Abstract
Keynote presentations
Keynote address 1
Neuroplasticity in Schizophrenia: Mechanisms and Treatment Implications
Professor Matcheri S Keshavan
Stanley Cobb Professor of Psychiatry, Harvard Medical School, Boston, USA
Cognitive deficits in schizophrenia are pervasive, severe, and largely independent of the positive and negative symptoms of the illness. These deficits are increasingly considered to be core features of schizophrenia with evidence that the extent of cognitive impairment is the most salient predictor of daily functioning. Unfortunately, current schizophrenia treatment has been limited in addressing the cognitive deficits of the illness. Recent studies have highlighted the importance of aberrant brain plasticity in understanding pathophysiology of schizophrenia, as well as the value of modifying neuroplasticity as a way to address such pathophysiology. Alterations in neuroplasticity are hypothesised to underpin cognitive and social deficits, and preserved neuroplasticity may offer an avenue towards cognitive remediation. Key neuroplastic principles to consider in designing remediation interventions include ensuring sufficient intensity and duration to remediation programs, ‘bottom-up’ training that proceeds from simple to complex cognitive processes, and individual tailoring of remediation regimens. I discuss several cognitive remediation programs, including cognitive enhancement therapy (CET), which embrace these principles to target neurocognitive and social cognitive improvements and which have been demonstrated to be effective in schizophrenia. Future directions in cognitive remediation research include potential synergy with pharmacologic treatment, non-invasive stimulation techniques, and psychosocial interventions, identification of patient characteristics that predict outcome with cognitive remediation, and increasing the access to these interventions in front-line settings.
Keynote address 2
DSM-5 Process Ethics: Lessons Abandoned, Learned and Missed
Professor John Z Sadler
Professor of Psychiatry & Clinical Sciences, The Daniel W Foster Professor of Medical Ethics, The University of Texas Southwestern Medical Center, Dallas, USA
The release of DSM-5 will be either accomplished or imminent in May 2013. This presentation will not review disputes over particular DSM-5 disorders and criteria, but rather will consider the process of developing the DSM-5. I shall consider the ethical aspects of this process: how the DSM-5 process may or may not contribute to the social good. Through a ‘DSM-5 Process Ethics’ I consider the ethical-moral considerations that go into the colossal task of building a DSM. I focus on four interrelated themes under this rubric. The first considers the extraordinary opportunity of the DSM-5 era in using the Internet as an information resource for the development of the new manual. I will consider the DSM-5 leaders’ interactions with digital culture, considering positives as well as negatives. The second theme looks at the early concerns about the privacy arrangements with Task Force and work group members, and the DSM leadership’s response to critical outcries from former DSM leaders like Robert Spitzer and Allen Frances. The third theme follows naturally and focuses on the role of democratic values in developing a scientifically based, de facto public policy document like the DSM-5. The fourth theme addresses responsible innovation, and considers the early dramatic innovations in the early years of DSM-5 development, and the process of ratcheting back such innovation over the DSM-5 developmental arc. I conclude with some ideas to consider for a DSM-6 developmental process.
Keynote address 3
Recent Advances in Psychological Therapies in Eating Disorders
Professor Janet Treasure
Director, Department of Psychiatry, Eating Disorder Unit, South London & Maudsley NHS Trust, London, UK
The NICE guidelines and Cochrane reviews secured the place for psychological treatments for eating disorders. These were recommended as a first step in treatment with inpatient services relegated to the second line. Involving the family is helpful as an early intervention for anorexia nervosa but less is known about how to help those who fail to respond or who present at an age when the family environment is less strong. In the most expert hands CBT is effective for about 50% of cases of bulimia nervosa but new forms of therapy have not substantially altered the response rate. A similar pattern is apparent for binge eating disorder. Approaches based on self-determination theory such as guided self-directed care appear to have benefits for long-term effects, even for those with complex presentations, in addition to the advantages of lower cost and transferability. Current talking treatments which focus mainly on ‘top down’ processes may need to be supplemented with treatments which can target ‘bottom up’ processes. The addition of treatments which focus on remediating core emotional anomalies (oxytocin, brain stimulation) or intensive new learning of emotional habits such as attentional bias training and exposure also need to be considered.
Keynote address 4
Treatment of Antisocial Personality Disorder and Psychopathy: Hopeful or Hopeless?
Professor Charles Scott
Professor of Clinical Psychiatry, Department of Psychiatry and Behavioral Sciences, UC Davis Health, Sacramento, USA
For centuries, various terms have been coined to describe the unlawful and antisocial behaviours of individuals. An important step in assessing such individuals is having a clear understanding of the diagnostic criteria for each term, particularly similarities and differences between the diagnosis of Antisocial Personality Disorder and the construct of psychopathy. The contribution and assessment of aggression, impulsivity, anger, empathy, and social competence to antisocial behaviours will be discussed. The ‘Risk-Need-Responsivity’ paradigm for guiding treatment will be reviewed. The role of pharmacotherapy will be noted. In addition, psychological treatments will be presented with updates regarding best practices for this difficult-to-treat population. Specific attention to cognitive behavioural and relapse prevention approaches will be given, with a particular focus on specific studies examining treatment of psychopathy. The development of Dangerous and Severe Personality Disorder Units in Great Britain and the resulting outcome of these intensive treatment programs will be reviewed.
Keynote address 5 Margaret Tobin Oration
Leading Change: Psychiatry in a Changing Health Sector
Dr Peggy Brown
ACT Health, Canberra, Australia
This paper details the perspective of an administrative psychiatrist who has moved into broader health sector management. It examines a number of the drivers for change in contemporary health service delivery across Australia and details key components of national health reform currently underway. It discusses their relevance to the mental health sector and to psychiatrists more broadly. The role of leadership in successfully delivering health sector reform is also explored.
Keynote address 6 Senior Research Award Recipient
Gaining Clarity on Bipolarity
Professor Gin Malhi1,2
1Discipline of Psychiatry, Sydney Medical School, University of Sydney, Australia
2CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Australia
Clinically, depression often emerges out of a milieu of anxiety and presents as an admixture of symptoms. Described variously as anxious depression and mixed anxiety and depression it reflects depression within community and primary care settings. Subsumed within this broader form of clinical depression lurk ‘purer’ forms such as melancholia and psychotic depression, which surface less frequently.
In practice, it has become apparent that bipolar disorder also initially masquerades as depression, prior to eventually heralding its onset as mania, and that it too forms a spectrum that perhaps envelops clinical depression. Arguably amongst mood disorders, bipolar I disorder, defined by mania, is the most pristine, and delineation of its boundaries will assist in charting mood disorders as a whole.
This talk discusses these issues and relates phenomenology to its underlying biology and presents the findings from two recent studies published this year that examined the neural substrates of emotional disorders and sought the separation of bipolarity from personality.
Keynote address 7
The Question of (Continuing) Competence
Professor Brian Hodges
Division of Behavioural Sciences & Health, Toronto General Research Institute, Toronto, Canada
Around the world medical education organisations are adopting programs to foster maintenance and development of professional competence for clinicians in practice. What is striking is the range of approaches taken, ranging from recertification examinations to reflective portfolios to point systems for continuing education activities. This diversity reflects a certain degree of uncertainty about what competence is and how its ‘continuation’ should be captured. Based on the book The Question of Competence, this talk explores different conceptions of competence and the implications for programs of continuing education for physicians.
Keynote address 8
Clinical Reasoning and Pattern Analysis in Psychiatric Diagnosis and Management
Professor Gordon Parker
Scientia Professor, University of New South Wales, Sydney, Australia
Just having a diagnosis means the rest of your life can start … Patients want to know what is wrong, if it’s serious, how long it will last, whether it will alter their life plans.
A skilled clinical psychiatrist should ideally provide a diagnosis and a formulation, offer a prognosis and choose from – or pluralistically meld – multiple treatment options. But how are such ‘skills’ of clinical reasoning derived and, more importantly, developed? Are they teachable and, if so, how?
In recent decades, psychiatrists have increasingly adopted a DSM diagnostic manual model – one which ignores aetiology and weights criteria lists – and been encouraged to view psychiatry is an ‘evidence-based’ speciality. Limitations to such weightings will be considered in arguing that psychiatry is quintessentially neither a science nor a technical skill/art, but incorporates components within a higher-order construct – phronesis or practical reasoning.
It will be argued that clinical reasoning requires an iterative process linking implicit observational (pattern) analysis and commonsense together with some regard for explicit discipline-based information. As such a process requires thousands of hours of clinical encounters to advance and recalibrate idiographic ‘patterns’, a neuroplasticity process can be postulated.