richer and more comprehensive theory to explain how families affect children with dysregulated emotions. There are many patients in whom the problem is not abuse, but a subtle kind of emotional neglect. Linehan usefully described the crucial environmental factor as “invalidation.” In other words, the families of future BPD patients do not listen to emotions but dismiss them. This stance might do little damage to children who have a different temperament, e.g., one marked by low neuroticism. But in those whose emotions are intense to the point of being overwhelming, invalidation can do real damage.

Our research group had earlier examined the relation of BPD to a construct developed by the Australian psychiatrist Gordon Parker, which he called emotional neglect (Frank & Paris, 1981; Paris & Frank, 1989). Like invalidation, this concept refers to the failure to acknowledge and support children in relation to emotions. In our studies, BPD patients described their parents as unusually high in neglect, and also as overcontrolling (exacerbating negative effects by keeping a child close to the family).

Yet while much research supports Linehan’s theory, these relationships are statistical rather than fully predictable. Children are often invalidated by their parents. And how can we explain that some BPD patients describe their families as reasonably supportive? One possibility is that parents who are “good enough” for children with a more normal temperament, may not be able to provide the additional input required by a child who is temperamentally at risk. Thus a combination of emotion dysregulation and environmental failure can be a recipe for BPD.

Summary

•

The term querulous is used to describe both behavior and the collective noun for individuals manifesting that behavior. The behavior at its simplest is an individual’s heightened tendency to find fault and grievance in life and to air their dissatisfaction recurrently. Such querulousness can vary both in degree and duration having been either present as a personality trait persisting throughout the individual’s life or having arisen anew at a certain period of their life.

In psychiatric and psychological domains, it is the morbidly querulous who have been the focus of attention. This is the group of individuals whose querulous behavior evolves over time accruing increasing losses and negative consequences for themselves or others.

There is a significant but aging body of research into the diagnosis of querulous paranoia, with little recent research. From the late 1800s, derived from the fusion of the concepts of partial insanity or monomania and paranoia, it was believed to be a discrete entity in which a single pathological preoccupation with a loss or injustice develops in an otherwise sound mind. There is complaint to authorities and courts and a gradual but increasing network of grievances with those same authorities and courts.

The history of paranoia mirrors the development of psychiatry in Western Europe over the last 2000 years. The words paranoia and paranoid are now part of the common tongue, focusing on misbeliefs, usually of a persecutory flavor. Yet this meaning is a mere shadow of its rich heritage in the history of psychiatry.

The term paranoia originates in the Greek language and was used as we might use crazy or out of his mind. Hippocrates used it to describe the delirium of high fever, and other writers used it to describe senile deterioration. Its medical use then disappeared from the literature.

In 1896 Emil Kraepelin initially felt that paranoia (progressive systematized insanity), while separate from dementia praecox, was nonetheless an endogenous disease process developing on “a defective constitutional basis.” It was a stable, nondeteriorating, monodelusional system, often with ideas of reference and over self-appreciation. It was without clouding of consciousness, disorder of form of thought, will, or conduct. Hallucinations might be present. Kraepelin separated querulous paranoia from other types of paranoia mainly because its psychogenic flavor was more distinct than in other types of paranoia. Even in the 1890s he felt that some querulous represented a separate group of purely psychogenic origin.

The presence of delusions has historically been the hallmark of insanity, and yet delusions have been defined in a number of ways, and as yet no agreement has been reached on their nature or origins. There have been investigators who have disagreed that they are even a form of belief but are rather empty acts of speech, with content that has no reference point in reality of the world or of the self.

Various psychiatric researchers have attempted to describe and categorize the querulous. They were influenced by their guiding psychiatric paradigms and by a significant selection bias in the querulous patients they examined, for the querulous do not voluntarily seek out psychiatric care. In fact, it is society, through its courts and other authorities, who refer the querulous patients to psychiatric professionals. As a result, researchers, particularly early researchers such as Krafft-Ebbing and Kraepelin, studied those querulous who had been referred to them by the courts or other authorities for involuntary incarceration and observation. They were therefore usually selected not only because of their particularly persistent and annoying level of querulousness but also because of their level of dangerousness.

Evidence of the difficulty of characterizing and defining querulous paranoia as well as of evolving classificatory systems is the profusion of terms found in the psychiatric literature. They range from paranoia querulentium (Krafft-Ebbing), querulous paranoia and querulent paranoia (Kraepelin), querulent paranoid, paranoia querulans, querulous paranoid state, litigious paranoia, litigious paranoid, litigious delusional states, justice seeker, querulous syndrome, morbid querulousness, delusional disorder, and persecutory type through to the compulsively querulous.

The most prosaic yet useful definition of the morbidly querulous is an individual who embarks on a persistent quest for restitution for real or imaginary wrongs through complaint, claims, petitioning of authorities and sometimes litigation, with resulting negative impact on their personal, interpersonal, and social functioning.

Diagnostic criteria: (1) Persistent, relentless petitioning of governmental and nongovernmental agencies and or the courts, with evidence of contagion, i.e., spread of foci of grievance; (2) Beliefs of having suffered loss or injustice that dominates the mental life. The beliefs have been of at least 6 months duration; (3) The resulting behavior is directed to attainment of compensation, vindication and vengeance, and stay of persecution.

For a significant portion of the time, since the onset of the behavior, one or more major areas of functioning such as financial management, work, or interpersonal relations are markedly below the level achieved prior to the onset. Further, there has been significant disturbance and distress caused to other targeted individuals, organizations, or their representatives.

Types: Primary: Querulousness is the only significant phenomena. There is no evidence for schizophrenia or mood disorder. Nor is there evidence that the querulousness is due to the direct physiological effects of a substance (e.g., a drug of abuse or medication) or a general medical condition. Secondary: The criteria for schizophrenia or mood disorder have been met or the querulousness is due to the direct physiological effects of a substance (e.g., a drug of abuse or medication) or a general medical condition.

Many researchers have attempted to isolate and describe the primary type of morbid querulousness (PMQ). However, their research methods and inclusion criteria vary considerably, and so the various prevalence rates found in the literature must be viewed with some skepticism.

Rates of PMQ appear to fall between 0.02% and 0.7% of inpatient psychiatric populations; the majority develop their querulousness in their thirties through to their fifties; approximately 70% have symptoms for up to 5 years and 30% for between 5 and 10 years, before presenting to a professional; and up to 80% of sufferers are male.

The most obvious external defining characteristic of the morbidly querulous is not their belief of having been wronged or their pursuit of redress. To distinguish the morbidly querulous complainant from their normal counterpart it is essential to weigh a number of qualities, of which the most significant are: (1) Proportionality (e.g., lack of balance between effort in all its modalities and potential loss or gain); (2) Focus (e.g., number of additional grievances accrued during progress of seeking redress for complaint); (3) Valuation (e.g., degree of importance ascribed to “perfect” resolution); (4) Victimization (e.g., degree to which the complaint had developed into a grievance and other past grievances are “bundled” with the current and the degree of personalization attributed to the grievance); and (5) Vindication (degree to which resolution becomes imbued with qualities that will validate their past life and its failures).

The querulent, vexatious, or unreasonable complainant presents an interesting study of offender as victim of their own behaviors. However, it is essential that the other victims in their sagas not be forgotten.

The pediatric psychopharmacologist

Unfortunately, the history of psychiatry, even more than other fields in medicine, has shown a tendency to use any treatment method with some positive effect on some patients until it has been shown to do more harm than good. Sometimes our failure derives from our efforts to be a healer, sometimes it is our narcissistic need to succeed and prove ourselves correct, failing to reexamine underlying suppositions. It seems we are at greatest risk when we have succeeded and been admired for it. So, accepting that medications can sometimes be helpful, it is worth stepping back to ask the following question: where does the urge to prescribe come from?

It comes in part from training. Child and adolescent psychiatry fellowship training began to emphasize attending to diagnoses and symptom clusters that might respond to pharmacologic intervention.1,3 This aspect of training seems to have grown from one of many core competencies to taking center stage as the introduction to one’s future professional role and job description as a pediatric psychopharmacologist.

This shift was consistent with a high demand for prescribers, which has led it to become a profitable sub-subspecialty. Child and adolescent mental health services have been willing to pay the higher rates of psychiatrists only for prescribing medication. As the medications became more complicated, pediatricians became more reluctant to share this role with child psychiatrists. The relative shortage of child psychiatrists resulted in clinics and health maintenance organizations using them almost exclusively for diagnostic evaluations and medication monitoring. Most of the psychiatric care, including psychotherapy for children in the United States, is provided by clinicians with varying backgrounds and experience in child and adolescent therapy.8,9 They are constrained by managed care and other insurance and cost pressures to limit the number of therapy sessions that can be offered to children and families. Targets that are, in effect, set by insurance companies influence their choice of therapeutic goals. These goals are usually based on symptom reduction and behavioral improvements at school and at home.3,8,9 Thus, therapists and psychiatrists move toward a medical, reimbursable model.8

Precursors to DSM

Although the first edition of the DSM was not published until 1952, mental disorders were topics of interest for the preceding centuries. The advent of institutionalization, although periodically viewed as a dark period in the history of psychiatry (Prins, 1987), provided substantial opportunity to collect data and learn about mental disorders in clinical contexts. Mental disorder began to be viewed through a medical lens, spurring the development of psychiatry as a profession. The work of influential figures in the development of psychiatry, such as Phillipe Pinel and Emil Kraepelin, was centered in the study of mental disorders.

Pinel, Kraepelin, and other psychiatrists, such as Wilhelm Griesinger and Eugen Bleuler, had authored psychiatric nosologies. These nosologies were essentially created from a top-down approach, using a priori assumptions to generate classifications (Kendler, 2009). These nosologies addressed biological, relational, and environmental factors that influenced presentation of symptoms (Grob, 1991). In reality, psychiatrists had little to go on outside of symptoms and extraneous factors. Interestingly, the DSM did not formally incorporate environmental factors into its classifications until the third edition when the multiaxial approach was introduced.

Individual nosologies put forth by psychiatrists in the late nineteenth and early twentieth centuries had the advantages of being holistic and centered on the individual. These nosologies also provided an important starting point for the development of a diagnostic language for psychiatrists. There were, however, a number of challenges inherent in an array of different nosologies. First, different nosologies meant different diagnostic languages were spoken, impeding communication between psychiatrists. Second, diagnostic similarities and differences between nosologies were difficult to distinguish because each nosology was based on different constructs of mental disease as conceptualized by different authors. Third, prevalence rates of mental disorders could not be determined without a standard nosology. These challenges would impede refinement and validation of these psychiatric nosologies, collaboration, prevalence estimates, and research. With a standardized nosology, psychiatrists would be able to learn and speak the same diagnostic language.

In 1917, the Committee on Statistics of the American Medico-Psychological Association (later called the APA) recommended a uniform classification system of mental disease. At the time, mental disorder classification was chaotic and did not allow for the collection of meaningful data. Clinicians and researchers were diagnosing mental disorders with little consistency. There was great confusion and variability in diagnoses of mental disorders because diagnostic systems were about as varied as the institutions and individuals that created them (Kendall, 1975). This problem was further compounded over time, as different diagnostic nomenclature spread across North America. This resulted in “a polyglot of diagnostic labels and systems, effectively blocking communication and the collection of medical statistics” (APA, 1952). In addition, the committee feared that having such a disordered way of classifying mental diseases would discredit the field of psychiatry. Subsequently, the association published the Statistical Manual for the Use of Institutions for the Insane (American Medico-Psychological Association, 1918), which delineated mental disorders into 22 groups. The manual became the definitive psychiatric nosology and continued in a number of editions until the 10th edition in 1942.

Some psychiatrists were opposed to a psychiatric nosology. Adolf Meyer, former president of the APA, and “Dean of American Psychiatry,” was opposed to a nosology demarcating “a one-word diagnosis marking the individual” (Grob, 1991). Rather, Meyer viewed mental illness in holistic terms and was a proponent of understanding the life histories of patients to understand the etiologies of mental disorders (Sabshin, 1990). He introduced a psychiatric nosology based on reaction patterns, but it was largely unused by psychiatrists. Meyer abandoned the nosology because he found each psychiatric case was unique and should be studied on its own terms (Neill, 1980).

A significant shift in psychiatric nosology occurred in the United States as a result of World War II. In the armed forces, each case of morbidity required a diagnosis by a psychiatrist, but only about 10% of cases fell within the nomenclature of traditional diagnoses as described in the Statistical Manual in use at the time (APA, 1952). Psychiatrists serving in the military also found that the early identification and treatment of mental illness in noninstitutional settings could help alleviate and prevent more serious mental health problems. This resulted not only in a rekindling of the institution/community debate of treating the mentally ill but also in increased optimism in the treatment of mental disorders. Because it was recognized through these wartime efforts that environmental stressors contribute to mental illness and that intervention could alleviate psychological problems, it also reawakened interest in psychodynamic and psychoanalytic theory, which emphasizes the psychological processes that moderate environmental forces with biological drives. This led to a shift away from the medical model of psychiatry toward a psychodynamically based therapeutic approach (Rogler, 1997).

In terms of the development of the DSM, one of the most important changes was that previous terminology, which was expressed in pathological language, underwent significant changes post World War II. The new terminology focused less on biological bases of behavior and more on developmental, environmental, and relational factors. Further updates to the Statistical Manual for the Use of Institutions were put on hold. In addition, the army made extensive revisions to the standard nomenclature, which was eventually adopted by all armed forces. The Veterans Administration followed suit with their own nomenclatures, similar to those of the armed forces.

In addition to these classifications used in North America, the sixth revision of the International Statistical Classification (International Classification of Diseases [ICD]) was produced in 1948, which included for the first time a section on mental disorders entitled “Mental, psychoneurotic, and personality disorders” (World Health Organization [WHO], 1948). The International Classification delineated these disorders into three broad groups of psychoses, psychoneurotic disorders, and disorders of character, behavior, and intelligence, with 26 categories and 61 subcategories in a rubric style classification. In the end, at least three nomenclatures were widely used in North America, none of which were in line with the International Statistical Classification, which was itself used primarily for statistical coding (APA, 1952). The journey toward a standard classification used for statistical and clinical work had taken a detour.

Training practices to achieve mental health equity

In addition to practices previously described, the authors believe that steps could be taken by regulatory agencies such as the ACGME, the American Board of Psychiatry and Neurology (ABPN), and state medical boards to further affect mental health equity. These agencies have a powerful influence on psychiatric education and the continuing education of board-certified practitioners.

During residency training, the ACGME could specify that training in the history of psychiatry links the contributions that biased diagnoses and unequal treatment to mental health inequity so that residents can appreciate the contribution of such practices to past wrongs. Education about biases (rather than training to “remove” biases) should be mandatory, and quality improvement should include activities such as advocacy experiences and meetings with community panels and partners about their needs and experiences with accessing mental health care. Requirements for training residents to work with community groups, schools, local law enforcement, and faith-based communities that interface with their patient population may also have an impact.

Additional educational materials that would enhance education in such areas could include developing Observed Structured Clinical Encounters for students and residents to provide practice in approaching patients with cultural humility and structural competency. Role-play supervision scenarios for faculty development could facilitate the often-difficult discussions about race, gender, and power that lead to problematic encounters with trainees. The American Association of Directors of Psychiatry Residency Training (AADPRT), Association of Directors of Medical Student Education in Psychiatry, and AACAP, among others, could produce such curricula through initiatives within the diversity, inclusion, and equity committees of their respective organizations and disseminate them among their members.

Following graduation, continuing education and maintenance of certification requirements specified by state boards and the ABPN should include a requirement for training about social determinants of health and advocacy. This would parallel similar requirements for quality improvement or opioid prescribing.

As discussed earlier, whom we train is equally important as how we train. Therefore, the authors recommend that institutional commitments to diversity (with measurable outcomes) be a part of the Clinical Learning Environment Review visit of the ACGME and the Liaison Committee on Medical Education requirements for residency and fellowship programs and medical schools. Because this requirement is often extremely challenging, there should be templates available for how it may be achieved. Finally, realistic parameters should be set for examination scores and effective remediation approaches disseminated to accommodate students who may be at a disadvantage taking standardized tests or who have had less access to science, technology, engineering, and mathematics curricula in secondary school and college.

Compulsive Sexual Behavior

In 1970, compulsive sexual behavior in PD related to dopamine replacement therapy65 being associated mainly with the use of dopaminergic agonists21,22,34,45,51,66–70 but also with high doses of levodopa was first described.45,51,66 In addition to compulsive sexual behavior,51,66,67,70,71 early PD67,72,73 with a history of psychiatry or cognitive impairment can exhibit a higher risk for men.66,71,74 Table 2.

Table 2. The main studies on the most common risk factors related to the development of compulsive sexual behavior in Parkinson's disease in men and women

CG = control group; CSB = compulsive sexual behavior; DA = dopamine agonist; PD = Parkinson's disease.

The levodopa is the gold standard in initial PD therapy, having been used since 196075 and showing improvements in 80% of patients.76 However, some adverse reactions can occur over time; for example, in the case of compulsive consumption of the levodopa, the so-called dopaminergic dysregulation syndrome can lead to compulsive sexual behavior23 and other compulsions in up to 4% of patients.22,77 In turn, the chronic use of levodopa can develop dyskinesias and motor fluctuations,78 resulting in less sexual attraction between partners.38 These adverse reactions are iatrogenies that can affect physical, social, and occupational life.24 Such differences in response to medication between people and gender are probably controlled by the machinery of the dopamine genes.11

In Brazil, epidemiological, behavioral, and clinical data related to sexual compulsiveness are very limited79 and more in PD where reports are scarce.62 However, this is a problem of serious proportions, which can impact on psychosocial, legal, and public health issues,25 leading to serious negative outcomes, such as social isolation,80 sexually transmitted infections, unemployment, divorce, financial problems, pregnancies unplanned, sexual harassment and abuse,38 and zoophilia.25

The WHO (2018)81 was concerned with providing access to treatment and reducing stigma and shame in seeking help due to the compulsive sexual behavior and further promoting research and international attention to this serious health problem has recommended including the disorder of compulsive sexual behavior in the 11th edition of the International Classification of Diseases.82,83 The exacerbation of the compulsive sexual behavior can lead to remarkable suffering associated with the loss of the feeling of gratification and sexual satisfaction and failure to control intense sexual impulses, identified in a persistent and repetitive pattern, for a prolonged period of 6 months or more, leading to damage of personal life, family, education, and occupation and neglecting health, activities, and responsibilities.83,84 Recently, the debate between clinicians and researchers has been intensified in the last 20 years,85 with the compulsive sexual behavior assuming different names such as nymphomania, satyriasis,25 sexual addiction, even sexual behavior out of control, or hypersexuality.86–88 Although used synonymously, both the increased risk for compulsive sexual behavior and its outcome for hypersexuality disorder are complications of PD.54

There is considerable frustration in the search for relief with sexual compulsion, similar to erectile dysfunction, limited performance sexual, and inability to achieve orgasm,32 raising concerns about failure and may lead to repeated attempts at sexual intercourse. Therapy for both partners and monitoring of problems involved must be alerted.89,90 In PD, the precise mechanism of compulsive sexual behavior is not clearly known,91 but both the dopaminergic and serotonergic pathways can contribute to the development and maintenance of compulsive sexual behavior92 and to the high level of anxiety in this disease.86,92 In addition, compulsive sexual behavior is commonly associated with depressed mood.86

It is essential to warn about the risk of pathological behaviors and side effects of the medication, as patients may not be able to immediately report the symptoms they feel voluntarily.90,93 Thus, in PD, compulsive sexual behavior can be a challenge because there is no approved therapy, and the urgent first step is to reduce or discontinue the use of dopaminergic agonists. Other interventions are psychotherapy, antidepressants, multidisciplinary team approach, sex education, family planning, monitoring of human acquired immunodeficiency syndrome and other sexually transmitted infections and evaluation of medicolegal problems.62 In a recent systematic review, naltrexone was used with promising results in compulsive sexual behavior refractory in PD, but further studies yet are needed with this drug to compulsive sexual behavior.86

3.4 Different levels of symptoms

The concept of ‘trouble generateur’ entails a deeper level of abnormalities that underlies the psychiatric symptoms as they can be observed on the surface, the behavior. In addition to the surface level of the objectively observable behavior, structural psychopathology assumes a deeper level. The assumption of such deeper level underlying the surface symptoms has resonated much in the history of psychiatry and has resurfaced several times in different concepts. These include Bleuler’s ‘primary symptoms, Jaspers’ ‘psychic processes (Japsers, 1997), and, more recently, Huber’s “basic symptoms” in schizophrenia (Huber, 2002; Ebisch et al., 2013).

Most recently, Kendler distinguished between ‘surface symptoms’ and ‘deeper symptoms’ when raising the following question: “to what extent should we continue our focus in our nosology on “surface” symptoms and signs picked or their reliability rather than trying to develop potentially more informative or “deeper” symptoms that might emerge from careful phenomenological analysis?” (Kendler, 2008, pp. 7–8) (see Fig. 2a).

Spatiotemporal Psychopathology aligns well with the distinction between “deeper” and “surface” symptoms linking both with distinct forms of neural activity. Surface symptoms are supposed to be related different functions, cognitive, affective, social, and sensorimotor which neurally can be accounted for by stimulus-induced or task-evoked activity, i.e., extrinsic activity. The “deeper” symptoms in contrast concern concepts like increased self-focus, decreased environment-focus, increased past-focus, and decreased future-focus. I assume that they are related to the brain’s intrinsic activity, and more specifically the resting state’s spatiotemporal structure. Accordingly, “deeper” symptoms are supposed to be primarily spatiotemporal symptoms which, due to the fact that extrinsic activity is based on intrinsic activity, is carried forth to the various functions and their respective “surface” symptoms.

In addition to surface and deeper levels, Spatiotemporal Psychopatholgoy assumes a yet even deeper level, the deepest level, as I say. The deepest level consists in the brain’s intrinsic activity and its spatiotemporal structure which is assumed to be manifest in both deeper and surface levels as in subjective experience and objectively observable behavior. Though tentatively at this point in time, Spatiotemporal Psychopathology assumes that the resting state’s spatiotemporal organization or form accounts for what Minkowski (and others) were searching for, “a kernel underlying the manifest symptoms in all their variety that keeps them meaningfully interconnected or united”, while at the same time extending it to the brain (see Fig. 2b and c).

How can we characterize the three levels, surface, deeper, deepest, in further detail? The surface level can be characterized by the different functions, cognitive, affective, sensorimotor, and social, and their respective contents. This is manifest in the objectively observable abnormalities in behavior as in various psychiatric symptoms like hallucinations, catatonia, delusions, psychomotor retardation and agitation, thought disorder, sadness, guilt, joy, happiness, social withdrawal, etc. Hence, neurally the surface symptoms are most likely related to abnormalities in extrinsic activity reflecting their neural correlates (i.e., the sufficient neural conditions) (Northoff, 2013a,b,c, 2014b).

The deeper level concerns the subjective experience of self, time, space, body, and others. This is reflected in the abnormalities in inner time consciousness in both schizophrenia and depression, ego-disturbances in schizophrenia, abnormal shift between self- and environment-focus in mania and depression, and the abnormal balance between past- and future focus in bipolar disorder. Phenomenally, one may associate the deeper level with the pre-reflective phenomenal level of experience while neurally the deeper level may correspond (more or less) to the spatiotemporal structure of the brain’s intrinsic activity.

Finally, the deepest level extends beyond the phenomenal realm of experience and consciousness to the pre-phenomenal realm of the brain’s intrinsic activity and how it relates to the world. This is the level that can no longer be directly experienced as such neither on the reflective nor the pre-reflective level of experience. This though does not mean that the deepest level does not bear any relationship to experience. Spatiotemporal Psychopathology assumes that the deepest level predisposes experience, it provides the necessary conditions of possible experience and must therefore be conceived as pre-phenomenal (rather than non-phenomenal) and refers to the neural predispositions (rather than neural correlates) of abnormal psychiatric experiences and behavior.