精神病司法鉴定1389例分析

目的 探讨我院进行的精神病司法鉴定案例特点。方法 对我院1987～2003年进行的1389例鉴定案例，按责任能力、性防卫能力、因果关系、民事纠纷、交通案件等鉴定类型进行回顾性分析。结果 在1389例鉴定中，疾病种类以精神分裂症、精神发育迟滞为主；鉴定类型以责任能力鉴定、性防卫能力鉴定为主，申办户口等的鉴定有增多趋势；犯罪类型以暴力犯罪为主。结论 应加强对司法精神病学的研究，尤其暴力案件、民事纠纷的研究，以适应时代的发展。     

Culture and history in psychiatric diagnosis and practice.

A brief review of the history of Western psychiatry underscores how happenings in Anglo European societies during the early modern and modern era impacted on regional populations in the midst of profound demographic, social and political economic change. Such factors along with cultural conventions created an amalgam of behavior problems: social responses to these under the aegis administrative bodies gave rise to the discipline and profession of psychiatry. Central tenets that we take for granted as facts about psychiatric disorders (e.g., their manifestations, natural history, diagnosis) were shaped by historical and cultural influences. Psychiatry may outline a science of the psyche and its disturbances but it also reflects a cultural interpretation about personal experience, responsibility, social behavior, and the requirements for social order. The cultural character of the psychiatric enterprise itself, just as much as the characteristics of its disorders, constitute the subject matter of cultural psychiatry. Events during the late eighteenth and nineteenth centuries in Anglo European societies gave rise to psychiatry. First, there took place the differentiation of psychiatric disorders from the pool of human social and behavior problems. Second, and in relation to this, a segment of the medical profession was accorded (or appropriated) a social mandate and acquired an obligation to treat victims of mental disorders. The historical sociology of psychiatry constitutes one aspect of cultural psychiatry. The second covers developments during the latter part of the twentieth century. At this juncture, psychiatry became the target of labeling theorists in sociology, cultural relativists in anthropology, antipsychiatrists from within the discipline itself, and revisionist and critical historians of psychiatry. An outgrowth of this is the perspective that underscores the important role played by values, ideas, and world-views in how individuals experience and carry out their lives, phenomena that are critical to the expression, interpretation, diagnosis, and treatment of psychiatric disorders. That the science and practice of modern psychiatry incorporate an ethnocentric, Anglo European bias or slant on psychopathology is an integral assumption of cultural psychiatry. By describing how other non-Western systems of psychiatry have operated, for example, their theories and practices, one gains a further appreciation of the important role of culture in shaping Western psychiatry. This is taken up in an article by Fàbrega elsewhere in this issue where concepts and practices of traditional Chinese and Indian medicine that pertain to mental health and illness are reviewed.     

Nosographie et classifications des maladies mentales dans l’histoire de la psychiatrie

Objective

Retrace the history regarding the classification of diseases, notably mental diseases, from the birth of psychiatry at the beginning of the 19th century and up to the 10th revision of the International Classification of diseases published by the WHO (in 1993).

Method

Study the classifications proposed successively by the nosographists during this period.

Results

In the 18th century, physicians classified diseases in the same way as animal and vegetal species (Carl von Linné). In the 19th century, following several attempts in France and Germany to classify mental diseases according to known or suspected aetiological and pathogenic factors (B.-A. Morel, Griesinger), psychiatrists classified psychosis and neurosis according to their clinical symptomatology and their development over time, from their onset up to the terminal stage. In 1893, J. Bertillon proposed a “Nomenclature of diseases” during the International Congress of Statistics in Chicago that permitted their classification, so as to classify-collect statistical epidemiological data on international level. Revisions were made between the two world wars by the Office of Health of the Society of Nations (Geneva). Following the foundation in 1948 of the WHO, it was the latter that continued the revisions of the International classification of diseases (ICD), Chapter V (F) of which is dedicated to disorders.

Discussion

The debate on the question of classifications in psychiatry has always taken place during the World Congress on Psychiatry since its initiation in Paris in 1951. In 1976, during the sixth congress in Honolulu, a resolution was adopted requesting the national psychiatric societies that had a classification of mental diseases to revise the latter so that they tallied with Chapter V(F) of the ICD. The American Psychiatric Association revised its Diagnosis and Statistical Manuel of mental disorders (DSM) and published the DSM III. In France, a group of pedopsychiatrists published a French classification of Mental disorders in children and adolescents (Classification Française des Troubles Mentaux de l’Enfant et de l’Adolescent- CFTMEA), the last revision of which was published in 2012 (CFTMEA R 2012).

Conclusion

This study shows that it is not possible to propose a classification of mental diseases, in particular according to the development of psychiatry at the time it is drawn up; it can only be of value within the cultural context of the country in which it is to be used.     

La psychiatrie et les disciplines extrinsèques. Ouvertures et compositions

ObjectivesPsychiatry as a discipline is oriented towards the other and towards otherness; not only that of the patient and of their psychological issues, but also for the alterity of external knowledge. Recognizing its own limitations and its inability to think alone, psychiatry, whose specific knowledge is undoubtedly quite limited, has since the beginning turned to other disciplines. This article does not try to propose a new model likely to articulate this conceptual heterogeneity, but tries to understand how this movement of opening towards other disciplines is carried out. Psychiatry undeniably finds a richness in this, but does not its subservience to currents that are external to it risk accentuating its dissolution and making its identity disappear?MethodBased on the distinction proposed by G. Lantéri-Laura between intrinsic disciplines (i.e. clinical disciplines such as neurology, psychoanalysis) and extrinsic disciplines, which use a theoretical elaboration that owes nothing to clinical engagement with subjects (such as anthropology, history, or linguistics), this article will endeavor to show the contribution of extrinsic disciplines throughout the history of psychiatry, using a number of specific cases.ResultsThis article describes several ways in which psychiatry is linked to extrinsic knowledge, focusing more specifically on the human and social sciences and on history. Firstly, we study the movement by which psychiatry seeks support for its practice, an ethic of care, and even a critical ‘third eye’ that can offer it this perspective on a practice that is often decried. Secondly, this study proposes to examine the extent to which psychiatry, through the knowledge that it isolates concerning the question of madness, opens up by itself to a questioning of humanity that can be taken into account by other disciplines. Sociology shows, in particular, how clinical categories can be linked to the prejudices and ideals of a culture and an era. History shows how an event such as Pinel's liberation from chains can benefit from historical interpretations, the meanings of which are never exhausted.DiscussionPsychiatry is inspired by other knowledges, but this borrowing is often based on displacements that reflect the need to adapt to clinical issues. This extrinsic knowledge is never imported without transformation and without some infidelity.ConclusionRe-examining what is most obvious, questioning what seems most customary, these are the benefits that psychiatry can obtain by choosing to decentralize and to call upon disciplines extrinsic to the clinical. The inclusion of the human and social sciences in the understanding of psychological disorders is now well established. The dialogue that results from the meeting of heterogeneous disciplines is not intended to lead to a consensus. The clinical practice of psychiatry retains strong specificities linked to the exercise of the encounter with mental disorder. The resulting knowledge is irreducible to other disciplines. The psychiatric act is based on a responsibility incumbent on the clinician alone, irremediably divided by the issues he or she must face.     

Risque et existence : un éclairage du risque thérapeutique en psychiatrie

Risk management is a principle of political action, an organisational strength that keeps increasing in our modern societies. In medicine, the benefit/risk ratio precedes any therapeutic treatment. Psychiatry also confirms this trend. It is undoubtedly desirable in many aspects. However, the notion of risk cannot be understood under the unique and technical perspective of an undesirable event to anticipate. Risk management is not limited to a predictive and preventive refinement, but disturbs the situation of the individual in its environment, granting him a new responsibility, changing his possibility to live in the world and take shelter in it. Beyond these anthropological aspects, from a phenomenological psychiatry perspective, the matter of risk is closely related to the question of authentic existence. Thus, the risk not only appears under the perspective of an undesirable event, but also as a founding instant of the existence in the world and within oneself. Therefore, the therapeutic project of psychiatry could also intend to recognize and promote a certain type of risk, the risk of any existential commitment. The therapeutic risk in psychiatry thus takes a new ontological dimension.     

La mondialisation de la psychiatrie et la Société Médico-Psychologique

Ever since the first World Congress of Psychiatry was organized in Paris in 1950, the French Société Médico-Psychologique, who played an important part in its organization, has kept profitable exchanges of views with national societies who are members of the World Psychiatric Association. These exchanges revolved around the main issues which have marked the history of psychiatry in the second half of the twentieth century and the beginning of the twenty-first: The rise of pharmacology in psychiatry, ethics, classifications of mental diseases, protest movements, clinical research, family and mental patients associations, legislation, medicine of the person and so on. These questions were debated in following world meetings, including the sixteenth congress which recently took place in Buenos Aires, but also during symposia organized by national societies in their own capital cities. Minutes of such meetings were often published in the Annales Médico-Psychologiques. It is to be hoped that the Société Médico-Psychologique, being one of the world's oldest psychiatry societies, will be able to make present French psychiatry known in the world, since it carries the legacy of a long tradition of research in psychopathology. The present circulation of the Annales Médico-Psychologiques shows that readers in distant and often unexpected countries are curious to discover it.     

Histoire des théories et des pratiques thérapeutiques dans la psychiatrie contemporaine (1950–2004). Progression des connaissances et exigence d'interdisciplinarité

The developments of knowledge, and the multiple mutations in our societies as well must be taken into consideration in the understanding and approaches of mental illnesses. The integration of these new data raises epistemological problems. New maps for the mental life are required, as a first step towards a new epistemology for psychiatry.     

De l’esprit et des modes de classification en psychiatrie

A classification is a system of classes designed to represent the mental disorders according to a fixed rule. The author stresses the paradox of the growing number of mental disorders versus the absence of a natural classification and then defines what a classification is, why it exists, how it is established, and what its evolution is like.The principle of classification is similar in all sciences, but it is more complex in psychiatry, because of the nature of the objects studied.Classification seems desirable for general reasons of representation, communication and action, as well as for singular reasons related to person and milieu which incite to elaborate it.Its construction depends on the agonistic-antagonistic paradigms chosen (relations which are real vs virtual, formal vs dynamics, qualitative vs quantitative) and on the way the data are collected (linear or circular steps, ontological or operational bipartition, type of reasoning).Its evolution shows its successive openings, passing from the concept of disease to the concept of grouping of criteria which are associated according to the underlying dynamic processes and finally to combinations of functional disorders.A conclusion leads rapidly to the intrinsic and extrinsic consequences.     

Some resolutions in difficulties of postgraduate psychiatric education in Japan]

1. Board Certification System of Psychiatry There was a heated debate about "Postgraduate Psychiatric Education and Board Certification of Psychiatry" in the annual meeting for the Japanese Society of Psychiatry and Neurology held in Nagasaki in 1968 and in Kanazawa in 1969. The oppositions of young psychiatrists were as follows; 1) Issues of low cost of medical expense as government politics, social protect politics from psychiatric patients, and improper management of patients in mental hospitals should be dealt before making Board Certification System of Psychiatry. 2) Management of the Society of Psychiatry and Neurology dissatisfies many psychiatrists. Board Certification Systems started in many medical societies from 1969 to 1987. Main nine departments except psychiatry started the system. In 1987, the Japan Association of Chairmen of Department of Psychiatry of Medical Colleges (JACDPM) proposed a program for a postgraduate course. The Japanese Society of Psychiatry and Neurology (JSPN) formed the Committee on Psychiatric Education in 1987 and Working Group on Accreditation Program (WGAP) in 1991 under the Committee of Psychiatric Education. After intensive discussions on the Board certification, the WGAP reported a summary of their discussions in 1994. The essence of the WGAP recommended model for the Board of Association was as follows: Minimal Requirements Outline Training Period--three years psychiatric training after two years primary care experience by rotation through other departments. Field of Training--WGAP recommended that post-graduate training should be given at different kinds of institutes such as the department of psychiatry in medical schools, mental hospitals, out-patient mental clinics, community experiences in rehabilitation, day care, social clubs and health centers. Assessment--both oral examination and case reports are requested for evaluation and board certification. Re-evaluation every five years is required. However, there have been the following opinions and the Board Certification System has not been realized. 1) Making improvement in mental hospital is more important than starting Post-graduate Training and Organization for Board Certification of Psychiatry System (PTOBCP). 2) Starting PTOBCP makes professors in department of psychiatry in medical colleges give great power to suppress the right of personal management. 3) Financial support for postgraduate trainee and trainer is insufficient. Medical and psychiatric situations have changed from 2001 to 2002. 1) A neutral organization instead of academic societies will make Board Certification System in each department in the future. 2) Postgraduate educational rotation system (two years) will start in 2004. 3) Advertisement of being certificated by the Board has been possible. In recent situation, necessity for making of PTOBCP is increasing and many members of JSPN long to make it. In the 98th annual meeting, 2002 it was decided to make PTOBCP. 2. Post-graduate mandatory education system including psychiatry Recently, it was legally decided that post-graduate education for two years should be mandatory for every medical doctor who has passed a national board from 2004. Furthermore, psychiatric training should be mandatory for every rotating resident. The period of psychiatric training is one, two or three months, which depends upon each teaching hospital. It is epoch-making that every resident should receive psychiatric training, however, in other words, it means that psychiatric education in Japan will be re-evaluated through such a new training system.     

The implication of transcultural psychiatry for clinical practice

This article deals with the main concepts of Transcultural Psychiatry and their applications to everyday psychiatric practice. Transcultural psychiatry has undergone a conceptual reformulation in the last two decades. Having started with a comparative approach, which focused on the diverse manifestations of mental disorders among different societies, it broadened its scope, aiming at present to incorporate social and cultural aspects of illness into the clinical framework. Therefore, transcultural psychiatry now focuses more on what is called the illness experience than on the disease process, the latter understood as illness as it is viewed by health practitioners. Western medicine, of which psychiatry is a part, is grounded in positivist epistemological principles that stress the biological processes of disease. The intention of the paper is to develop an interest in alternative but also complementary ways of thinking. Modern transcultural psychiatry interprets some epidemiological and clinical aspects of major mental disorders (such as schizophrenia and depression) in a different light. However, it also distances itself from the absolute relativism of antipsychiatry, centering on clinical facts and helping clinicians in their primary task of alleviating suffering. An important contribution in addressing this task is the formulation of a cultural axis within the DSM model of multiaxial evaluation. A clinical vignette of a cultural formulation applied to a clinical discussion of a case is described.     

Limites et dangers des DSM

The publication of the DSM-III rating scale in 1980 marked a definite turning point in the development of modern psychiatry. For those responsible for elaborating it, it appeared to have resulted in psychiatry being accepted as a science. However, this was at the expense of eliminating the subjective aspect, both that of the patient and that of the clinical practitioner. As a result of this, it was possible to utilize a common language which permitted high inter-scoring diagnostic accuracy. The success of the DMS-III and IV is based on their affinity with scientific ideals, and with their association with clinical medication. In focusing on target symptoms devoid of all dynamism, they implicitly relate them to bodily dysfunctions. Twenty years after the introduction of this approach presented as being atheoretical, its main justification, i.e. diagnostic accuracy, has been shown to be ill-founded, while the problems of diagnostic validity are eluded. The DSM scales have relegated mental disorders to being infinitized, and the pursuit of this approach could eventually lead to treatment by computerized psychiatry. These rating scales also lead to an impoverishment of clinical consultations; they do not take into account the possible reticence of the patient; and they generate implicit normative ideals. Even amongst their proponents, certain individuals are beginning to see that they could constitute a serious disadvantage to the progress of psychiatry.     

La santé du sommeil en psychiatrie : à la croisée de la physiologie et de la santé publique

The concept, and analysis, of sleep can often open the door to new health studies and strategies in psychiatry. Sleep is indeed a physiological and behavioral function essential to mental health. First, we need to screen and treat comorbid sleep disorders in persons with mental disorders. A sleep disorder is a pathological condition related to a sleep dysfunction that interferes with an individual's health. Scales can be used to help screen for sleep disorders in persons with a mental disorder. In return, psychiatry, through its attention to mental symptomatology, can provide important elements to better detect, delineate, and define sleep disorders. Second, we need to assess sleep alterations and a person's sleep health related to mental disorders. Indeed, the absence of a comorbid sleep disorder is not necessarily associated with good sleep health in persons with a mental disorder. The mental disorder may indeed impact sleep through a common pathophysiology, but also through non-optimal sleep behaviors for health. Scales can be used to assess sleep health in persons with a mental disorder. The implementation of preventive measures targeting sleep as a modifiable behavior in psychiatry is also necessary. In return, psychiatry, with its attention to behavior, can provide important elements for the development of integrative models to predict the relationship between sleep health and mental health, and propose an iterative approach between behavioral change models and pathophysiological models of mental disorders and sleep disorders, and can also design prevention strategies that improve sleep health that will have a real impact on mental health.     

Les analyses par réseau : vers une nouvelle conceptualisation et prise en charge des troubles mentaux ?

In a break with categorical and dimensional approaches and thus the classical medical model, the network approach applied to psychopathology constitutes a holistic approach to mental disorders. In this approach, mental disorders are conceived as an interconnected system of symptoms in which symptoms are the cause of each other. It is suggested that the interaction between the different symptoms would result in a feedback loop that leads to the installation and maintenance of these symptoms/disorders. In addition, this approach proposes that co-morbidities are the result of symptom-symptom interactions that cross the diagnostic boundary and interact with symptoms from other psychiatric disorders. A growing number of studies have applied the network approach to elucidate causal interactions within the symptoms of depression, post-traumatic stress disorder, schizophrenia, or anxiety disorders. The overall objective of this review is to raise awareness among researchers and clinicians in psychiatry and clinical psychology of the network approach applied to psychopathology. To do this, we present the main concepts and principles of the network approach and its application in post-traumatic stress disorder. We also discuss recent criticisms of this approach and its clinical applications.     

Sport psychiatry and psychotherapy. Mental strains and disorders in professional sports. Challenge and answer to societal changes

Professional athletes are subject to massive somatic, social, and mental stress. Despite great public interest for athletic achievements, the emotional strains thereof are very poorly investigated and discussed. The main reason for this is the widespread assumption that only emotionally very strong athletes are able to compete at the highly professional level and therefore mental disorders do not exist in professional sports. But available research data about the prevalence of mental disorders in this area suggest that this hypothesis must be revised. With respect to depression and the overtraining syndrome, attempts have been made to demonstrate the difficulties with etiology, diagnostics, and treatment for sports psychiatry and psychotherapy. Scientifically, sport psychiatry and psychotherapy can be defined as a discipline, whose focus is the investigation, treatment, and prevention of the extreme and sports-specific emotional strains and disorders. In addition to sport psychology, which focuses mainly on performance enhancement, mental stress, and disorders can hereby be recognized, disorders be treated and the athletic performance sustained. With the foundation of the Task Force for Sports Psychiatry and Psychotherapy at the German Association for Psychiatry and Psychotherapy, scientific research, further education, prevention, and treatment for mental disorders in professional sports will be improved.     

General hospital psychiatry and deinstitutionalization: a systems view

The shift in responsibility for the care of chronic mental patients has generated a variety of problems for general hospital psychiatry. In response to these new demands, general hospital psychiatry has evolved a variety of effective strategies. Nevertheless, widespread concern over the appropriateness of serving chronic patients in an acute care setting persists. The level and direction of general hospital psychiatry's involvement with chronic mental patients will vary according to the specific characteristics of a community's patient population, its goals for those patients, and the resources at its disposal for realizing those goals. General hospital psychiatry must make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated by distant authorities. It must assume, instead, its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.     

Stepping stones for psychiatry residents who pursue scientific research careers

Abstract

Advances in areas of neuroscience are highly relevant to psychiatric disorders but there exists a gap between discoveries in neuroscience and the practice of clinical psychiatry. Psychiatry is a field in need of high impact research conducted by physician-scientists who have first-hand experience treating patients with mental illness and who use this clinical knowledge to improve and discover better or novel interventions. This paper focuses primarily on the training of psychiatry residents for successful scientific research careers and what residency programmes and others can do to help them succeed. Changes also need to be made at a regulatory level to enhance the research training and literacy of psychiatry residents. The shortage of psychiatrists who are well trained in basic and translational research can only be remedied if the path to becoming an independent investigator is lined with stepping stones that support success, including during the residency years. Partnerships among funding agencies, professional societies and training institutions can lay the groundwork for our psychiatric trainees to stay on the path to rewarding scientific research careers.     

Integration or polarization of psychiatry]

Integration vs. polarization is an issue which presents in various aspects of psychiatry. Its position within medicine is still insecure, partly because of a one-sided preoccupation at times with psychodynamic or social factors. The same divisive tendencies are evident within psychiatry itself. Biological science can make an essential contribution to psychiatry, as recent research on depression demonstrates. But only by combining pharmacotherapy with psychosocial interventions can optimal treatment results be achieved. Within psychotherapy there is an ever stronger trend towards integration of schools and methods. Research in outcome could not demonstrate any clear superiority of one single method over the other approximately 200 methods now known. Consequences for research and practice are discussed. The relationship of psychiatry with society is rather tense, being largely based on prejudice. This should be understood less as a global criticism than as an attempt of individuals and society at large to cope with the potential threat of mental illness. Psychiatry must take its responsibility towards society seriously, especially with regard to economic and ethical issues, and afford priority in care to those in the urgent need.     

International Perspectives on Old Age Psychiatry Training

Psychiatry of old age is a psychiatric subspecialty that has been developed in many countries since the 1950s as an attempt to improve the care of older adults with mental health disorders. Psychiatry of old age specialist training programs were subsequently established to develop a medical workforce that has the required competencies to work in this subspecialty. This article describes the psychiatry of old age specialist training programs in Australia, New Zealand, the United Kingdom, and Mexico. These training programs have varying durations, ranging from 1 to 3 years. Although it may not be a mandatory requirement to complete a psychiatry of old age clinical rotation, psychiatry of old age experience and competencies are expected during general psychiatry training. There is generally a lack of opportunity to learn about other clinical specialties relevant to older adults, such as geriatric medicine and neurology. Finally, much work is needed to better coordinate psychiatry of old age specialist training positions, workforce development, and service delivery to ensure there is a sufficient supply of psychiatry of old age specialists to meet the mental health needs of older adults in different countries in the coming years.     

Child and adolescent psychiatry its problems and foresight]

Accompanying the fall in birth rate, problems pertaining to the child's mind such as school in attendance, bullying, violence in the school, intrafamilial violence, eating disorders, substance abuse, and child abuse have rocketed and diversified, in addition to affecting increasingly lower age groups. The importance of child and adolescent psychiatry has never been more profound, but our country, without a chair in Child and Adolescent Psychiatry in the medical school framework, and lacking recognition of Child and Adolescent Psychiatry as a clinical department has undoubtedly become an underdeveloped country in terms of child and adolescent psychiatric care. The medical schools have been in the process of review and reorganization these past few years. The range of mental science is wide, and despite being a major discipline constituting one of the two arms of medical science together with somatic medicine, it is regarded as a minor existence in our country. This is the time to re-establish mental science, with areas such as child and adolescent psychiatry, geriatric psychiatry, social psychiatry, and crime psychiatry placed on an equal footing with general psychiatry. Turning our eyes on the world, the children are being robbed of their mental health as refugees, through child labor, starvation, and civil war. The demand of this age is true symbiosis, surpassing differences in race, religion, language, and culture, which is probably the indispensable element in the quest for a happy future for the children of this age.     

Vers « la fin de la psychiatrie » ? Analyse épistémologique

Psychiatry is now confronting a critical movement, which predicts not only its « collapse », but also its « end » and even its « death ». After a reminder of the facts, this problem is approached by an analysis of the components and of the structure of psychiatry. First all the domains constituting psychiatry, their internal and external links, and their general coherence are reviewed. An analysis of psychiatry's diverse components shows that the nature of mental trouble is not restricted to mental suffering only; it is also necessary to consider the role of biological factors, of representations, of the milieu, and of the tools for thinking, as well as that of the institutions and of the treatments which have evolved over time. Psychiatry is subsequently considered as a structure which has evolved from its roots, its conceptual evolution, and the crises it has overcome. It is thus possible to show the limits of present assertions and to deny the exclusive role of neurosciences or of sociology. The actual forms of psychiatry are certainly open to criticism, but this does not imply the disappearance of this discipline, the specificity of which rests not only on its objects of study, but also and especially on the nature of its procedures aiming at precising them more precisely.