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Psychosis: Bartolomé Llopis

We intend to refer in this entry to the concept of axial syndrome of psychosis , as developed by Bartolomé Llopis, staunch advocate of the concept of single psychosis , whose importance and presence has alternately flourished and declined throughout the historical evolution of psychiatry and psychopathology. We will continue to do the text only psychosis. selected writings, that collects several works by this author. Llopis argues that the crucial problem of psychiatry is whether psychological symptoms are produced and set in each case for a particular cause or pathogenetic represent only existing response options that can be shown by various causes. The author denies the specificity of the real physical symptoms and helped to revive the theory of psychosis only (or unit, others prefer translation). In the words of Llopis, speaking of psychosis is only wants to express that mental symptoms are the same in diverse diseases, the brain, which directly or indirectly dependent condition always those symptoms, you have the same answers to all attacks, like other organs. Moreover, among all these responses there is a continuity, a transition insensitive, so that the various psychotic symptoms represent only varying degrees of intensity of the fundamental disorder.

Commenting historical background of the thesis of the single psychosis, Esquirol says: " Madness successively and alternatively can affect all these forms: mania, mania and dementia are replaced, are complicated in the course of the same disease, same individual. " For him, mania, mania and dementia are not disease entities but only forms, ie, syndromes, and also be a transition from one to another. In this sense, can be considered to Esquirol as one of the first representatives in modern times of the thesis of the single psychosis. Speaking of the causes of insanity, said that its etiology are so numerous and varied. But considering the etiology is essential for delineation of disease entities. If madness is due to so many and varied causes, is because it is a disease entity but a syndrome. Otherwise, it would have so many follies as etiological factors. Esquirol claimed that madness, in the singular, it can be produced by many different causes and may also manifest itself in diverse ways. According to Llopis, could express the thought of Esquirol saying that psychosis is a syndrome common to many diseases and that this syndrome may adopt or pass on to various forms, and also that Madness is a basic or fundamental syndrome, divisible into syndromes subordinates. Georget defended the view that mental illness was a brain disease idiopathic with a wide variety of demonstrations, which would not, however, independent diseases. He said: " can see a series of intermediate types, ensuring that there is a seamless transition between both forms of l mint condition." Neumann says in his treatise published in 1859: "We can not believe real progress in psychiatry until the general has taken the decision to throw overboard all classifications ." Also: " There is only one kind of mental disturbance and call madness." In the opinion of this author, they do not form any mental disturbance, but only stages of one and the same pathological process. Neumann was able to recognize and highlight clearly the difference between isolated events and complex symptomatic manifestations, on the one hand, and actual pathological processes, on the other. Called "elements" to those isolated events, as opposed to the real disease, which he described as "processes." He said: "The true diagnosis has nothing to do with the naming , that is knowledge of the individual case, it is the product of abstraction, and indeed an abstraction based on analogies premature. " The idea of \u200b\u200bpsychosis only reached its peak under the influence of Griesinger, who begins his treatise published in 1861 saying that insanity is not, in itself, rather than a symptom, this symptom can not be claimed more that a brain disorder. Regarding the rankings, said: " The establishment of the various groups of mental illness can only be done from a symptomatic point of view "and" can be justified only from existence. "

According Llopis, the decline of the concept of psychosis really only seems to start work Hoffmann (1861) and Snell (1865) that break with what they see as the dogma of the exclusively secondary paranoia, describing the " monomania as a primary form of mental disorder ." Griesinger accepted a "primary paranoia" and Westphal in 1876, made his classic description of the disease, emphasizing the abnormality of considering representations and affective disorders as incidental or unimportant. Thus began a process that collapsed, at least temporarily, the notion that delusions are always secondary to mood disorders, a concept that was one of the strong pillars of the theory of psychosis only. Nevertheless, the decisive blow against the single psychosis was struck by the tremendous work of nosographic Kraepelin, on the other hand, had the predecessor to Kahlbaum . Kraepelin laid causal-symptomatic principle, whereby each cause of the disease is linked to a certain psychological symptoms. It is not, however, that each corresponds a specific disease process status box. Symptomatological differences for the various diseases are much finer, much more difficult to perceive than those between the various categories of state (melancholy, mania, stupor, delirium, paranoia ...). The differences between them are so obvious that their separation has not ever offered great obstacles. In contrast, the finding of specific physical symptoms for various disease processes is a task fraught with difficulties. You can not do directly, regardless of pathological processes, a classification of major psychiatric symptoms. According to Kraepelin, natural syndromes, ie, those who can differentiate a direct and spontaneous, are accessories for the recognition of disease entities, while small symptoms of the syndrome accessories in total in which they appear, may be critical to the diagnosis of underlying disease. Also admits that the difference in disease processes is often most clearly highlighted in the course of the disease. He says: " precisely why the consideration of the progress and completion of the mentally ill seems to me extremely important for delimitation. " With Kraepelin, reaches its climax psychiatric systematics based on the specificity of psychiatric symptoms and collapses completely unique concept of psychosis, and seriously undermined by the theft of your emotional base to the paranoia.

Subsequently, the first-symptomatic etiology Kraepelin was subjected to multiple attacks. As pointed out by Llopis, after the collapse of the theory of psychosis only appeared four ideological currents that converged to the resurrection of this thesis: the recognition of the specificity of psychological symptoms (Hoche, Bonhoeffer, Specht, Hartmann, Bumke, etc. ), the application of evolutionary perspectives to the study of nervous system disorders (Jackson, Monakow, Janet, Ey, etc.) overcoming the consideration atomistic psychology unit of psychic life (psychology of the whole , psychology of form, etc..) and also overcome the old doctrine brain locations of mental functions and views that emphasize especially the importance of joint activity throughout the brain (Flourens, Lahsley, Goldstein, etc..). Common to all these trends is a tendency synthetic, unifying, which openly opposes the momentum analyzer, specific and distinctive characteristic of all attempts at classification. After this overview, it is clear that since the beginning of scientific psychiatry have taken two approaches to the problem of mental disorders: a synthetic, meeting the symptoms in the great unity of the so-called single psychosis, which represents the same response but with varying degrees intensity, the more varied attacks, another analytical, which breaks down and distributes multiple psychotic symptoms specifically determined by the various pathogenic causes. Both tendencies have fought, sometimes with burning, but as stated Jaspers, " instead of fighting, could be complemented ." Llopis argues that there really is no argument between the two compatible. Nor the necessary classification of mental illness can destroy the unity of psychic disorders flowing nor the recognition of this unity means no obstacles to psychiatric nosology. Mental diseases called leads to impaired mental activity, which may have varying degrees of intensity. When all these conditions is what has been called "one psychosis", and Llopis, to avoid confusion, has proposed to call " axial syndrome common to all psychoses ." The varying degrees of this syndrome are not pathognomonic axial any disease, but could support a possible causal disease, especially if we consider also its temporal variations, ie the course of psychosis.

Llopis Turning to what he calls his own concepts about psychosis only, it is necessary to clarify what is meant by syndromes of the state and content of consciousness. considers Awareness as the ability to know and knowing is always distinctions or differentiations. Knowing is one thing to distinguish, to separate what is not herself. There is no mental act than an act of knowledge. Consciousness and psychic activity are therefore synonymous concepts. Call state of consciousness to the degree of clarity or lucidity, which is expressed by a greater or lesser capacity to know. Content consciousness is all that is known (noticed sense, perceived, apprehended) by consciousness. Contents pathological consciousness can not be more than those that reflect the abnormal situation of the organism itself, that is, in general, any content provided not by the external senses, but by the internal sensitivity for the cenesthesia. In contrast, pathological states of consciousness pertain to both external and internal stimuli. The pathological contents of consciousness can not be regarded indeed as psychological disorders. Their awareness is limited to take cognizance of a disorder of the body.

However, the fact that the syndromes of the content of consciousness are not mental disorders per se, does not mean lack of extraordinary importance in the shaping of the psychotic disorders, ie what Llopis called syndromes mental picture. The mentally ill do not express an immediate and pure content, ie, feelings, plastic materials offered to the activity of conscience, nor the same activity, what they say are the works that those materials build their awareness. In such works, or psychotic symptoms are integrated, for both content disorders such as mental activity or state of consciousness. The fact that these works are also still qualify as content ( psychotic content) should not lead to confusion. The psychotic episodes are, in effect, rather than psychological content, but psychic contents which has left its stamp on disorders of consciousness. To be designated as containing psychotic need to reveal the existence of a disorder of the state of consciousness. Table psychological syndromes are psychotic symptoms such as is an empirical observation. Now if we consider the essence of any mental disturbance as a projection experiences the outside world caused by internal stimuli, we can formulate the following questions: What is the degree or intensity of the projection? What is projected? Thus Table psychotic breaks in its two constituent factors: the syndrome of the state and the syndrome of the contents of consciousness. The transformation of the contents or primary disease (syndromes of the content of consciousness) in psychotic or secondary content (Table psychological syndromes) is performed, then, under the action of the true and only conditions of psychic activity, which are the syndromes call status consciousness. This action metamorfótica mental disorder on the contents of consciousness seems to be regulated by two fundamental principles: principle of "like" or metaphor and introversion principle.

The principle of "like" or metaphor explains that the somatic sensations produced by stimuli internal, normal or pathological, can not be analyzed and described if not comparing with sensory impressions caused by external causes. Pellagra patients, for example, describe their pain and numbness: "I ran like snakes ... as if a dog bit me ... as if it were on fire ...". They are images, metaphors of the external world with which patients express their inner impressions miss. The same applies to those internal anomalies, more diffuse, which we perceive as feelings or emotions: "I notice a sense of unease, as if danger threatens me ...". The feeling is invariably adequate image of the outside world to the affective. Kinesthetic impressions are always linked to representations of the external world. These representations or images arise automatically, aroused by the inner impressions, and serve the normal subjects to describe metaphorically, through the phrase "as if" the particular quality of those impressions. But these individuals do not confuse the feeling with the image, the internal with the external reality with the metaphor.

Moreover, the principle of introversion is explained from the point of view that any disruption psychic is a reduced ability to learn in a decreased level of consciousness. As this decline is occurring, patients are losing touch with the outside world and immersing himself in his own inner world. Gradually abandon the objective world, common to all, and are enclosed in increasingly subjective world, individual. As to the introversion simultaneously be losing the ability to know, to differentiate, prove that parallel to the loss of contact with the outside world, they will be breaking down the boundaries between the sensations and representations, internal and external, the subjective and the objective, reality and metaphor. Patients lose awareness of the metaphorical significance as before, in the experience of "as if" they lived properly as a metaphor, now living as a reality.

Doubt is the great achievement of man because it involves self-knowledge, ie differentiation between self and world, or between an inner and outer world. When human consciousness declines with fatigue, sleep, or illness in psychosis, man loses the privilege of the doubt and sinks an unshakable security. This security is all the more regrettable that due to the Introversion principle, the content offered to consciousness are becoming less objective picture of the outside world and more and more images created by your own imagination under the influence of internal stimuli. We tend to project into the outside world, to live as if they were objective realities, all kinds of subjective fantasies. Llopis Cree only different degrees of such a projection (which does not express, in short, more than a car and alopsíquica disorientation, an inability to discriminate between the given objectively in the outside world and given only in the self) can explain purely quantitative transitions between the different syndromes of the state of consciousness, despite its apparent qualitative differences.

From their point of view, neurosis can not be considered rather than syndromes content consciousness. It is not in them of true changes in mental activity, but affective states, among which is a particularly prominent anxiety. These affective states are only the expression subjective somatic disorders and the fact that the fundamental somatic disorder lacks a clear objective expression does not mean it does not exist. The fact that arouse affective disorders, depending on the experience of "as if" representations or memories (biographical anecdotes) easily leads to the error of confusing cause with consequence. As for affective syndromes, syndromes are considered content of consciousness that do not involve any disturbance of mental activity. However, longtime supporters of psychosis only consider melancholia and mania as phases of this psychosis. This apparent contradiction is explained by the process of introversion of consciousness. At the beginning of this process, the consciousness becomes less intellectual and more emotional, affective content then dominate over all other possible contents of consciousness. The more advanced the process more intense psychotic introversion and acquire predominance emotional content, but as simultaneously launches the mechanism of projection, the affections are clad increasingly apparent objectivity, it covers an increasingly external events alleged plot, so that these alleged events (paranoid ideas, hallucinations ...) acquire hegemony in the box psychotic while those with truly primary and fundamental, reduced almost to vanish, apparently, to mere reactive consequences. Thus, although the affective syndromes may persist through all stages of psychosis may manifest itself only with evidence in the initial stage. It should be stressed that melancholia and mania are psychic contents and, therefore, are not genuine stages of psychosis, much less subsequent stages. What happens is that in the first stage of the psychosis which reveals more clearly the emotional situation, regardless of the patient, may occur it is neither sad nor happy, but indifferent, what should be possible to poverty or lack of kinesthetic stimuli.

Referring to the paranoid syndromes, and within the normal psychic is a tendency to project one's own feelings in the outside world, ie to distort the true picture of the world in favor of their own emotional situation. For this projection becomes more severe disease requires a decrease in the level of consciousness. In the most serious obsessions, the projection still faced with an emotional understanding of reality, with a critical consciousness, which can reject objectively unreasonable or absurd occurrences or representations awakened by affection. However, paranoid ideas, the projection is stronger and no longer question the external justification of such occurrences, which are experienced as if they were the exact meaning of external reality. Typical of the paranoid ideas is that the projection of subjective state, without actually modifying the sensory image of the external world, gives it a peculiar significance in relation to self. Consciousness is lost chance and all people live as if you were encouraged by certain designs, which can be favorable or hostile, as the subject's emotional state. Affection is the force that gives direction and paranoid ideas, resulting in a factor essential constituent of any idea of \u200b\u200bthis nature. But affection is not enough, with addition of a decreased level of consciousness that the experiences aroused by the affection is projected onto the external world, ie to live as if they are justified not by the inner reality, but by external reality. The old debate about the origin primarily emotional or intellectual paranoia would be ill-conceived, as both disorders (the content and the state of consciousness) are also indispensable for the genesis of paranoia.

About hallucinatory syndromes, Llopis insists that all psychopathological phenomena, even the most disparate, can be explained by only quantitative variations of a single critical condition. Thus attributed the passage of paranoid ideas to hallucinations, ie, thought disorders to disturbances of perception, for the simple progressive decrease in the ability to know. The thoughts and perceptions are yields of a single function, which is the ability to learn. Perceptions are simple knowledge of the physical presence of things while thoughts are knowledge of the meaning or significance of such transcendent things. Thus, disorders of thought and perception are not qualitatively different, but only modes of expression of different degrees of intensity of a single critical condition.

Moreover, the author argues also the analogy between psychosis and sleep, noting that the process of introversion, loss of contact with the outside world, to plunge into the inner, is a phenomenon common to the madness and sleep. Awareness or ability to learn can not be altered more than one sense of the decline in their yields. It does not matter that this alteration is caused by abnormal pathological factors for the normal action of physiological fatigue. The axial syndrome common to all psychoses or series of mental states constituting the single psychosis, there is therefore nothing but the same sequence of states of consciousness that we in the transition from wakefulness to sleep.

box because everything can be decomposed into a psychotic syndrome and content-based state of consciousness , we must consider what the relationship between each of these two kinds of syndromes and diseases that produce them. Syndromes of the content of consciousness are merely subjective manifestations of disease, depending on both the soma sensitive sites that have been attacked by the disease. Refers here to involvement of different receptors or sensory systems, both in the brain itself as anywhere in the body. In contrast, syndromes of the state of consciousness correspond to different degrees of reduced ability to learn, and this ability depends on the joint activity of the brain. Their cause must be sought in those pathogenic insults affecting the unitary and global function of the brain. Syndromes of the state of consciousness correspond to different degrees of what Jackson called "uniform solution nervous system, in which the whole system is under the same corrupting influences, although the most recent ones under higher yields, "yield" in the first place and there is a progressive and homogeneous regression to lower functional levels. The declines at progressively lower levels of functional activity of the nervous system does not reflect a different location within it, but just a different intensity, a different degree of "harmfulness" of pathogenic noxa. In short, the syndromes of the content of consciousness depends on the particular affinity for locating the pathogenic noxa with respect to the various parts of the body, while the syndromes of the state of consciousness depend on the degree of psychological harm that noxa. That is different origins, including syndromes of the state of consciousness there are only quantitative differences that allow their management in a continuous series (the single psychosis or axial syndrome common to all psychoses), while in the syndromes of the content of consciousness are qualitative differences as they may affect different sensory qualities. Within the general specificity of these syndromes, the contents of consciousness have greater value in the differential diagnosis. Both syndromes show, at least within certain limits, certain trends causal disease processes, and such trends is much more affinity localizatoria constant and characteristic that the harmfulness psychic. The diagnostic value increases dramatically if you take into account the combination of both syndromes in which we have called mental picture syndrome. In such symptoms are units of a higher order, which keep a dual relationship with the organic process grounds, will serve much better to find out. Units of a still higher order syndromes that are psychic box psychotic courses. These express the sequence, ie the sum over time of those pictures. Translate not only the harm and the location of the process but also their temporal variations.

However, only in very exceptional cases we can make a diagnosis with absolute certainty, taking into account only the psychic manifestations disease. In many diseases, especially those that underlie the so-called endogenous psychoses, our inability to discover somatic targets only forces us to diagnose the psychological symptoms. It is certain that we are satisfied many times misdiagnosed. We stop, Finally, in discussions carried out by Llopis about schizophrenia. Believes that under that label is not showing more than a syndrome, or rather, a series of psychopathological syndromes without somatic basis determined. On such grounds as may be determined somatic probably dissolve the nosological concept of schizophrenia in a multitude of heterogeneous. Do not forget that these syndromes are essentially nonspecific and can occur not only endogenous but also exogenous diseases, diseases of somatic bases inaccessible to our means of investigation and in other well-known and well diagnosable. The diagnosis of schizophrenia is always recognition of our inability to discover the fundamental organic disease, it's like hide our ignorance under a label. Many times we are not individually responsible for such failure, because this depends on the state of our science, but many times yes, because the diagnosis is made without depleting the patient's mental status examination, because it gives a specific meaning to the mental symptoms, because syndrome is attributed to a psychic the value of a disease entity.

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Medical Progress with vested interests (COUNTRY dixit)

ago For some time we read in the newspaper El Pais article by the Advocate reader Milagros Pérez Oliva. Is this a weekly newspaper, which includes criticism or suggestions from readers on the same day. We recognize that we like to read regularly and which we see now in this post certainly impressed us as you will be with you if you come to the end (we know that the tickets are long, what can we do ...). But unfortunately, as we have said before, we were impressed but not surprised ... Andaman cured of ghosts ...

We

entries in the chamber to be published on the single psychosis of Bartolome Llopis on ethics in Stoic philosophy and its relation to Lacanian psychoanalysis or the conceptual definition of delirium , from a deconstructive analysis the same as the parameters of the DSM-IV ... And I swear it's true.

But remember an old joke about Mafalda, where he saw her (or was it Mickey?) Asking a worker who worked in a hole in the ground: you looking for happiness? And he answered: No, honey, a gas leak ... Mafalda (definitely a she) walked away thinking: as always, the urgent does not leave time for what matters. And that happens to us, which we have been feeling some choking the continued presence of the pharmaceutical industry and their minions in our working environment makes us feel the need tickets like this while the other would be a lot prettier (anyway, if we end up falling hack before the blog page ...).

And then article Mercedes Pérez Oliva, who is worth it:

often arrive in the newsroom studies and apparently rigorous and reliable data, however, may mislead readers or hide advertising or commercial interests. Discovering and avoidance is a duty of rigorous journalism. Who, doctors and patients still have to deal with chronic pain, must have felt a great relief to read that "in the last European Congress of Pain, held in Lisbon, was presented tapentadol (...), the first analgesic that appears in 25 years of a new generation that will mark a before and after ", and" the experts said in Lisbon that begins a new era in the management of difficult acute and chronic pain. " I said Mayka Sanchez COUNTRY contributor to health issues in the article "Pain as the fifth vital sign," published Dec. 22 in Society. Described in the same unfortunate situation: "Despite nine million English chronic pain, only 10% of primary care physicians used measurement scales for better therapeutic approach, an issue that causes up to half of the cases, the pain may become a symptom badly treated ". The conclusion was clear: most doctors do not act properly and most poorly treated patients. To alleviate this situation had arisen Painless Platform, an initiative whose goal was to "sensitize" the doctors and the society " with medical advances, pain can and should be monitored.

Several

Doctors called the Ombudsman to complain about being given such a bad image of your work without citing the source of statistics. But one of them, Enrique Gavilán, Plasencia, saw something else: "I have been searching the main database of scientific studies, the U.S. PubMed bookstore, I reviewed the studies that have been published about this new drug and believe me, the results show that it is far superior to placebo and in any case is very similar in effectiveness to others that there is a lot more clinical experience and its price, I suspect, be much lower. " In its letter to the Ombudsman asked to investigate whether it is a case of surreptitious advertising and conflict of interest.

Mayka Sanchez clarified that the data are drawn from the Guide to Good Clinical Practice in Pain and its assessment of tapentadol is based on the statements made by Anthony Dickenson, one of the specialists who participated in clinical trials at the congress of the European Association for the Study of Pain, held in Lisbon, which she attended. The drug, he says, is supported by "177 articles published in international journals and conferences, all equipped with" an editorial and scientific committee which monitors the accuracy, objectivity and quality of work presented. "To Mayka Sanchez, suspected of surreptitious advertising referred to Dr. Hawk" is a very subjective opinion and not based on the published text, "as he says, are only talking of one of the molecules presented in Lisbon, not to mention your business name. The Advocate, this explanation does not seem enough. All studies on new drugs, including those quoted on the tapentadol Mayka Sánchez, are funded by vaccine manufacturers and sometimes the Congress in presented. On the biases in clinical research and the publication of the results there is ample scientific literature. The work of a journalist is to verify information and avoid bias on the part it may contain.

Was justified introducing this drug as a breakthrough drug "before and after" or "new era" in the treatment of pain? To clarify the professors I consulted Xavier Carner, president of the Drug Evaluation Committee of the English Medicines Agency, and Rafael Maldonado, a researcher at the University Pompeu Fabra working for the National Institutes of Health, USA. Neither considers the drug to be a novelty. Even the laboratory that produced it goes so far as Mayka Sánchez. In the press release in its submission in June states that "shows comparable efficacy to opioids classic" but offers "a more favorable tolerability profile." Nor is new: it has the same mechanism of action tramadol, the same laboratory.

But there is only a matter of exaggeration. The way information is presented justify the suspicions of Dr. Hawk, because it conceals all content comes from a single source, and omitted to disclose that source is, ultimately, the drug manufacturer name . Quote Grünenthal the Foundation of the Platform as driving without pain, but does not say that it belongs to the laboratory Grünenthal Pharma specializes in analgesic therapy, which is funding the campaign platform and the measurement of pain. The report also clarifies that the drug presents a revolutionary part of this laboratory . Only readers already know that lab can guess the relationship.

The information is dangerously scheme of new pharmaceutical strategies used to promote the prescription of drugs, after eradication the outrageous incentives that reward doctors. In fact, doctors are no longer the sole objective of the marketing departments of the laboratories. Now try to influence prescribing by patients themselves. That strategy is to bring out (sometimes even creating) a health problem, mobilizing scientific leaders and if possible, patients with the aim of "raising awareness" about the problem which has the solution .

Given the suspicion with which information is received from the industry, it has been forced to seek indirect forms and greater authority to vehicular activity. For this have created foundations and platforms theoretically independent and nonprofit, composed of academics and specialists, but funded by the industry itself .

All this is present in this case. The report begins by describing the serious problem of pain, based on studies funded by industry, presents to the platform that will fight against this scourge, saying that it is promoted and funded by the lab, and just reporting a drug that appears as revolutionary without saying that it is the same laboratory . For sake of completeness, the holder of the report coincides with the central slogan of the campaign funded by Grünenthal . And not even a novel information, as the very Mayka Sanchez had published three months before the same theme in El País Semanal. The only new thing was the reference to the drug. The report cites the Lisbon conference but does not mention that Mayka Sanchez traveled to the capital invited by the laboratory lusa . Style Book Country establishes the subject: "The newspaper, as a rule, does not accept invitations for processing information. Exceptions will expressly be authorized by management. In the information made after accepting an invitation shall state that the trip has been sponsored.

Over all, the deputy director responsible for Society, Bern González Harbour, said: "The newspaper is becoming the target of a massive flood of reports and studies, many of them partly filled with interesting conclusions at first glance but they lose their legitimacy in the interest checks from its own promoter. Our task is to analyze, identify and submit all the most scrutiny, and filter and publish only what is truly contrasted and objective that is of interest to our readers. The controls have not worked in this case and apologize. This article is an example of what not to do .

far article, emphasis added, repentance and apology from the newspaper and need to reflect, we believe, is all ...

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About the (depressing) the effectiveness of antidepressants

In the book Inventing mental disorders, several sometimes recommended in this blog, González Pardo and Pérez Álvarez provided by the fact that by 1980 depression was a rare disorder, affecting 50 to 100 people per million, while estimates of the decade just passed The are around 100,000 people per million. If we believe (and we believe because, given the existing evidence seems indeed a matter of faith), as they say from certain sectors of the profession, we are facing a brain disease caused by imbalances in neurotransmission, we should ask what happened in the human brain in these three decades that where before there was a depression, now has 1000. We will respond, no doubt, that what happens is that previously underdiagnosed. That is, as before (in 1980, in the seventeenth century, ie relatively recently that at least one of the authors of the blog remember that year) we had 999 people undiagnosed depression per 1000 patients we have today, , which received no treatment while now they are benefit from it. This would lead to the conclusion that people were much more unhappy or even commit suicide in 1980 than in 2010 but does not seem to have data to suggest such a thing (OK, we admit that the Madrid scene, Moran and jokes could be Naranjito depressive equivalents, but even so, the accounts do not we go ...).

And these figures are more striking when we consider that it is in the 80's when they start to market the new (and expensive ) antidepressants, with the paradigmatic example of Prozac. In medicine we have seen the advent of antibiotics causes a reduction in morbidity and mortality due to infectious processes. Or how the emergence and development of antiretrovirals have been achieved dramatically increased life expectancy in HIV patients. Or how the development of TB drugs TB became a very rare disease. It turns out that the emergence of new (and expensive ) antidepressants, presumably effective and well tolerated ( and, if we did not mention, expensive ) not only fail to reduce the number of depression, but they 1000-fold increase ... We must recognize that depression, a disease for biological neurochemistry nature, behaves more like a sales index powered to infinity for greater glory and benefit of some lucky company (" and why we think of that this comparison ?).

And after these comments, we would dwell on the question of the effectiveness of antidepressants to prescribe (and so many people take). Today, we believe, there remains an unwritten rule of "maybe something help." And because we also note we have used: "a recent match, but I send the antidepressant because maybe something help," you have been kicked out of gigs, but I send the antidepressant because maybe some help " "Their parents have separated, but send him the antidepressant because maybe something help" ... For every difficulty vital, prescribe (and recognize the plural) any antidepressant, often underestimating bothersome side effects such as dizziness, drowsiness, tremors, nausea, sexual dysfunction than common ... And also underestimating side effects very rare but very serious, such as serotonin syndrome ...

Not to mention how we create the role of sick people suffering from difficulties in life that no pill will fix that, instead of having to take up the pieces and find their own resources and support in your environment, leaving our consultations with the message that do not have to work, that his family has to put up if you want to spend all day doing nothing and that has to expect little calm, without taking any decision until a few weeks, the pill will encourage ... And if not encouraged, we will send another ... And if not encouraged, they are changed by two and add lamotrigine ... And if not encouraged and we like him we put aripiprazole, which is also cheaper and safe ... And if we do not like, then we say that you are a hysterical and seeking refuge in psychiatry, but do not remove any of the drugs ...

perhaps exaggerated, but the real base is so real ...

Because if antidepressants in question effectively cured all that we call depression , and also no significant side effects, it would be wonderful (we would take ourselves without hesitation). But what if it turned out are not effective in most of what we call depression but they do have side effects? And not to mention today that price ...

psychiatrists will say that Multiple studies have demonstrated the effectiveness of antidepressants (and please nobody tell us not to believe in the studies but has drug tested and will work, as if there were no placebo effect or bias observer, which seems to be listening to the nearby lava swearing that your detergent cleaner and he knows because he has proven ).

A study published in the New England Journal of Medicine found that in 74 studies registered with the FDA about the effectiveness of various antidepressants, 31% (including 3449 participants) did not were published. 37 studies were published with positive results for the drug tested and with only one positive result was not published. By contrast, studies with negative or questionable results, 3 were published, 22 were not published and 11 were published so that in the opinion of the authors, induced to perceive a positive outcome. In the published literature, 94% of the trials were positive, while the FDA analysis showed only 51% of positive results. Separate meta-analysis of data from the FDA and publications show that the increase in effect size ranged from 11% to 69% for each drug individually, with 32% for total.

magazine PLoS Medicine published a meta-analysis in 2008 to study the relationship between initial severity of depression and the effectiveness of antidepressant medication, based on data provided by the FDA for clinical trials provided by the pharmaceutical industry to gain approval for the indication antidepressant fluoxetine, venlafaxine, nefazodone and paroxetine. The data came from both published and unpublished studies. The meta-analysis included 5 clinical trials with fluoxetine, 6 with venlafaxine, nefazodone and 16 8 with paroxetine, which accounted for a total of 5,133 patients, of whom 3,292 were randomly assigned to receive medication and 1,841 to placebo. The authors analyzed the data, concluded that there was no statistically significant difference in antidepressant response between placebo groups and groups with any of the four antidepressants studied. All groups improved, but no statistically significant difference between active and placebo, except in the most severe cases of major depression, which itself showed an effect that antidepressants placed slightly ahead.

A meta-analysis published in the British Journal of Psychiatry concludes that the studies analyzed show that it is unlikely that there is a significant clinical benefit for antidepressants versus placebo in patients with minor depression.

An article in the British Medical Journal includes a meta-analysis published and unpublished studies of reboxetine. The conclusion is that an antidepressant reboxetine is ineffective and potentially harmful, saying the evidence (correct translation of evidences ) published are affected by publication bias.

A study published in the Journal of the Canadian Medical Association on paroxetine, analyzing published and unpublished studies of treatment of depression in adults, concluded that in moderate to severe major depression, paroxetine was not superior to placebo in terms of effectiveness.

there any other work in the same line but we think it's enough for today. We do not want staff or depressed depress us (lest someone would prescribe an antidepressant because maybe something help ...).

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Reviews (important people) with which we agree

Alberto Fernandez Liria is one of our teachers. His writing substantive and pragmatic concepts of mental illness. clinical implications in the book Facts and Values \u200b\u200bin Psychiatry, edited by Baca and Lazarus, is absolutely essential and should be worked carefully (as we did at various seminars for residents). His two books, written with Beatriz Rodriguez Vega, entitled The practice of psychotherapy and interview skills psychotherapists studied in the context of the Masters in Integrative Psychotherapy at the University Alcala, also marked a significant extent our professional. We pick up an entry in this interview with Alberto by Salvador López Arnal and published in June 2008 in the magazine Rebellion, entitled " In the shadow of the conservative revolution mental health has become in pharmaceutical industry market . believe has a certain interest and reproduced below:

; Psychiatrist, Mental Health Coordinator of Area 3, Madrid and Head of Psychiatry Department of the Hospital Universitario Príncipe de Asturias, an associate professor at the University of Alcalá and director of the Master of Psychotherapy at the University of Alcalá, Alberto Fernández Liria has written numerous papers in scientific journals on psychotherapy, psychosocial rehabilitation, intervention in disasters and violence and the transformation of services for mental health. He has written several books, among which we highlight here: The practice of psychotherapy: the construction of narrative therapies , Desclée de Brouwer, 2001 (with Beatriz Rodriguez Vega); interview skills psychotherapists. Desclée de Brouwer, 2002 (also with Rodriguez Vega) and Crisis Intervention, 2001 (with the same co-author).

say that Alberto Fernandez Liria psychiatrist was to alleviate human suffering wherever it took place. Perhaps that is why one day he went to the former Yugoslavia where he was wounded by a shotgun blast.

I do not know if it is impertinent to express here that had long since I felt so moved by an interview. Both give you are on the fourth or fifth rereading. I remain on tenterhooks. I know well that all the credit goes to Alberto Fernández Liria, but let me steal a 1%, only 1% significant, and that I dedicate to my son Daniel López Martínez. I'm sure, as would Gil de Biedermann (Jaime, of course), you can not make us any harm and also to Albert does not mind at all. Thanks.

Is there a rational and not hurtful use the term "madness"? Are there limits or twilight zones defined bounded rationality and madness?

The term "madness" has several drawbacks. One is that considered stigmatizing. Probably today, "madness" can have positive connotations to which they are not using terms like "psychosis" or "mental illness." The other problem is precisely that "madness" can mean almost anything, which is an inappropriate term when we need to be precise. And to meet conditions for people suffering from mental disorders need to be precise.

As the boundaries between mental disorders and mental health, as the boundaries between sickness and health in general, certainly not because the companies are net defined as a function of many factors which will consider "disease" and what does not. In fact, the delineation of borders, and therefore the performance of mental health professionals, is one of the tasks to be undertaken in the XXI century. But in this controversy, the boundaries between health and mental disorders do not correspond to the rationality and madness because the mental disorder only very rarely results in a loss of reason.

How to define mental illness? Why "mental"? What is here the mind?

might ask also not the mind or what not mental. In fact the Cartesian distinction between res extensa and res cogitans , between mind and body, which has done is making things much more difficult time to understand not only mental health disorders, but the human being and living things in general.

said Kraepelin, often considered the founder of modern psychiatry that mental illnesses are mental illnesses that have symptoms (irrespective of their cause.) A delirium, acute confusional state, is a mental disorder but the cause is poisoning, a metabolic disorder or trauma. In the early twentieth century, Kraepelin did not believe it necessary to explain in his treatise on what he meant by the term "mental."

Today the meaning of the term seems much less obvious. Living things are to the extent they are able to take notice of the environment in which they live and act on it according to what they perceive to maintain their existence. The experience of living a certain level (eg an animal) is the joint action of living beings of a lower level (in this case, cells) that constitute its soma and directs an action in which the body top level as a unit interacts with its environment. The mind would be the process by which such action is organized unit of the body.

What characterizes man as animal is the fact that it operates in an environment that - in the words of English biologist Faustino Cordón - is an environment "stuck for words." In other words, the atmosphere of a man are men, with which it interacts through specific behavior, language. Therefore, their relationship with the environment are, necessarily (or at least what is specifically human) through language. We live a constructed reality in the terms that the language allows and imposes. In some way we live the stories we tell. And we call to mind the scenario displayed the thoughts, intentions, emotions and narratives that organize so that we can recognize as ourselves and recognize others and the world we live in, giving them a sense.

So when can we properly speak of mental disorders?

As a psychotherapist I use to think that talk of mental disorders in two situations. Firstly, when the narratives with which we make sense of our existence are not useful for cooperation with our neighbors because they are not compatible, as with those of a schizophrenic patient who believes that others can read your mind, that the ideas that come to mind have been put there by another or who think they know for certain the intentions of others. This is what happens with the pictures we call psychotic. Secondly, when master narratives which produce avoidable suffering, such as the hypochondriac patient, who can not live without the certainty that any of their bodily sensations is not a sign of malignant disease. They are what have been called neurotic disorders.

But the first criterion - "are not useful for cooperation with our neighbors because they are shareable" - Is it not a difficult criterion conclusion? How do we know, without error or madness, that narratives of this or that subject is not shared and that are not useful for cooperation with their fellow citizens if the subject does not support this intuition of ours?

In practice it is very difficult to agree on a subject raving (has beliefs that, besides not being shareable occupy a central place in the organization of their way of being in the world) having hallucinations (perceiving things that others do not perceive), as, in practice, it is not difficult to agree on one thing or another are have undesirable consequences for him or others in living with others. But, of course, there is no hard criterion. Ultimately we are talking about someone who is excluded from a minimum consensus that we consider necessary. With regard to other criteria, there is no hard criteria for determining when suffering is avoidable. So there is a discussion about the boundaries between mental disorders called comunes2 and normalcy.

"Why do you think that citizens have, say, so much interest in these issues? Why the mass inculcation of ideas, issues and information often grow with so little shame these issues?

The importance of mental health has had on the social debate has undergone important changes over the twentieth century. For example, the introduction of psychoanalysis was a real shock in the early twentieth century, the contributions of psychiatrists culturalist were best sellers in the fifties, and will figure out the kind of questioning of social practices, which contained the madness, it was in the sixties and seventies of the hand of so-called antipsychiatry, the reformers of psychiatry or Michael Foucault and its aftermath.

In the eighties the references to the health or disorders mental outside the specialized fields and be spent only marginal. In the shadow of the great revolutions conservative, mental health care is no longer considered a challenge to the welfare state or a source of inspiration for critical thinking to be regarded only as a potential market in which the industry could make benefits.

psychiatric thought and activity of psychiatrists were dependent then, especially for this purpose. Mental health is no longer thought of as an achievement hardly built through the efforts of individuals and communities to be considered a natural state only threatened by alterations biochemical brain function was expected that the parallel development of neuroscience can explain and even photographed by the equally impressive advances in neuroimaging techniques.

we become psychiatrists prescribing of drugs, and in any case, witnesses and spokesmen for the benefits of the remedies that were vying for new market.

You spoke of Michael Foucault and its aftermath. What are these consequences? Do not you have anything good opinion of Foucault's theoretical interventions in this area?

No, I mean that. I sido un lector apasionado de Foucault. Textos como El nacimiento de la clínica o Historia de la locura en la época clásica han sido importantísimos en mi formación. Si tuviera algún reparo respecto a la obra de Foucault, no sería, desde luego, en sus contribuciones a éste área.

Decía lo de las secuelas, sin ánimo peyorativo, para referirme a autores como Robert Castel. De Castel también aprendí muchas cosas. Castel, como Foucault, a mi modo de ver ha sabido mostrar magistralmente como los gestos cotidianos de la atención a la salud mental reflejan los mecanismos del poder en las sociedades contemporáneas. El problema en todo caso es one thing is that the reflected and another to play an important role in sustaining them. I sincerely believe that the role of psychiatry and mental health care in this is quite marginal. And, in large part, the enthusiasm with which some psychiatrists supposedly progressive welcomed the idea had to do with that, even in the dark side, we gave importance to us that it was a consolation for the modesty imposed on us by day day reality of the clinic. It seems to me that next to the school, television, family, police or prison, psychiatry is quite dispensable for maintenance of order.

And that Perspective I was talking about remains hegemonic ...

Although this perspective introduced in the eighties remains hegemonic, today we have sufficient data to support that has proved a failure: the remedies that were supposed to be increasingly specific for disorders increasingly precisely defined, proved to be anything but specific. Remember that SSRIs, selective serotonin reuptake of serotonin (the paradigm is the Prozac), claimed to have become the "silver bullet" that was against what was supposed to specific alteration of depression, compared with the specificity of the former - And so cheap - tricyclic antidepressants. Today, SSRIs are the first choice pharmacological treatment of depression but also panic disorder, generalized anxiety, obsessive compulsive disorder, the personality disorders, disorders of impulse control and many other . Considering that, in turn, respond to antipsychotic drugs on positive symptoms of schizophrenic patients, delusions chronic manic tables, the psychotic symptoms of organic mental disorders and other, perhaps we could think that, if only consideration of what we can learn from prescribers and clinical work would need to articulate our classifications - or, even better, think about mental health and mental disorders - on new bases.

In recent years there have been some signs that there is a new social concerns and mental health disorders at least in what we call the developed world. Not to mention the proliferation of self-help tools designed to respond to the need to subjectively experienced by multitudes to preserve your mental health. If we only find that institutional manifestations of health and mental disorders have become a cause for concern policy at least in Europe. Since the World Health Organization, the European Commissions and the Council of Europe have promoted new and significant guidance documents, based on some of which were signed in Helsinki agreements that have been committed to health ministers Union.

Some governments, like the British or Scandinavian, have increased funding dedicated to mental health care and have diversified the type of resources devoted to it in a very significant, both as regards attention to serious disorders as common disorders.

The prestigious medical journal The Lancet , Has devoted a series of articles echoing the above and propose courses of action through a series of articles written by a call Lancet Global Mental Health Group, which brings together 38 international experts on the subject echo of the aphorism WHO "no health without mental health."

But there is hardly news that information in the media ...

The mass media have barely echoed these movements. In the media, at this time, which are displayed or self-help or news sections in which the disorder is treated as metal absolutely gruesome, absolutely wrong on the idea that the mentally ill are dangerous (the seriously mentally ill commit actually less violent crime that citizens are not) or that the criminals whose actions we want to distance are mentally ill, rather than simply evil. Probably because accepting that evil exists in our species and our culture, and seek an explanation, is more uncomfortable than attributing its effects to causes that have nothing to do with us.

Let me ask you some questions about what you just said. The first two. You were saying that if we consider that, in turn, to antipsychotics Positive symptoms respond schizophrenic patients, delusions chronic manic tables and others may think that we would need to articulate our rankings, or think of mental health and mental disorders, on new bases. Are you suggesting then that antipsychotics are not effective for the diversity of cases dealt with them?

Absolutely. Precisely what we know, and so we use - is that they are effective. No doubt the efficacy of drugs, but the usefulness of the classifications. I understand that diseases are not, as believed at the end of the early seventeenth century protopsiquiatras who were sent by the directory revolutionary take on the hospitals of Paris, naturally occurring entities whose diversity was to be manifest in his sight by observing, as the diversity of plant species had been deployed in the eyes of Linnaeus. Diseases (all, not only or especially mental) are constructs that allow us to predict the effect they can have the actions of doctors and other healers for certain forms of discomfort for a company that has agreed to grant to anyone who suffers sick role

And on what basis should we think then new mental disorders?

precisely on that. Their usefulness for guiding the activities of healing. Medicine (such as architecture or engineering) is not a science but a technology (Although, as any technology claims to have a scientific basis). And their goal is not to produce knowledge but to produce a social good (in this case health.

disease call a state-unintentional and undesirable, that produced an upset against a society is prepared to articulate a process that includes exemption of duties, provision of special care and healing activities (in our culture, medical) efforts to resolve or alleviate.

From this perspective, the determination of what conditions will be considered as a disease and what not, for each society. So there are societies where certain other conditions are considered normal (and sometimes even desirable) are considered illnesses.

The distinction between disease in general and what is not depends, accordingly, a decision that would be better understood as a policy or, in any case, cultural as a result of a natural science research.

The distinction between different diseases makes sense insofar as it serves to implement various procedures and to make predictions about what the results obtained with this. The Maya know what to do and what to expect to happen with the ghosts, and what to do with the evils thrown or ontonil k'ak'al or ti'ol ek. Our families and our doctors know what to do and what to expect to happen with chickenpox, and what to do with Down syndrome, tuberculosis or panic attacks. Therefore, even if they have the same causal agent, chickenpox and herpes zoster are different diseases.

According to this way of seeing things, we could say that in our culture constructs diseases are related to conditions in which an individual experiences discomfort, for which there is consensus that the idea should be put in place a procedure that includes the involvement of the health system, and allow to make predictions about the actions of physicians.

No morbid species hidden in some part of nature waiting to be embodied in sick. Nothing is beyond sick. It is the action of doctors, and expected results emanating therefrom, which distinguishes some other diseases. The claim that a patient is one who goes to the doctor, is more than a tautology. There is nothing surprising the fact that if we want to study the epidemiology of mental disorders we should resign ourselves to the definition of psychiatric case should be in terms of one patient suffering from an upset against the doctors suggest a method of treatment or care.

If we accept this hypothesis, the logical thing is to build our nosology looking more to the constraints of the intervention to the observation of symptoms.

you elaborate a bit. Do you mean with this last statement.

It's not that there is no other medical disciplines that have lost their direction unless psychiatry. Breast cancers are not classified by the hardness or the proximity to the areola of the tumor. They are classified into grade I or grade n as the practice shows that it is the expected response to each of the procedures available to act on them. And this classification allows to determine the protocol to be applied to a given patient and what to expect to happen with him (which seems likely in view of what happened with other similar patients). Pragmatism has taught surgeons oncologists to guide your thinking of the intervention to the symptoms rather than the symptoms to the intervention.

In psychiatry the exact opposite is happening today. Possessed by what I like to call the illusion of Pinel (one of these prtotopsiquiatras to which I referred to earlier) psychiatrists strive to observe the symptoms hoping that these (conveniently passed through the cluster analysis) to draw their own institutions those which someone (the pharmaceutical industry, perhaps?) then find appropriate remedies. Attempts to find more and more specific remedies for getting better defined pictures have failed. More specific remedies (before we mentioned the case of SSRI antidepressants) have been applied for paintings that are unrelated to each other in our nosology. And this has happened only with psychotropic drugs. It is well known for Christopher Fairburn, who provided intervention for placebo to be compared manualized cognitive-behavioral therapy for bulimia nervosa decided to use the manual of Klerman's interpersonal therapy for the treatment of depression. What happened was that, although cognitive-behavioral therapy produced better results at the end of the 18 sessions of treatment, results at 6 and 12 months of patients who received interpersonal therapy (which continued to improve after completion of therapy) were even better. Thus, Fairburn discovered (not invented) interpersonal therapy for bulimia nervosa. Something similar had happened before with an antidepressant such as clomipramine.

We can be proud of such discoveries. But, even help us to better serve our patients, which ultimately shows is that in our work as classifiers has not responded to our expectations. We'll have to ask which lessons can be learned from it.

So you think that the research has been directed by this bias.

Research in the field of psychopharmacology has been relatively corseted by this bias. In the field of psychosocial interventions, the effects are still devastating. Guided by this idea is to organize research on the effectiveness of psychosocial interventions (and, subsequently, to establish indications and payment) from the categories defined by the shiny new consensus classification system. The various lists of empirically validated psychotherapies that have brought together various groups (most notably the American Psychological Association) are configured in this way, and have the various categories of DSM headings under which interventions are listings usually begin with term cognitive behavioral therapy or interpersonal therapy, and end in the name of the category or subcategory.

Until the groups led by Beck and Klerman (whose guidance refer these prefixes) decided, in the late 70's, submit their work to the test of randomized clinical trial, there was a consensus among psychotherapists about that the diagnostic categories, such as sketched classifications were not a useful guide for practical work with patients. Today, many systems have been proposed constructs that they are, and have achieved, often through a fine job of research, acquire empirical support. But the lack of correspondence between these systems and classifications to use this work makes it difficult to pass the filter neopineliana the psychiatric community is organizing itself to impose, under the banner of evidence-based medicine, all information that may reach members.

What diseases are constructs, you said, forms of discomfort for which the company has agreed to grant to anyone who suffers from a sick role. Is not that very idealistic vision, very sociologist? Do not forget you too much to determine what is real? This is not to argue that our theories are rubbings of reality but then to say that illness is a construct ... Jacques Bouveresse sick if you read and I promise you will not build your illness. Is there not an epistemological break too? On the other hand, what society is that you agree to this?

I do not think that is neither idealistic nor sociologist, because social constructions are not produced on the vacuum. By following his example, which can happen to Jacques Bouveresse (hope not) or any other, is that the emotion of anger to move it offensive text is translated into a very important stimulation of the autonomic system may even to even alter an irreversible operation or structure of any of the cells that constitute the soma (This Faustino Cordón sick calls him up and down; ward on bottom-up change when the malfunctioning of certain cells - by the action of a toxic, for example, prevents them from making their necessary contribution to the emergence of our organism animal). Now if we say that this is "sickening" (and not "possessed", "feeling that one is in disagreement" or simply "turned to righteous indignation") is because there is a consensus call that disease. If this is so Bouveresse will give you the floor, read not to attend a conference that was scheduled for today, take her mother to bed broth and cut-outs and treatment will be prescribed some of which pay between all our taxes.

You are president of the English Association of Neuropsychiatry? What is Neuropsychiatry? What is the status of this scientific discipline in our country?

The name of the association is the one that put its founding in 1924, a brilliant generation of psychiatrists who considered themselves followers of Ramon y Cajal and who made contributions the field of neurology and psychiatry in the two disciplines were not distinct. Today the association has the subtitle "Mental Health Professionals" and is mostly by psychiatrists, clinical psychologists, nurses and other professionals who are inter-teams from which today makes the care of mental health problems .

And what is the mental health situation in our country? Do you think progress has been made in recent years?

the past thirty years we have gone from a system looked at the mental hospital as an alternative care for severe mental disorders and neglect or a caricature of care for common mental disorders (such as anxiety and depression), some complex network-based systems of care that integrate multiple devices such as centers mental health inpatient units in general hospitals, day hospitals, psychosocial rehabilitation centers, day centers, therapeutic communities, alternative forms of sheltered housing or home care ... In short you are testing alternatives that are new. And, of course, new problems are emerging ...

In general, there is an agreement between the regions (which are those with skills in health care) and the European bodies on which model of care that should be developed. This is the agreement that reflect the European documents previously referred and which is embodied in the Mental Health Strategy in the National Health System, which was adopted in 2006. The problem is that the degree of development of the various elements of the model is very different in some other regions and, in fact, there are significant disparities in the resources devoted to the care of people with mental disorders and the benefits they receive in one and the other communities.

I think the model based on community care is surely preferable to the institutional and coercive model that preceded it. Although, as I said, this has generated new problems including the psychiatric or psychologizing of the problems of everyday life and the illusion that the current malaise can be processed rather than encouragement to act on the environment, not the least. Nor is the health improvement is envisaged primarily as an opportunity to develop a market and aims to finish made conditional to the primary purpose of serving to make profits. Or that, in countries like ours the goal of keeping the community for people with severe mental disorders at the expense of the effort of some families increasingly less responsive to the traditional family model aunaba resources of three generations in a collective effort from which all benefited.

"current malaise? What do you mean by current malaise? Moreover, you say, it is envisaged the improvement of health as an opportunity to develop a market and profit taking. Could you specify a little more?

I refer to the discomfort, for example, that after death of a loved one. Healthy is experiencing. Precisely what would not feel anything morbid or feel anything.

In a market economy like ours there is a remediable discomfort using a product that can be sold is an opportunity to make profits by selling that product. And that chance is what determines, at times, the increased focus by the medical community to certain diseases. Or the idea that there may be, for example, use a sort of "cosmetic" of the antidepressant. If someone says he is better off taking an antidepressant Why not sell?

What improvements would introduce you in these areas? What aspects seem more urgent rectification?

must consider that the model advocated in the documents to which I referred, presupposes the principle that mental health, as health in general, is a community responsibility and the society as a whole to which corresponds the first effort to promote it and prevent its loss, and then to address the best way possible to people who have failed to keep or suffer the consequences of their loss. Ie brings us, somehow, to the idea of \u200b\u200bwelfare state is far from proposals that have been deregulated widespread on the planet under the dictates of the World Bank, the Intenational Monetary Fund or other personifications of capital, and have been dutifully carried out by governments that have not always been conservative (in Spain the policies that were developed in the U.S. and England by Ronald Reagan and Margaret Thatcher were enthusiastically introduced in our country by the governments of Felipe Gonzalez). To the extent that the welfare state threatens to become regarded as one of the extravagant dreams of the sixties, the model health and mental health care that was consistent with it, it will be unsustainable.

Si we ignore the above, Today, we can say that most of the regions, the system has almost all or almost all the elements that should be. The fundamental problem is that the doses in which it is. Berlin, with not much more than a million inhabitants, has more than three thousand people in sheltered accommodation for people with severe mental disorders. The area that I lead in Madrid, with three hundred and eighty-five thousand inhabitants, is barely forty. We have a third of the psychiatrists or clinical psychologists Scandinavian countries have per hundred thousand inhabitants and twenty to forty times less than nurses working in the community than the English.

must be assumed that meet the conditions that we now know are possible in people with mental disorders is expensive. Surely it is more expensive than transplanting livers or faces or to hip or knee. But it is much less brilliant. Advances in surgery occupy the front pages of newspapers. Today (as yesterday and tomorrow) also visited someone in your house to a schizophrenic who, otherwise, would lead a subhuman existence in an institution, in the street or in jail is not news. And less in a time when passing laws that allow lock with no guarantee human beings for the sole crime of being born in another site provides votes.

So unscrupulous, so inhuman you see our political leaders and managers of media (mis) information?

Absolutely. No malice is a question of individuals but of irrationality of an economic and political system.

Otherwise, you spoke of visits to homes of schizophrenics. Also your visits to our homes might add. What kind of life can lead a schizophrenic? Does the term does not include cases very different?

know that many types of life. And to a large extent which of them will take depends on what we do to address them.

And you are right, probably what we call "schizophrenia" encompasses many different conditions, and surely the people we call "schizophrenia" are as different as people enter each other that we call "rheumatic ".

Do you know any country that is perhaps not a model but a landmark in the way it treats mental health patients?

We should compare ourselves with countries in our immediate environment. In Europe, some governments like Britain's, have increased in the last few years, the funds dedicated to mental health care a very significant way, setting up programs for those who have seen the light, in addition to the significant resources that already existed before, the assertive community treatment teams, the crisis care teams or teams in early intervention. On July 31, 2007, the health minister of that country announced the launch of the first teams of the plan by which the NHS will acquire ten thousand psychotherapists estimates that are needed to provide psychotherapy as a routine treatment for patients with anxiety or depression. And the latter do so because, according to a report from the London School of Economics may pay thereby saving on pensions if their work, get one month on average reduce the incapacity due to these disorders the United Kingdom.

For psychiatry do you have any interest in the theories and practices arising from psychoanalysis and its different currents?

Historically, psychoanalysis had an irreversible effect not only on how to look at mental health and its changes, but the way in which our society is contemplated Northwest itself. The practice of psychoanalysis as conceived by Freud and as is still practiced by orthodox psychoanalysts dealing with today, unquestionably, a marginal rise in mental health care and its alterations. But many of his ideas and his discoveries are the basis of the ways to clinicians who work in the public sector both with people with common mental disorders as serious patients. And some of their developments have been confirmed by any of the discoveries of neuroscientists who study the development, which very often have built their hypotheses based on observations of psychoanalysts.

Could quote us an example of the latter consideration?

The clearest is that of child psychotherapists who have completed developments producing what has been called relational neurobiology, and Stern and Siegel (whose book on the development of the mind just translated into Castilian) have been able to find links between what we know about the development and operation of the central nervous system and the findings of attachment theorists or those who have studied the effects of traumatic experiences mental health.

psychiatry Can or should talk about psychiatric trends? Is there a dominant paradigm and accepted within the scientific community?

can speak of psychiatry as one can speak of medicine or architecture or engineering of bridges. There is a body of knowledge and practices on existing agreements and points of view on issues that we are considered well resolved or are debatable, because psychiatry, medicine, architecture or engineering must produce a product that must be considered useful and acceptable to society is not monolithic and whose needs change.

The moments in which psychiatry and psychology were a battleground in which schools faced were based on incompatible assumptions, languages \u200b\u200bspoken and proposed untranslatable irreconcilable objectives, are obsolete.

This has been associated with two phenomena that, in my view merit a different assessment. The first is that there has been a kind of integration movement has forced us to clinicians (driven by the dissatisfaction to find that the results obtained from the dogmatism of any school were not optimal) to try to incorporate the findings from those of other schools, questioning aspects of their own or try to think outside no. This has not only within, for example, the field of psychotherapy. There has been, sometimes at the boundaries with other disciplines, so that, for example, some of the latest advances in psychotherapy have drunk findings of geneticists and neurobiologists or talk with them (and vice versa). This - something that Freud dreamed of - I think something very positive.

At the same time, mainstream psychiatry in the eighties he embarked on a kind of embodiment for the profession thought. After noting that the existence of psychiatrists in each school and each country sometimes used identical terms to describe completely different phenomena, and others, called differently to the same things, the American Psychiatric Association on the one hand and the World Health on the other, endeavored to build a common language, a classification of mental disorders that define operational criteria and do not use this theoretical constructs that could grind to someone so that applying the manual, we were sure that any psychiatrist in the world, belonged to the school he belonged, was to use the same term at the same table clinician. This led to the so-called DSM and ICD manuals.

What role do these manuals psychiatric?

Initially intended to serve both manuals for statistics. But then, what should have been an instrument has become the organizer of psychiatric thought if not the excuse to avoid having to think. Furthermore, diagnostic categories such as sacred texts have become the focus of research activity, built on the idea that one should be a specific remedy (which, as I said earlier, very little has been close to the truth). But on this basis, we designed the building whose practical result has been that thought has somehow been expropriated from clinicians, to which the problems will get resolved by the managers and the pharmaceutical industry, on the other hand, dominate the training, research funds distributed and controlled to the publications, thus perpetuating the cycle.

Who says you dominate the training, publications and research funds distributed? "The pharmaceutical corporations? Do policy makers? If so, why allowed? ¿Dónde está la autonomía y desarrollo libre y creativo del conocimiento?

Las corporaciones farmacéuticas, los gestores políticos y las empresas que controlan el gran negocio de la producción y la publicación científica, como Thompson-Reuter, propietaria del concepto de “factor impacto” del que se valen nuestras universidades e institutos de investigación para seleccionar los investigadores.

Insistiendo sobre lo anterior. Sugiere usted entonces a los profesionales de la salud mental que arrojen los dos manuales citados -el DSM y el CIE- al archivo de los libros inútiles y/o malintencionados.

Not exactly. And certainly not malicious. These instruments have played a role in the generation of a common language, useful for many purposes (administrative, epidemiological ...). But not suitable for others, like the development of new therapeutic drugs

Is there some anti-psychiatry of the 60's and 70's? Should we continue to claim the opening of mental hospitals, perhaps his humanization? Do you think there were excesses, which Laing or Basaglia, for example, over-politicized medical field?

criticism that made people like Laing, Cooper, Szazs, Goffman Jervis (who had the first news of an interview in El Viejo Topo ) served as the engine changes that are now irreversible, although academic psychiatry these are now forgotten authors. Surely there have been other factors that have contributed to make this happen, but today nobody is surprised that the systems of mental health care to dispense altogether with something similar to what they were (and unfortunately are still in some places) asylums. And family interventions in psychotic patients, for putting a case, they appear as recommended in all clinical practice guidelines. In this there is a debt to those authors as there is, in a broader field, in May 1968 on many of the things that we consider normal in our society. Laing was a brilliant psychiatrist who recovered for fruitful traditions psychiatric thought had been abandoned after World War and that he recognized as creative as some new contributions. And a good writer.

Basaglia 's case and Democratic Psychiatry in Italy is even more questionable. And I do not think what they did was to politicize the field of health care. What they did was use a good policy instrument built - the law forbidding asylums 180 and now Berlusconi has proposed to revise - to achieve an objective that could not be achieved without policy intervention.

usually left in place too much emphasis on environmental issues and we tend to perceive with slanted eyes and ears tuned few tests that point to genetic inheritance and the like. Do you see this error, blur, dream, theoretical confusion? Is or is not in the genes? To be more specific, "a schizophrenic born or made? Is it society that makes us sick?

Under this bias is the bias depending on what interventions we can do about a particular disorder must be of the same nature (biochemical or psychosocial) that their cause. And some leftist tradition, has been easy to imagine interventions in the social environment, because that's what we were doing for other purposes in other fields, and hard to accept the resignation that would impose assume that basic changes were coming and marked unmodifiable by nature, it seemed that one begins to accept this illness and has to stop accepting it for class differences, or something. But the attitude to which it refers, and this underlying prejudice, no more than that, a prejudice, a tic that, in fact, have acted as obstacles to critical thinking.

What we know today is precisely the interaction between the inherited and the acquired is highly complex. In conferences and publications is very common to find geneticists fascinated with the discovery of the environment and psychotherapists with the genetic and inherited.

For give you an example that illustrates this: The primate studies have provided an animal model for borderline personality disorder. In a 2005 article on personality disorders, psychoanalyst Glen Gabbard, considered the main psychodynamic psychotherapy spokesman for American, we summarize some experiments carried out with rhesus macaques. Between 5 and 10% of rhesus macaques are likely to carry out dangerous stunts which severely damaged and exhibit since before puberty socially unacceptable behavior by the herd that lead them to mistreat the weaker monkeys and risk recklessly with the strongest. The presence of this type of behavior appears to be related to the metabolism of serotonin. Has detected an inverse relationship between measures of metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid, and the propensity for these impulsive behaviors. But inherited susceptibility appear to change with attachment experiences: the monkeys raised by mothers consistently showed a higher concentration of this 5-hydroxyindoleacetic acid that have been created without peer and mother. The gene for the serotonin transporter has variations in its promoter region resulting in two alleles (variations) differ. The short allele confers reduced efficiency for transcription of this promoter region, which could translate into a decrease in serotonergic function. However, as Gabbard says, what people who have investigated these monkeys have found is that monkeys with the short allele do not differ in 5-HIAA concentration with the long allele if they are raised by mothers while they do if they are raised by peers. Similarly, macaques with short allele exhibited more aggressive behaviors many of the long allele if they are raised by peers and this difference between those raised by mothers, who both have the same level of aggression than those raised by peers with long allele . Even more striking are the results of an experiment in which it makes available an alcoholic beverage monkeys. Of the monkeys raised by peers, the monkeys with the short allele show a greater propensity than others to consume greater quantities of alcohol. However, among those raised by mothers, the long allele monkeys consume more alcohol than the short allele, it seems that would show that the short allele of HTT gene may determine the presence of disease in monkeys with suboptimal parenting experience while it could be adaptive in monkeys with a secure upbringing. Gabbard notes the importance of these findings for psychotherapy, as this could be understood as one of the experiences that modify the expression of genes in human action.

But you're talking about monkeys, primates ... We had not talked of human beings and their unique language for example?

Well, we are just a few primates that are capable of speaking. Primates in which, precisely why the relationship with the environment is even more complex and subject to mediation.

right. Continue, if you will, with his previous explanation.

On the other hand, decoding the human genome has been, without doubt, significant progress of biologists and treatment options open, until recently, unsuspected, for some diseases. But comparison with other genomes decoded parallel (from the fruit fly the chimpanzee), the illusion becomes unsustainable, there not long ago who proclaimed without shame, that, somehow, that tape containing the target DNA of the organism that arose from the joint action that formed cells. In an excellent article published in 2005, Kendler geneticist criticized some of the myths that physicians in general and psychiatrists and clinical psychologists in particular, we have assumed about the genetics and relocating in place the knowledge gained in recent years, invites us to turn our eyes to the environment and especially the complex, bidirectional relationship between them. According to this study, no you do not already know what is the schizophrenia gene. Is that we know not only that there is no gene for schizophrenia, but if we are to understand the role of genetic life in general and the sick in particular have to leave the optical Kendler preformationist called (according to which life is not only a development of the content of genes) and build complex models that allow for the interplay of heritage with the environment (or, better, middle). Kendler suggests that we might make more sense to find a gene for something like the "novelty seeking" or "harm avoidance", which today are considered character traits or temperament, and track the interaction of these features with the possible environments in which development can occur, which for an entity such as schizophrenia, defined as a disease entity existing in nature and that, somehow, is embodied in one patient.

Let me ask with words and thoughts of others. You talk about environment, emotions, social environments, community. How do you think that the conditions involved in the biochemical development of an individual? Is there, like it or not, very consistent, regardless of social and emotional environments, a 1 in 100 individuals with schizophrenia, for example?

Because what development theorists to which I referred earlier have taught us is that experience shapes the central nervous system development in their structure and function making potential is expressed or not inherited. Probably the differences between the environments in which human beings live up contemporary societies are not so important as to produce large differences in the amount of people who develop schizophrenia and tables that the prevalence of this disorder is more or less than 1 % in all countries (Some have said that schizophrenia is the price you paid for the human species by the development of language). But know that the prognosis of schizophrenia (in terms of quality of life) is better in rural societies in urban areas. And that these are different depending on how care systems.

I change the subject. Why do so many soldiers (and many mercenaries) involved in wars, like the current war in Iraq invasion, they need psychiatric treatment and psychologist? What happens in their minds, what happens in their souls ?

know that certain experiences that we call traumatic, characterized by a questioning pose of basic beliefs (others are not bad, that the world is predictable ...) that allow us to face daily life can affect mental health. We also know that most people who suffer are not chronically altered. The metabolism of these experiences is easier for people who live in environments that may confer a sense. The soldiers or mercenaries, when again suffer environments in which their experiences are strange, not shared. That makes them more vulnerable. Having described the clinical entities that can result in the alteration and if any become the subject of compensation, it has paradoxically become more visible and added a factor for the chronicity of these disorders.

Can mental illness be cured? How does the chemistry in these cases? What cure when cure? Why are effective in some patients certain drugs and other needed instead try other means?

What we call common mental disorders such as those related to anxiety and depression that can affect some time in their life to one of every four people, or refer to (albeit more slowly) without treatment . Serious mental disorders such as schizophrenia or disorder bipolar, do not talk about "healing" but its course, and the impact they have on the lives of people, greatly improved with treatment, which today generally must include a drug and a psychosocial component.

As for why some people respond to some measures and others not, we know for sure, beyond the illusions of what is called evidence-based medicine is that treatment can not be " fits all "and that, as I like to say when I talk about training future professionals, if I were to choose a single ability to develop these, would choose to customize, that of tailor the intervention to the particular characteristics of each patient and their environment.

"A mental patient can live a life, say, standard?

Today recovery (that reintegrate into normal life) is the objective that is considered acceptable in dealing with serious mental disorders. Since then recovery may be required in severe mental disorders, as a rule, care for life. But recovery is possible.

What are the main tasks performed by the National Association of Neuropsychiatry que usted preside?

La Asociación Española de Neuropsiquiatría aunó, desde su fundación en 1924 su papel de sociedad científica con el de elemento de denuncia y lucha por la reforma del sistema de atención a la salud y la enfermedad mental. En 1977 cuando una candidatura de izquierdas (formada por los psiquiatras que habían participado en los intentos de reforma que se produjeron en condiciones a veces de extrema dureza, en los últimos años del franquismo) desplazó a los psiquiatras que la dirigieron desde después de la guerra, se convirtió en una asociación interprofesional, incorporando profesionales no psiquiatras, lo que dio lugar a that psychiatrists displaced, more linked to the academic world, was located in another association called the English Society of Psychiatry. The NEA has played a critical role in driving the reforms he has experienced over the last thirty years the system of mental health care. Today, NEA aims to keep those original identity, while maintaining independence from both industry and government. Compared to other professional associations has been characterized by its defense on the entire system of public health care and the community model and has placed particular emphasis on the importance of psychosocial interventions, the need to understand mental health care as a process that requires inter-branch and as a field of confrontation between corporatism. And above all, it aims to maintain a critical attitude. He now faces the challenge of adapting to a new European framework in which the role of scientific associations will be important and very different from the traditional. And it is requiring no little imagination and effort on issues such as performance scoping of mental health professionals (and therefore the concepts of health and mental disorder), the generation of criteria for clinical practice, diffusion of ideas and alternatives, collaboration with other entities such as Consumer and family associations, protection of human rights and the fight against stigma still experienced by people with mental disorders.

As you know, in English psychiatry from the forties, we quote Mr. Vallejo-Najera, a diagnosis of insanity Republican political commitment and red. How could it come to such a thing? How a scientist can defend hard, and with the known consequences, a theoretical conception of these features? So strong is the ideology, political power, the fascist fanaticism?

I'm not sure that Dr Vallejo Nájera was exactly a scientist. And, if I hurry, I'll tell it (even though she is stupid) I do not think of things more monstrous to which has led fascist fanaticism.

So far, the interview to Salvador López Arnal Alberto Fernández Liria, to whom we express our admiration and respect.