Introductory Chapter: Unmet Needs and Future Developments

1. Different society = different psychopathology?

Major mental illnesses have modified according to time and space—different historical moments and different countries/cultures (modifications either in prevalence or in form), and as such they are sparked and shaped by the ethos of particular times and places. As enlighted by Shorter in one of his works, every culture possesses a “symptom repertoire”—a range of symptoms (either pure psychological or mixed physical) shaped by the cultural dominant model [1]. Culture shapes the way general psychopathology is going to be translated partially or completely into specific psychopathology. The problem becomes especially worrisome in a time of globalization and world web communications, when symptom repertoires can cross borders with ease and can be absorbed and integrated by different cultures. Our dominant western cultural influence on mental health and illness representation can shape, with a high level of probability, the expression of illnesses in other cultures but the issue is rarely discussed in the professional literature. Despite this, we cannot eliminate the individual suffering of psychopathology: whatever is the name of the illness, a psychotic experience for the individual is devastating and it has profound pitfalls on society and family. But in the meantime, a solely psychopathological (anthropological, sociological, and phenomenological) approach is a limit not in understanding the sufferance but in understanding the underlying mechanisms of the illness. The rapid development of neurosciences will open us a new world in terms of biological mechanisms, of possible specific targets of interventions, a more individualized and specific therapeutic intervention (as it is happening with oncology).

Nevertheless, in the same time, the human ambient (culture, living spaces, human organization) showed a powerful shaping power on illness manifestation and possible treatment (in terms of resources—formal and informal ones). Three large international studies carried out by the World Health Organization since early 1970s showed that schizophrenia has better prognosis in developing countries than in the developed world (International Pilot Study of Schizophrenia (IPSS), Determinants of Outcome of Severe Mental Diseases (DOSMeD), and International Study of Schizophrenia (ISoS)) ([2], for a synthesis). The researches showed that despite a lack of health resources, patients outside the wealth world (United States and Europe) had as much as two-thirds lowering of relapse rate. These apparent incongruities have put in relation with the way we talk about mental illness, since symptoms are (differently from more “medical” illnesses) deeply influenced by a person’s complex interactions with those around him or her. This is what we call also “high expressed emotion” ([3], for a critical review). Some other interpretations underline the role of such factors as the individualistic and internalizing trend of industrial and postindustrial society, with the loosing of social support and of the traditional family environment, the most stressing nature of work, the development of stigma in the more medicalized societies, and the differential survival rates of vulnerable individuals [4]. The role of stigma in postindustrial societies is well described by Watters and by McGruder [3, 5].

2. The role of biology

In this complex systemic organization (biology, culture, and ecological living space), only the understanding of neural, and before them biological at all, mechanisms will be of value in developing more efficient and efficacious treatments, pharmacological but also psychosocial. Interpreting mental illness solely from a neurobiological perspective is by sure dehumanizating, not recognizing the individual experiences and development, but an exclusive sociological reading of mental illnesses will conduce to confusion and a potentially dangerous negationistic position [6, 7].

An interesting point of view on the enormous growth of neurobiological data is that expressed by Prof. Maj, a prominent Italian psychiatrist former President of Italian Psychiatric Association: “The huge mass of ‘data’ or ‘evidence’ which is being accumulated in this area is not perceived anymore as an indication of a continuing increase of ‘knowledge.’ Rather, this mass of data is increasingly seen as a sign of uncertainty and confusion.” [8].

Taking into account the caveats of Maj, but also underlining the importance of ambient and of individual differences, a modern view of the biological basis of mental illnesses is the epigenetic approach [9, 10, 11]. Epigenetic poses that over the biologically “hardware” of genome, there is a sort of “interactive software” between genes and environment where environment has a main role in determining genetic expressivity. This approach can be of help in understanding old concepts like vulnerability, resilience, protective factors, stress reactions, and so on [12].

Afore general observations are needed to understand the only apparent heterogeneity of topics covered by the present volume. First of all, the choice to treat in the same volume different “psychosis”. The editorial decision is the consequence of the rapid development of neurosciences, which are unraveling common factors underling different phenotypical expressions of mental illness, but also the substantial unspecificity in treatment approach. In this book, thanking the contributes not only of clinical psychiatrist but also of neurobiologists, specific issues of psychotic disorders (mainly schizophrenia and mood disorders) are then reviewed according to the general considerations already described.

3. Do not forget persons

A particular topic is the need to develop (or, better, rediscover) an awareness of an urgent need for an evidence-based “personalized” but also “human” approach of treatment. In this respect, the contribute of Susan Weiner is of central impact in introducing us in the deep personal experience of psychotic breakdown. It is an inside witnessing of psychosis, very well written, but also it stresses the importance of a trustful relationship between patient and his caregiver in order to reach a clinically significant result.

Other topics are then developed, ranging from the concept of insight and adherence to the influence negative symptoms have in the clinical management, to the peculiar management of bipolar depression. Other topics of interest are related more specifically to biological basis of psychosis.