Purpose: Descriptive psychopathology (DP, sometimes called psychopathology or phenomenology) is the language of psychiatry and is dedicated to the description of mental symptoms. Due to its importance, there is an ongoing case to put it back at the heart of psychiatry and its training. This study seeks to examine the literature on how to train psychiatry residents in DP, including reported educational interventions and educational methods. Method: The authors conducted a systematic review following the PRISMA and BEME guidelines to identify literature on how to train psychiatry residents in DP. In May 2019, they searched in Embase, ERIC, PsycINFO, PubMed, Scopus, and Web of Science; of 7,199 initial results, 26 sources were finally included for analysis. The assessment tools were the CRAAP test, Kirkpatrick’s 4 levels, and (when applicable) the Medical Education Research Study Quality Instrument (MERSQI). Results: The mean CRAAP score was 38.885 of a possible 50 (SD 0.983; range: 36.859–40.910). Fourteen sources (53.8%) had some kind of training evaluation: Kirkpatrick’s level 1 was present in nearly all (13) and was the highest in half of them (7). Regarding the educational interventions, the mean MERSQI score was 10.592 of a possible 18 (SD 2.371; range 9.085–12.098). Lectures were the most widely reported educational method (5); among those in clinical settings, the live supervised interview with feedback was the most usual (4). Conclusions: Despite its core importance as the language of psychiatry, the literature about training psychiatry residents in DP is scarce and heterogeneous. General lack of training evaluation and ongoing overemphasis on Kirkpatrick’s levels 1–2 at the expense of levels 3–4 are causes for concern. During the review process, the authors identified a selection of educational interventions that could serve as the basis for the design of new training efforts in both clinical and nonclinical settings. Topics for future research are also suggested, such as the role of DP in competency-based training frameworks now in vogue and a series of neglected contents. Finally, the combined use of the CRAAP test and the MERSQI may be useful for future systematic reviews in medical education.

Psychiatry is the branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders [1]. Descriptive psychopathology (DP, sometimes called psychopathology or phenomenology) is the language of psychiatry, a systematic collection of assumptions, vocabularies, and grammatical and syntactic rules which is dedicated to the description of mental symptoms [2].

DP: History and Epistemology

Psychiatry emerged in Europe in the wake of the 19th century as a medical approach to madness, following social and legal changes across several countries at the time. Those early psychiatrists (alienists) needed to record what happened to their patients, so they had to create a psychopathological language to capture in words that phenomena and construct units of analysis. Pinel’s 4 categories of mental alienation were broken up into fragments, some of which were to be reconstructed as mental symptoms [3].

This development of DP was conducted in the image of the semiology of medicine (itself based on the anatomoclinical model) and influenced by psychological theories then in vogue (such as associationism and faculty psychology). As a language, DP was practically completed when Chaslin and Jaspers published their texts in the 1910s; it has remained stable since then, so the current DP we use nowadays still keeps conceptual views of those days [4].

Mental symptoms, as the units of analysis of DP, include subjective complaints (e.g., feeling anxious and hearing voices) and signs and behaviors determined through observation or instruments (e.g., delusions, psychomotor retardation, cognitive deficits, and disinhibition) [5]. The Cambridge School of Epistemology and Psychopathology led by Professor Berrios states that mental symptoms are genuine actions, through which a distressful experience (of either biological or semantic origin) is configured by means of personal, social, and cultural templates, first by the patient himself/herself and then through a hermeneutic process by the clinician who will record it in the casenotes [6].

Thus, in historical and epistemological terms, psychiatry and its language (DP) are rooted in both the natural and social sciences [7]. The objects of inquiry, mental symptoms, are neither natural nor abstract objects; they are hybrid objects, constituted by the blending of components arising from disparate sources of knowledge as they combine biological and cultural information [8].

The Importance of DP

It has been argued that at present, mental symptoms play a more important epistemological role in psychiatry than medical symptoms in medicine, as medical symptoms are being gradually replaced by “biological” markers [5]. In contrast, psychiatry remains dependent on mental symptoms for diagnosis, treatment decision-making, evolution assessments, research, etc. Just as pointed by Fish half a century ago [9], the need for careful description of clinical phenomena in psychiatry is greater than ever before.

DP has faced strong pressure in recent decades from classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association, which has a neopositivist-analytic orientation and gives preference to observable external behavior while subjective experience is for the most part dismissed. DSM assumes mental symptoms as well-demarcated, mutually independent, natural objects with no intrinsic meaning and indicative of a specific physiological dysfunction. In this view, mental symptoms are thing-like objects waiting to be grasped, so they are open to context-independent operational definitions and can be unproblematically registered and quantified. Following this rationale, the structured interview and subsequent checklists mimicking the operational diagnostic criteria of DSM are widely regarded as adequate methods of obtaining valuable information. The process of collecting data is done by circumventing or shortcutting the complexities of subjectivity and intersubjectivity in the patient-clinician exchange [10-13].

In essence, DSM and its associated mainstream psychiatry have failed to acknowledge mental symptoms as admixtures of biological and sociocultural components (hybrid objects) that are co-constructed by both the patient and the clinician. This failure in understanding the basics of DP has come at a cost to psychiatry. In the field of assessment and diagnosis, procrustean errors (to stretch and trim the patient’s experience to fit operational criteria) and tunnel vision (avoiding the assessment of phenomena not included in standardized interviews) have sadly become common practice [14]. On behalf of interrater diagnostic reliability, validity has been sacrificed, and treatment decisions and research are made without a proper psychopathological assessment [15, 16], which may jeopardize patients’ prognosis.

Moreover, the misguided assumption of mental symptoms as thing-like objects that can be located in time and space in the brain and can guide us toward their biological causes, without realizing that they are hybrid objects with varying degrees of brain inscription, has led to an increasing gap between psychiatry research and clinical psychiatry [11-13]. For decades, most research efforts have tried to establish correlations between alleged mental symptoms and neuroscience findings (e.g., neuroimaging). This hegemonic yet ill-fated approach has failed to produce real benefits for patients; it is also impeding the development of a flexible and conceptually sophisticated psychiatry [10]. The new Research Domain Criteria (RDoC) project developed by the US National Institute of Mental Health considers mental disorders as “disorders of brain circuits” [17], arguably misleading brain mediation/inscription with etiology. Due to its dismissal of the basics of DP and its overemphasis on biological over psychosocial variables, RDoC may well be conceptually flawed as well [18-22].

Nevertheless, the most costly of the consequences for psychiatry has been dehumanization: as a true dialogue between interviewer and interviewee has been discouraged and the patient qua person and the clinical encounter have been dehumanized [14, 15]. This is particularly painful and troubling for psychiatry because as pointed by Berrios [23], patients are its only raison d’être. DP, due to its properties [24], is the guarantee that psychiatry stays rooted in the patient and the patient-clinician encounter.

The Case for Training in DP

DP is said to be neglected in contemporary training in psychiatry [25]. As psychiatric textbooks limited their psychopathological section to reprinting operational diagnostic criteria [13], DSM became the basis for psychiatric teaching to both residents and undergraduates. Over the last several decades, there has been a substantial decline in training in careful clinical assessment targeted to the individual person’s problems and social context [15].

This is critical, as cultural configurators from both the patient and the clinician (background, education/training, experience, and personal biases) contribute to the way in which a distressful experience is identified, interpreted, and named as one or more mental symptoms [10]. While detailed history taking has been replaced by structured psychometric scales, a magnificent thesaurus of psychopathological knowledge and in-depth, fine-grained descriptions has been removed from psychiatric educational programs [14]. Failing to train in the knowledge, skills, attitudes, and clinical use of DP implies psychiatry mortgaging its own identity and future [25].

Amidst this climate, there is a case to be made to rediscover and highlight the relevance of DP, thereby putting it back at the heart of psychiatry and its training [16, 26-28]. It has been stated that DP should be a basic educational prerequisite in the curriculum for mental health professionals [24]. Also, training in DP should be implemented with innovative instruments and approaches within psychiatric curricula [25].

Hopefully, well-trained and aware 21st-century psychiatrists will take part in the recalibration of DP in order to have a language that lives up to this century. By doing so, they will engage in the objective of having a psychiatric language in the best interest of patients, either for clinical practice or research [29].

Training Psychiatry Residents in the 21st Century

In a world in constant change and full of uncertainties that have a direct impact on health systems, society demands health professionals (e.g., psychiatrists) who are flexible in adapting to the new times and challenges [30]. Despite some differences between countries, becoming a psychiatrist usually involves 2 consecutive phases: undergraduate medical education (medical school) and postgraduate medical education (psychiatry training or residency) [31]. Psychiatry residency is essential for the psychiatrists of the future (who may have clinical, managerial, educational, and research duties) [32], as it provides them not only the tools (knowledge, skills, and attitudes), but also real-life scenarios (with actual patients, families, colleagues, managers, and resources) to put them into practice.

As pointed by Kirkpatrick and Kirkpatrick [33], there are 3 major reasons to evaluate training programs: (1) to improve the programs, (2) to maximize transfer of learning to behavior and subsequent results, and (3) to demonstrate the value of training to the stakeholders (accountability). In the field of medical education, evaluation and research of educational efforts are considered essential to learn what has worked or not. Evaluation and research are also important in order to construct an evidence based on best practice that can be disseminated and adapted to improve training worldwide [34].

Training in psychiatry and other medical specialties is undergoing the transition from opinion-based education to evidence-based education [35]. In this sense, a systematic review is an explicit, rigorous, and transparent process of searching, selecting, appraising, interpreting, and summarizing results from published studies on a specific topic. In contrast, traditional literature reviews are not so rigorous regarding their methods and are susceptible to selection bias, preventing the presentation of a broader view. Thus, systematic reviews are an important tool for professional educators who seek the best available evidence to inform their actions, and they are recognized as such among other institutions by the Best Evidence Medical Education (BEME) Collaboration and the Association for Medical Education in Europe [36-39].

Research Objectives

As there is an argument for ensuring that DP is at the heart of psychiatry and its training, we decided to conduct a systematic review to examine the literature on how to train psychiatry residents in DP. Our secondary objective was to know what educational interventions have been reported in these publications for training psychiatry residents in DP, as well as the educational methods involved.

We conducted a systematic review following the PRISMA guidelines and also considered recommendations by BEME guidelines [36-38, 40].

Identifying the Literature

Once we had developed the idea, we set the inclusion and exclusion criteria (Table 1). Then, we constructed the search syntax: “phenomenology/education,” “phenomenology AND (education OR pedagogy OR teaching OR training) AND (residen* OR intern* OR trainee),” “psychopathology/education,” and “psychopathology AND (education OR pedagogy OR teaching OR training) AND (residen* OR intern* OR trainee).”

Table 1.

Inclusion and exclusion criteria

Inclusion and exclusion criteria
Inclusion and exclusion criteria

Based on already known recommendations [41], as well as our research question and topic, we selected the following databases: Embase, ERIC, PsycINFO, PubMed, Scopus, and Web of Science. We conducted the search from May to June 2019, and the 4 previously detailed search syntax yielded 1,041, 1,591, 81, and 4,473 studies, respectively. Besides these 7,186 results coming from databases, we also included 13 studies from the gray literature for consideration, for a total of 7,199 search results.

Using the Mendeley Reference Manager, 970 results were automatically identified as double hits, leaving us with 6,229 results for manual screening using the previously set inclusion and exclusion criteria. We dismissed 6,013 because of the title, 134 because of the abstract, and 53 after having read the full text. As for the remaining 29 results, 3 were parts of the same paper [42-44], whereas 2 corresponded to different but nearly identical editions of the same book chapter [45, 46]; this left us 26 sources for the review. The whole process is summarized in a flow diagram (Fig. 1).

Fig. 1.

Flow diagram

Assessment Tools

Based on already known recommendations [47], we decided to use the CRAAP test, Kirkpatrick’s 4 levels, and the MERSQI as assessment tools for this review. The CRAAP test evaluates 5 domains to rate a source: currency, relevance, authority, accuracy, and purpose. Used by librarians around the world, it can be converted into a numerical scale, and it has already been used in articles of medical journals for that purpose [48]. We followed the model adapted by the librarians of the Texas State University, which proposes to evaluate each domain at 0–10 points, giving a total score of 0–50 points with different levels: excellent (45–50), good (40–44), average (35–39), acceptable (30–34), or unacceptable (<30) [49].

Kirkpatrick’s 4 levels are arguably the most widely used training evaluation model in the world. It consists of level 1 or reaction (the degree to which participants find the training favorable, engaging, and relevant to their jobs), level 2 or learning (the degree to which participants acquire the intended knowledge, skills, attitude, confidence, and commitment based on their participation in the training), level 3 or behavior (the degree to which participants apply what they learned during training when they are back on the job), and level 4 or results (the degree to which targeted outcomes occur as a result of the training and the support and accountability package) [33].

The MERSQI (Medical Education Research Study Quality Instrument) assesses the methodological quality of published medical education research reports on 10 items clustered in 6 domains: study design, sampling method (number of institutions involved and response rate), type of data, validity of evaluation instrument (content, internal structure, and relationship to other variables), data analysis (sophistication and appropriateness), and outcomes. The total score of any intervention has a range of 5–18, with higher scores reflecting more rigorous studies; the instrument has been reviewed as a useful and reliable tool [50].

Data Extraction and Assessment

We conducted data extraction and assessment from July to September 2019. From every source, we took its first author, publication year, and country. We specified what type of source it was, and we wrote a brief summary of it. In order to assess each source’s appropriateness regarding the research question and its level of training evaluation, we used the CRAAP test and Kirkpatrick’s 4 levels, respectively.

Those sources that included an educational intervention with some kind of training evaluation (Kirkpatrick’s level 1 or higher) were of special interest regarding our research question, so we analyzed them in more detail. Based on earlier benchmark systematic reviews in medical education [51], we extracted relevant data (participants, interventions, evaluations, and results) and rated each intervention using the MERSQI scale in order to assess their methodological quality as medical education research pieces.

Both raters scored the sources of our review independently, using the CRAAP test and (when applicable) the MERSQI, and then took the mean value for the table. Before using these instruments in this review, both raters had undergone a preparation stage in order to ensure interrater reliability: first, we had reviewed the characteristics of each tool and discussed every item to clarify their meaning in the scoring schema; second, we practiced in the use of these 2 instruments in selected example articles of a different but related topic (training in psychopharmacology) both independently and together for greater clarification; finally, we both scored the set of sources of this review independently.

Analysis

We used SPSS 26.0 for Windows (IBM Corp., Armonk, NY, USA) for statistical analysis. For the analysis and interpretation of the data, a biological researcher and lecturer was included to incorporate the view of a nonpsychiatrist who is involved and interested in biosanitary academics but is not familiar with DP.

Publications about How to Train Psychiatry Residents in DP

The 26 sources are summarized in Table 2. Sorted by decades, 3 were published in the 1970s (11.5%) [42-44, 52, 53], 3 in the 1980s (11.5%) [54-56], 4 in the 1990s (15.4%) [57-60], 8 in the 2000s (30.8%) [61-68], and 8 in the 2010s (30.8%) [45, 46, 69-75]. As for the country of origin, the USA led with 19 sources (73.1%), followed by continental Europe with 3 (11.5%), the UK with 2 (7.7%), and Canada and Chile with 1 each (3.8% in both cases).

Table 2.

Description of 26 studies of training PR in DP, including their appropriateness (CRAAP test) and training evaluation (Kirkpatrick’s levels)

Description of 26 studies of training PR in DP, including their appropriateness (CRAAP test) and training evaluation (Kirkpatrick’s levels)
Description of 26 studies of training PR in DP, including their appropriateness (CRAAP test) and training evaluation (Kirkpatrick’s levels)

CRAAP Test

As for the CRAAP test and the appropriateness of the sources regarding the research question, 3 were excellent (11.5%), 10 good (38.5%), 9 average (34.6%), 3 acceptable (11.5%), and 1 unacceptable (3.8%). The mean total score for the whole of the sources was 38.885 (0.983), with a 95% confidence interval [CI] of 36.859–40.910. We conducted the Shapiro-Wilk test (p = 0.06) and concluded that the total CRAAP score did not have a normal distribution.

The raters’ CRAAP scores, which can be consulted in full detail in online suppl. Digital Appendix 1 (see www.karger.com/doi/10.1159/000512791 for all online suppl. material), were used to calculate intraclass correlation coefficients (ICC) to determine interrater reliability. The ICC for the total CRAAP score was 0.90 (95% CI: 0.80–0.96).

Kirkpatrick’s Levels of Training Evaluation

Fourteen sources (53.8%) reported some kind of training evaluation, that is, at least one of Kirkpatrick’s 4 levels. Level 1 or reaction was the highest in half of them.

The most frequently reported was level 1 or reaction, which was present in 13 sources (92.9% of those that did have some kind of training evaluation and 50.0% considering all the sources). Level 2 or learning was present in 3 sources (21.4, and 11.5% overall), level 3 or behavior in 4 sources (28.6, and 15.4% overall), and level 4 or results in 1 source (7.1, and 3.8% overall).

Concerning the 12 sources with no training evaluation, 9 were either designs or proposals (7 curriculum designs, plus 1 framework proposal and 1 course design). The remaining were 1 systematic review and 2 literature reviews.

Reported Educational Interventions for Training Psychiatry Residents in DP

Out of 14 sources with some kind of training evaluation, 3 sources were in fact describing the same survey [70, 72, 73]; they were thus grouped together, making a total of 12 educational interventions that are analyzed in detail in Table 3. Of them, 8 came from the USA and the rest from Canada, Chile, Europe, and the UK with 1 each.

Table 3.

Description of 12 educational interventions of training PR in DP

Description of 12 educational interventions of training PR in DP
Description of 12 educational interventions of training PR in DP

Besides 2 surveys (1 in Europe asking early career psychiatrists and 1 in the USA asking psychiatry residency programs), the other 10 were course or curriculum implementations either for psychiatry residents alone (7) or together with other participants (3); one of them was a controlled, nonrandomized educational trial. Two courses did not detail the participating psychiatry residents’ postgraduate year; when specified, PGY-2 psychiatry residents participated in 7 courses, PGY-3 in 4 courses, PGY-1 in 3 courses, and PGY-4 and PGY-5 in 1 course that was actually the same.

Educational Methods

Seminars or didactic sessions made the most widely reported format, as they were present in 8 interventions. Regarding the educational methods, 5 consisted of passive learning through traditional lectures by members of the staff [56, 64-66, 69]. The other 3 involved active learning, as psychiatry residents were requested to search about 1 topic and then report back to the group, usually followed with some discussion [60, 66, 75]. Other reported nonclinical educational methods were case discussion out of clinical setting (4) [64, 66, 75], annual workshops (2) [64, 67], weekly role-playing (1) [67], generic videos (1) [66], giving an expressly elaborated didactic textbook (1) [67], and suggesting readings (1) [67].

Clinical interviewing with actual patients was reported in 4 interventions [52, 53, 56, 67]. All of them involved the psychiatry resident conducting a live interview with a real patient in the presence of a supervisor, who then gave immediate feedback. Videotaping was also present in 3 of these interventions: the psychiatry resident’s interview with a real patient was recorded and then visualized by a supervisor to give deferred feedback; one of them also included clinical videos by members of the staff as a reference [56, 66, 67]. Other reported clinical educational methods were the tutor/mentor figure (3) [53, 56, 67] observing a senior psychiatrist’s clinical work (2) [56, 65] and reviewing the clinical record elaborated by the resident (1) [53].

MERSQI Score of Methodological Quality

As for the MERSQI score and the methodological quality of the educational interventions, the mean total score for the whole of them was 10.592 (2.371), with a 95% CI of 9.085–12.098. We conducted the Shapiro-Wilk test (p = 0.53) and concluded that the total MERSQI score did not have a normal distribution.

The raters’ MERSQI scores, which can be consulted in full detail in online suppl. Digital Appendix 2, were used to calculate ICC to determine interrater reliability. The ICC for the total MERSQI score was 0.98 (95% CI: 0.80–0.96).

Overall State of the Literature

This systematic review summarizes available publications in the literature about how to train psychiatry residents in DP. It also summarizes what educational interventions have been reported for training psychiatry residents in DP, as well as the educational methods involved and their results.

Heterogeneity of the Sources

The heterogeneity of the sources is notable. There are some conceptual differences about what mental symptoms are; this often occurs in the form of implicit assumptions, since the authors rarely explain their framework. Action scopes are equally diverse: either outpatient or inpatient adult psychiatry, child and adolescent psychiatry, consultation-liaison psychiatry, addiction psychiatry, research, etc.

In addition, the role of DP and its training varies from some papers to others: it may be the main focus of the study, it may be integrated into a broader training program that includes nosology and treatment issues, or perhaps the publication may verse about training in some of the constituent components of DP (clinical interviewing and cultural configurators). Transcultural psychiatry has been actively involved in the field of training in cultural configurators, including the efforts of renown groups such as those led by Kirmayer at McGill University and Nikapota at the Institute of Psychiatry of King’s College, London. This heterogeneity at multiple levels and the fact that some sources treat the issue of training in DP tangentially may explain why the mean CRAAP score (appropriateness regarding the research objectives) was just average.

Lack of Evaluation and the Pending Bridge towards Kirkpatrick’s Levels 3–4

It is however the lack of training evaluation that should be the cause for major concern: only half of the sources included some kind of educational assessment, and among those, half reached Kirkpatrick’s level 1 only. Without good evaluation of educational efforts, it is difficult to learn what has worked or not worked in DP training. Consequently, there will be little evidence based on best practice that can be disseminated and adapted to improve training worldwide.

Out of 14 sources including some kind of training evaluation, 13 sources (92.9%) included level 1 and/or level 2 evaluation; only 6 sources (42.9%) included level 3 or level 4 evaluation. This goes very much in line with the already condemned current overemphasis on levels 1–2 at the expense of levels 3–4, which are precisely more related to the real goals of training: on-the-job application and targeted outcomes in real life. Building a connection bridge between levels 1–2 and levels 3–4 is challenging, yet crucial when conducting training programs and evaluations [33].

In the case of DP, this seems to be especially the case because of epistemological reasons, as mental symptoms are hybrid objects that are co-constructed between the patient and the psychiatrist during the clinical encounter. It would make little sense to assess psychiatry residents only for their knowledge and skills in nonclinical settings, instead of their actual performance with real patients. Use of simulated patients may be suggested as an alternative, but it has intrinsic limitations in psychiatric education, most notably in aspects like empathy and interpersonal relationship [62]. This seems particularly troubling for DP training, as empathy and patient-psychiatrist relationship are essential in the dialogue that eventually leads to symptom formation.

Newer Does Not Mean Better

Even if over 60% of the sources included in this review have been published since 2000, it should be noted that most recent publications are not necessarily better than the old ones. In fact, all 3 sources published in the 1970s were highly rated in the CRAAP test despite being penalized by the tool’s currency item, thanks to their relevance, accuracy, authority, and purpose. Two of them had a Kirkpatrick’s level 3 training evaluation, including the educational intervention with the highest MERSQI score. The third source of the 1970s was a three-part curriculum design for training in consultation-liaison psychiatry that established behavioral objectives in core areas [42-44], very much in tune with current trends in medical education [34].

Recommended Reads When Designing DP Training

The surveys carried out in Europe and the USA may be useful as a starting point [68, 70], although they come up short for more specific guidance. Altogether, because of their appropriateness to the topic and methodological quality, we consider that the core of this review lies in the following works: Santos et al. [66], Shea et al. [56, 67], Stein et al. [52], Valdivieso et al. [75], and Wilmuth and McKegney [53]. They are all educational interventions with some kind of training evaluation, albeit with different characteristics. Thus, depending on each reader’s needs and interests, some may be more useful or suitable than others.

On the one hand, studies by Santos et al. [66] and Valdivieso et al. [75] deal with educational interventions in nonclinical settings, thus achieving at most Kirkpatrick’s level 2. The former highlights that despite problem-based learning being considered engaging, both psychiatry residents and faculty members agreed that theoretical lessons were needed to cover some topics in more depth [66]. The latter consists of a series of seminars with an intriguing synergy between content (classic authors) and form (flipped classroom principles, in which residents play an active role) [75]. We consider these 2 articles of special interest for those who want to start a teaching program in DP at their organization, as training in nonclinical settings is easier to establish and is currently the standard. They could also be useful for those who already have a formal training program in DP at their organization and are willing to introduce new educational methods to make lessons more appealing.

On the other hand, studies by Shea et al. [56], Stein et al. [52], and Wilmuth and McKegney [53] deal with educational interventions in real-life, clinical scenarios [67], thus achieving Kirkpatrick’s level 3. All in all, 3 educational methods emerge as crucial for DP training from these 4 works: direct supervision, feedback, and self-reflection. Supervision of the clinical interview with real patients is crucial and must be done in person, with the supervisor present; reviewing the written record should be considered, and videotaping can be a good training supplement. Feedback should be given immediately after the interview; it may be extended in writing on a deferred basis. The resident’s self-reflection can be complemented by a mentor. Direct supervision, feedback, and self-reflection are along the lines with the demands of psychiatry residents regarding DP training [70]; they also happen to be compatible with competency-based training principles [76]. We therefore consider these 4 works benchmark articles that should be the basis for the design of future interventions, as well as an inspiration for new research projects regarding the training in DP.

Ongoing Challenges and Suggested Topics for Future Research

The Role of DP within Competency-Based Training

Competency-based training has been formulated as the best approach to the current social and healthcare challenges [34, 77, 78]. Since 2000, several leading countries in medical education have already developed their own versions for competency-based training of various medical specialties such as psychiatry: CanMEDS in Canada, the Accreditation Council for Graduate Medical Education (ACGME) in the USA, Core Psychiatry Training in the UK, etc. In Europe, where significant differences have been reported between countries regarding psychiatry training, the European Union of Medical Specialists (UEMS) also advocates for a common competency-based training and evaluation framework [79].

As the language of psychiatry, DP is essential for any patient-centered care by psychiatrists and should be a core element of competency-based training programs and their evaluation process. However, according to our review, there seems to be no published evidence in peer-reviewed journals as to how these ongoing competency-based training frameworks for psychiatry residents are doing on training in DP. Moreover, there is no available literature on how to articulate training in DP within competency-based frameworks, the peculiarities of both DP and competency-based training, and subsequent implications for their association, how to properly integrate DP with the rest of competencies expected in a psychiatrist (e.g., professionalism, communication, and adaptability), etc. This subject may not only be suitable but imperative for future research.

Neglected Contents of DP in Residency Training

After conducting this systematic review in the available literature on how to train psychiatry residents in DP, we consider that there are a number of neglected contents that represent an opportunity for research. The ostracism of epistemology in DP training is particularly striking, as there are no documented experiences that include it in their teaching programs. The case for a recalibration of language and the need to involve current residents in this process are equally absent.

The conceptualization of mental symptoms as hybrid objects entails reflection on how to design training programs for residents that integrate natural sciences and social sciences. Since psychiatry residents come from medical schools with a background based on the contributions of the natural sciences, training in social sciences (history, sociology, anthropology, etc.) that is appropriate and relevant for psychiatry residents should be incorporated for a proper understanding of DP. Although there has been some initiative in this regard [63], it is still an area for further development.

Introducing the CRAAP Test into Medical Education Reviews

We found the CRAAP test, Kirkpatrick’s 4 levels, and the MERSQI to be useful and complementary tools to measure the quality of medical education research. We consider that the CRAAP test allows for evaluation of the appropriateness of a source regarding the research question, something that the other 2 tools fail to do. By ensuring that the raters knew the instruments and were trained in their use, we obtained good interrater reliability for both the CRAAP test and the MERSQI; these tools may be useful in association for future systematic reviews in medical education.

Limitations

A number of limitations should be acknowledged regarding this systematic review. As for the authors, the BEME Collaboration recommends that the review group has international composition and considers 6–12 members as an optimum number, which was partially the case here as we are a locally established group consisting of 5 psychiatrists and a biologist. Other BEME recommendations about the review group were fulfilled, such as having knowledge of the specific area being reviewed as well as other usually required skills when conducting this type of search [80].

Regarding the inclusion and exclusion criteria, only sources that were either in English or Spanish were included. We took this decision so that all reviewers involved could read and evaluate the sources on their own. We acknowledge the risk of language bias in this regard: at least 1 article with its abstract in English but the manuscript in French would have made it to the full-text read phase of the screening process [81].

Data extraction and assessment was conducted by 2 members of the group. It may be argued that these are too few reviewers, especially when using the assessment tools that required scoring. We tried to solve this question by ensuring that both raters had a proper preparation on the use of these instruments and all items had been fully discussed and clarified in advance. We think that the good interrater reliability shows that the approach was valid.

As previously exposed, the CRAAP test has not been used before in the field of medical education systematic reviews to assess the appropriateness of each source regarding the research question. Thus, it is not possible to compare our CRAAP test scores and interrater reliability with those of other groups. Nonetheless, our approach is consistent with BEME recommendations for choosing and implementing a critical appraisal scale in systematic reviews [38]. All in all, we reckon this work as a first approximation that we hope could serve as a stimulus for new contributions and approaches by other authors and, ultimately, for an enriching debate on how to improve training in DP.

The authors would like to thank the staff and trainees at the Psychiatry Service of the Hospital Clínico Universitario de Valencia (HCUV) for their inspiration, as well as Rosa María Pradera Jauregui for her remarks.

The paper is exempt from ethics committee approval, as it is a systematic review on already available, publicly accessible literature.

On behalf of all authors, the corresponding author states that there are no conflicts of interest regarding this paper. The authors alone are responsible for the content and writing of the paper.

The authors have not received any funding for the present manuscript.

The original idea and its development belonged to J.I.E.P. Inclusion and exclusion criteria were set by J.I.E.P. and D.M.U. The search syntax was constructed by D.M.U. and E.J.A., with further assistance by J.I.E.P. The search was conducted by J.I.E.P. and D.M.U. Data extraction and assessment were conducted independently by J.I.E.P. and D.M.U., with further assistance by E.J.A. Statistical analysis was done by F.B.P. and J.C.G.P. As for the discussion, it was coordinated by J.I.E.P. with relevant contributions coming from D.M.U., J.N., and E.J.A. Meanwhile, F.B.P. and J.C.G.P. offered additional points of view.

1.
American Psychiatric Association
.
What is psychiatry? [Internet]
. [cited 2019 Aug 11]. Available from: https://www.psychiatry.org/patients-families/what-is-psychiatry.
2.
Berrios
GE
.
The history of descriptive psychopathology
. In:
Mezzich
JE
,
Jorge
MR
,
Salloum
IM
, editors.
Psychiatric epidemiology: assessment concepts and methods
.
Baltimore, MD
:
The Johns Hopkins University Press
;
1994
. p.
47
68
.
3.
Berrios
GE
,
Marková
IS
.
Symptoms: historical perspective and effect on diagnosis
. In:
Blumenfield
M
,
Strain
JJ
, editors.
Psychosomatic medicine
.
Philadelphia, PA
:
Lippincott Williams & Wilkins
;
2006
. p.
27
38
.
4.
Berrios
GE
.
The history of mental symptoms: descriptive psychopathology since the nineteenth century
.
Cambridge, England
:
Cambridge University Press
;
1996
.
5.
Marková
IS
,
Berrios
GE
.
Epistemology of mental symptoms
.
Psychopathology
.
2009
;
42
(
6
):
343
9
. .
6.
Berrios
GE
.
History and epistemology of psychopathology
. In:
Kendler
KS
,
Parnas
J
, editors.
Philosophical issues in psychiatry. III, the nature and sources of historical change
.
Oxford, England
:
Oxford University Press
;
2015
. p.
30
50
.
7.
Marková
IS
,
Berrios
GE
.
Epistemology of psychiatry
.
Psychopathology
.
2012
;
45
(
4
):
220
7
. .
8.
Berrios
GE
.
Psychiatry and its objects
.
Rev Psiquiatr Salud
.
2011 Oct
;
4
(
4
):
179
82
.
9.
Fish
F
.
Fish’s clinical psychopathology: signs and symptoms in psychiatry
. 2nd ed.
Bristol, England
:
Wright
;
1985
.
10.
Berrios
GE
,
Marková
IS
.
Toward a new epistemology of psychiatry
. In:
Kirmayer
LJ
,
Lemelson
R
,
Cummings
CA
, editors.
Re-visioning psychiatry: cultural phenomenology, critical neuroscience, and global mental health
.
Cambridge, England
:
Cambridge University Press
;
2015
. p.
41
64
.
11.
Parnas
J
,
Gallagher
S
.
Phenomenology and the interpretation of psychopathological experience
. In:
Kirmayer
LJ
,
Lemelson
R
,
Cummings
CA
, editors.
Re-visioning psychiatry: cultural phenomenology, critical neuroscience, and global mental health
.
Cambridge, England
:
Cambridge University Press
;
2015
. p.
65
80
.
12.
Parnas
J
,
Sass
LA
,
Zahavi
D
.
Rediscovering psychopathology: the epistemology and phenomenology of the psychiatric object
.
Schizophr Bull
.
2013 Mar
;
39
(
2
):
270
7
. .
13.
Parnas
J
.
Foreword
. In:
Jansson
L
,
Nordgaard
J
, editors.
The psychiatric interview for differential diagnosis
. 1st ed.
Copenhagen, Denmark
:
Springer
;
2016
. p.
v
vii
.
14.
Stanghellini
G
.
Psychopathology: re-humanizing psychiatry
.
Acta Psychiatr Scand
.
2013 Jun
;
127
(
6
):
436
7
. .
15.
Andreasen
NC
.
DSM and the death of phenomenology in America: an example of unintended consequences
.
Schizophr Bull
.
2006 Dec
;
33
(
1
):
108
12
.
16.
Rossi
A
.
Psychopathology: education, evidence and translation. the 23rd Congress of the Italian Society of Psychopathology
.
J Psychopathol
.
2019 Mar
;
25
(
1
):
1
2
.
17.
Insel
T
,
Cuthbert
B
,
Garvey
M
,
Heinssen
R
,
Pine
DS
,
Quinn
K
, et al
Research Domain Criteria (RdoC): toward a new classification framework for research on mental disorders
.
Am J Psychiatry
.
2010 Jul
;
167
(
7
):
748
51
. .
18.
De Leon
J
.
One hundred years of limited impact of Jaspers’ general psychopathology on US psychiatry
.
J Nerv Ment Dis
.
2014
;
202
(
2
):
79
87
. .
19.
De Leon
J
.
DSM-5 and the Research Domain Criteria: 100 years after Jaspers’ general psychopathology
.
Am J Psychiatry
.
2014 May
;
171
(
5
):
492
4
.
20.
Kirmayer
LJ
,
Crafa
D
.
What kind of science for psychiatry?
Front Hum Neurosci
.
2014
;
8
(
435
):
435
12
. .
21.
Lilienfeld
SO
,
Treadway
MT
.
Clashing diagnostic approaches: DSM-ICD versus RdoC
.
Annu Rev Clin Psychol
.
2016
;
12
:
435
463
.
22.
Fuchs
T
.
Ecology of the brain: the phenomenology and biology of the embodied mind
.
Oxford, England
:
Oxford University Press
;
2018
.
23.
Berrios
GE
.
Towards a new epistemology of psychiatry
.
Buenos Aires, Argentina
:
Polemos
;
2011
.
24.
Stanghellini
G
,
Broome
MR
.
Psychopathology as the basic science of psychiatry
.
Br J Psychiatry
.
2014 Sep
;
205
(
3
):
169
70
. .
25.
Volpe
U
,
Sass
H
.
Why, what and how should early career psychiatrists learn about phenomenological psychopathology?
In:
Fiorillo
A
,
Calliess
IT
,
Sass
H
, editors.
How to succeed in psychiatry: a guide to training and practice
. 1st ed.
Chichester, West Sussex
:
Wiley-Blackwell
;
2012
. p.
82
97
.
26.
Stanghellini
G
,
Fiorillo
A
.
Five reasons for teaching psychopathology
.
World Psychiatry
.
2015 Feb
;
14
(
1
):
107
8
. .
27.
Marková
IS
,
Chen
E
.
Rethinking psychopathology
.
Cham, Switzerland
:
Springer
;
2020
.
28.
De Leon
J
.
Is psychiatry scientific? A letter to a 21st century psychiatry resident
.
Psychiatry Investig
.
2013
;
10
(
3
):
205
17
. .
29.
De Leon
J
.
Is it time to awaken sleeping beauty? European psychiatry has been sleeping since 1980
.
Rev Psiquiatr Salud
.
2014
;
7
(
4
):
186
94
. .
30.
Morán-Barrios
J
.
Un esid esidentsal para una nueva sociedad. respuestas desde la educación médica: la formación basada en competencias
.
Rev Asoc Esp Neuropsiquiatr
.
2013
;
33
(
118
):
385
405
.
31.
Wijnen-Meijer
M
,
Burdick
W
,
Alofs
L
,
Burgers
C
,
Ten Cate
O
.
Stages and transitions in medical education around the world: clarifying structures and terminology
.
Med Teach
.
2013
;
35
(
4
):
301
7
. .
32.
Hudziak
JJ
.
Crisis in American psychiatric education: an argument for the inclusion of research training for all psychiatric residents
. In:
Zorumski
CF
,
Rubin
EH
, editors.
Psychopathology in the genome and neuroscience era
.
Arlington, VA
:
American Psychiatric Publishing, Inc.
;
2005
. p.
203
28
,
Chapter xiii, 239 Pages
.
33.
Kirkpatrick
JD
,
Kirkpatrick
WK
.
Kirkpatrick’s four levels of training evaluation
.
Alexandria, VA
:
ATD Press
;
2016
.
34.
Frenk
J
,
Chen
L
,
Bhutta
ZA
,
Cohen
J
,
Crisp
N
,
Evans
T
, et al
Health professionals for a new century: transforming education to strengthen health systems in an interdependent world
.
Lancet
.
2010
;
376
(
9756
):
1923
58
. .
35.
Harden
M
,
Grant
J
,
Buck
RG
.
BEME guide no. 1: best evidence medical education
.
Med Teach
.
1999 Jan
;
21
(
6
):
553
62
.
36.
Haig
A
,
Dozier
M
.
BEME guide no. 3: systematic searching for evidence in medical education: part 1: sources of information
.
Med Teach
.
2003 Jan
;
25
(
4
):
352
63
. .
37.
Haig
A
,
Dozier
M
.
BEME guide no. 3: systematic searching for evidence in medical education: part 2: constructing searches
.
Med Teach
.
2003 Jan
;
25
(
5
):
463
84
. .
38.
Hammick
M
,
Dornan
T
,
Steinert
Y
.
Conducting a best evidence systematic review. Part 1: from idea to data coding. BEME guide no. 13
.
Med Teach
.
2010 Jan
;
32
(
1
):
3
15
. .
39.
Sharma
R
,
Gordon
M
,
Dharamsi
S
,
Gibbs
T
.
Systematic reviews in medical education: a practical approach: AMEE guide 94
.
Med Teach
.
2015 Feb
;
37
(
2
):
108
24
. .
40.
Liberati
A
,
Altman
DG
,
Tetzlaff
J
,
Mulrow
C
,
Gøtzsche
PC
,
Ioannidis
JP
, et al
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration
.
BMJ
.
2009 Jul
;
339
:
b2700
. .
41.
Bramer
WM
,
Rethlefsen
ML
,
Kleijnen
J
,
Franco
OH
.
Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study
.
Syst Rev
.
2017 Dec
;
6
(
1
):
245
. .
42.
Houpt
JL
,
Weinstein
HM
,
Russell
ML
.
The application of competency-based education to consultation-liaison psychiatry: I. Data gathering and case formulation
.
Int J Psychiatry Med
.
1977 Dec
;
7
(
4
):
295
307
.
43.
Houpt
JL
,
Weinstein
HM
,
Russell
ML
.
The application of competency-based education to consultation-liaison psychiatry: II. Intervention knowledge and skills
.
Int J Psychiatry Med
.
1977 Dec
;
7
(
4
):
309
20
. .
44.
Russell
ML
,
Weinstein
HM
,
Houpt
JL
.
The application of competency-based education to consultation-liaison psychiatry: III. Implications
.
Int J Psychiatry Med
.
1977 Dec
;
7
(
4
):
321
8
. .
45.
Hung
E
,
Azzam
A
.
Supervision of trainees in the psychiatric emergency service
. In:
Riba
MB
,
Ravindranath
D
, editors.
Clinical manual of emergency psychiatry
.
Arlington, VA
:
American Psychiatric Publishing, Inc
;
2010
. p.
315
47
.
Chapter xxvii, 406 Pages
.
46.
James
M
,
Hung
E
.
Supervision of trainees in the psychiatric emergency service
. In:
Riba
MB
,
Ravindranath
D
,
Winder
GS
, editors.
Clinical manual of emergency psychiatry
. 2nd ed.
Arlington, VA
:
American Psychiatric Association
;
2016
. p.
295
326
.
47.
Sullivan
GM
.
Deconstructing quality in education research
.
J Grad Med Educ
.
2011 Jun
;
3
(
2
):
121
4
. .
48.
Garcia
M
,
Daugherty
C
,
Ben Khallouq
B
,
Maugans
T
.
Critical assessment of pediatric neurosurgery patient/parent educational information obtained via the internet
.
J Neurosurg Pediatr
.
2018
;
21
(
5
):
535
41
. .
49.
Texas State University Libraries
.
LibGuides: finding and evaluating web sources: the CRAAP test [Internet]
.
2019
[cited 2019 Oct 4]. Available from: https://guides.library.txstate.edu/c.php?g=184587&p=4604817.
50.
Cook
DA
,
Reed
DA
.
Appraising the quality of medical education research methods: the Medical Education Research Study Quality Instrument and the Newcastle-Ottawa Scale-education
.
Acad Med
.
2015
;
90
(
8
):
1067
76
. .
51.
Kothari
D
,
Gourevitch
MN
,
Lee
JD
,
Grossman
E
,
Truncali
A
,
Ark
TK
, et al
Undergraduate medical education in substance abuse: a review of the quality of the literature
.
Acad Med
.
2011 Jan
;
86
(
1
):
98
112
. .
52.
Stein
SP
,
Karasu
TB
,
Charles
ES
,
Buckley
PJ
.
Supervision of the initial interview. a study of two methods
.
Arch Gen Psychiatry
.
1975 Feb
;
32
(
2
):
265
. .
53.
Willmuth
LR
,
McKegney
FP
.
A basic clinical skills tutorial for first-year psychiatric residents
.
Acad Psychiatry
.
1977
;
1
(
2
):
151
6
. .
54.
Janzen
CL
,
Philips
I
,
Malloy
M
.
Child psychiatry education in early child development: description of a training program
.
Child Psychiatry Hum Dev
.
1981
;
11
(
3
):
158
66
. .
55.
Marin
RS
,
Foster
JR
,
Ford
CV
,
Reifler
BV
,
Reisberg
B
,
Robinowitz
CB
, et al
A curriculum for education in geriatric psychiatry
.
Am J Psychiatry
.
1988 Jul
;
145
(
7
):
836
43
. .
56.
Shea
SC
,
Mezzich
JE
,
Bohon
S
,
Zeiders
A
.
A comprehensive and individualized psychiatric interviewing training program
.
Acad Psychiatry
.
1989 Jun
;
13
(
2
):
61
72
. .
57.
Halikas
JA
.
Model curriculum for alcohol and drug abuse training and experience during the adult psychiatry residency
.
Am J Addict
.
1992 Jan
;
1
(
3
):
222
9
. .
58.
Hodes
M
.
A core curriculum for child and adolescent psychiatry
.
Eur Child Adolesc Psychiatry
.
1998 Dec
;
7
(
4
):
250
4
. .
59.
Thompson
JW
.
A curriculum for learning about American Indians and Alaska Natives in psychiatry residency training
.
Acad Psychiatry
.
1996 Mar
;
20
(
1
):
5
14
.
60.
Yates
WR
,
Gerdes
TT
.
Problem-based learning in consultation psychiatry
.
Gen Hosp Psychiatry
.
1996 May
;
18
(
3
):
139
44
. .
61.
Blass
DM
.
A pragmatic approach to teaching psychiatry residents the assessment and treatment of religious patients
.
Acad Psychiatry
.
2007 Feb
;
31
(
1
):
25
31
. .
62.
Brenner
AM
.
Uses and limitations of simulated patients in psychiatric education
.
Acad Psychiatry
.
2009 Mar
;
33
(
2
):
112
9
. .
63.
Bromley
E
,
Braslow
JT
.
Teaching critical thinking in psychiatric training: a role for the social sciences
.
Am J Psychiatry
.
2008 Nov
;
165
(
11
):
1396
401
. .
64.
Kirmayer
LJ
,
Rousseau
C
,
Guzder
J
,
Jarvis
GE
.
Training clinicians in cultural psychiatry: a Canadian perspective
.
Acad Psychiatry
.
2008 Jul
;
32
(
4
):
313
9
. .
65.
Nikapota
A
.
Transcultural training in child and adolescent psychiatry
. In:
Garralda
ME
,
Raynaud
JP
, editors.
Culture and conflict in child and adolescent mental health BT: culture and conflict in child and adolescent mental health
.
Lanham, MD
:
Jason Aronson
;
2008
. p.
205
22
.
Chapter xviii, 274 Pages
.
66.
Santos
CW
,
Harper
A
,
Saunders
AE
,
Randle
SL
.
Developing a psychopathology curriculum during child and adolescent psychiatry residency training: general principles and a problem-based approach
.
Child Adolesc Psychiatr Clin N Am
.
2007 Jan
;
16
(
1
):
95
110.
67.
Shea
SC
,
Green
R
,
Barney
C
,
Cole
S
,
Lapetina
G
,
Baker
B
.
Designing clinical interviewing training courses for psychiatric residents: a practical primer for interviewing mentors
.
Psychiatr Clin North Am
.
2007 Jun
;
30
(
2
):
283
314
. .
68.
Taylor
MA
,
Vaidya
NA
.
Psychopathology in neuropsychiatry: DSM and beyond
.
J Neuropsychiatry Clin Neurosci
.
2005 May
;
17
(
2
):
246
9
. .
69.
Etkin
A
,
Cuthbert
B
.
Beyond the DSM: development of a transdiagnostic psychiatric neuroscience course
.
Acad Psychiatry
.
2014 Apr
;
38
(
2
):
145
50
. .
70.
Fiorillo
A
,
Sampogna
G
,
Del Vecchio
V
,
Luciano
M
,
Ambrosini
A
,
Stanghellini
G
.
Education in psychopathology in Europe: results from a survey in 32 countries
.
Acad Psychiatry
.
2016 Apr
;
40
(
2
):
242
8
.
71.
Fluyau
D
.
Integrating DSM/ICD, research domain criteria, and descriptive psychopathology in teaching and practice of psychiatry
.
Front Psychiatry
.
2018 Oct
;
9
(
Oct
):
484
. .
72.
Luciano
M
,
Del Vecchio
V
,
Sampogna
G
,
De Rosa
C
,
Ambrosini
A
,
Fiorillo
A
, et al
Training in psychopathology in Europe: results from a survey
.
Eur Psychiatry
.
2015
;
30
:
676
. .
73.
Sampogna
G
,
Del Vecchio
V
,
Luciano
M
,
De Rosa
C
,
Fiorillo
A
.
Training in psychopathology in Europe: Are we doing well? A survey among early career psychiatrists
.
J Psychopathol
.
2014 Dec
;
20
(
4
):
377
80
.
74.
Tobia
A
,
Draschil
T
,
Sportelli
D
,
Katsamanis
M
,
Rosenberg
S
,
Williams
JM
.
The horror!: a creative framework for teaching psychopathology via metaphorical analyses of horror films
.
Acad Psychiatry
.
2013 Mar
;
37
(
2
):
131
6
. .
75.
Valdivieso
SA
,
Brockering
W
,
Mejias
M
,
Villarroel
L
,
Maldonado
G
,
Sirhan
M
.
Evaluación de un modelo de enseñanza de la psicopatología para esidents de psiquiatría
.
ARS Med Rev Cienc Méd
.
2016 Feb
;
40
(
1
):
19
27
.
76.
Lockyer
J
,
Carraccio
C
,
Chan
MK
,
Hart
D
,
Smee
S
,
Touchie
C
, et al
Core principles of assessment in competency-based medical education
.
Med Teach
.
2017 Jun
;
39
(
6
):
609
16
. .
77.
Frank
JR
,
Snell
L
,
Englander
R
,
Holmboe
ES
.
On behalf of the ICBME collaborators. Implementing competency-based medical education: moving forward
.
Med Teach
.
2017 Jun
;
39
(
6
):
568
73
.
78.
WFME
.
WFME global standards for quality improvement: postgraduate medical education. The 2015 revision
.
Copenhagen, Denmark
:
WFME
;
2015
.
79.
Etxeandia-Pradera
JI
,
Martinez-Uribe
D
,
Bellver-Pradas
F
,
Gonzalez-Piqueras
JC
,
Aguilar
EJ
.
The challenge of introducing competency-based psychiatry training in Spain
.
Acad Psychiatry
.
2020 Dec
;
44
(
6
):
770
4
. .
80.
BEME
.
Steps in the review process: forming a review group [Internet]
. [cited 2019 Nov 29]. Available from: https://www.bemecollaboration.org/Step+2+Review+Group/.
81.
Mombour
W
.
Teaching psychopathology using the AMDP system in postgraduate education
.
Acta Psychiatr Belg
.
1987
;
87
(
2
):
159
64
.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.