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Review of "Defining Psychopathology in the 21st Century"

By John E. Helzer and James J. Hudziak (editors)
American Psychiatric Publishing, 2002
Review by Christian Perring, Ph.D. on Aug 26th 2003
Defining Psychopathology in the 21st Century

Defining Psychopathology in the 21st Century is a collection of 15 mostly-brief papers on the future of psychiatric classification and diagnosis. The papers focus on scientific findings rather than conceptual issues, although of course philosophical assumptions always lie in the background of such work. While the subtitle of the book mentions DSM-V, it is likely that most of the ideas that the authors propose would in fact only be applicable to later editions of DSM, unless there are major scientific breakthroughs in the next few years. For example, Part II of the book has three papers on Imaging Psychopatholgy, but none of the papers claims that it is yet possible to use brain imaging as a reliable diagnostic tool. Rather, they talk in terms of hypotheses supported by data and promising findings, as well as the urgent need for more research. Similarly, three of the papers in the final part of the book discuss the role of genetic abnormalities in mental illness, and they survey a range of fascinating studies that suggest genetic factors in disorders such as ADHD, OCD, tics, and schizophrenia. But they do not report the availability any definite tests to indicate people have these disorders. Estimates as to when we will find genetic markers for major mental illness vary. In a recent Charlie Rose interview, James Watson said that we have the technological capability to discover the genetic abnormalities that cause some of the most prevalent forms of manic depression with just six months of intensive research, but that there is currently not enough funding to carry out research at such a pace. Watson, whose own son has schizophrenia, is clearly impatient for the research to be carried out, because he believes that it will help to improve the quality of our lives. Strikingly though, he says that if it were possible to test for possibility that one will develop Alzheimer's disease before one developed any symptoms, he himself would not want the test, because he would not want to know that he would was at high risk for developing the disease. Of course, there is research being done on ways to cure genetic disorders -- for example, it was recently announced that trials are starting on genetic therapy for Parkinson's disease. Nevertheless, it is clear that it will be decades before any genetic therapy for major psychiatric illnesses are available to the public as standard treatment.

The first part of Defining Psychopathology in the 21st Century concerns mostly methodological issues. In "Five Criteria for an Improved Taxonomy of Mental Disorders," Robert Kendell sets out come of the central issues and notably argues that for some mental disorders, it might be appropriate to adopt a dimensional approach in assessing the severity of a cluster of symptoms rather than use a categorical approach that simply decides whether or not a person has a disorder. He recognizes that there is resistance to the dimensional approach both because it seems more complex and cumbersome and also because people have become used to the categorical approach. Kendell also argues that there is no particular reason to be skeptical about some surveys that have shown using current definitions of mental disorder that during any given year, nearly 30% of the population suffers from a mental disorder. He compares this with surveys that have shows that in a 14-day period, 95% of respondents considered unwell at some point.

Darrel Regier and William Narrow also address the concern about the possible over-inclusivity of DSM criteria and they argue that the increased emphasis in DSM-IV on the need that disorders have "clinical significance" has helped to deal with this problem. They support their views through reanalysis of the data from the Epidemiological Catchment Area (ECA) program and the National Comorbidity Survey (NCS). In these surveys, clinical significance is measured rather crudely with questions such as "Did symptoms interfere with your life or activities a lot?" along with data about mental health service utilization. In a reply to this paper, Jerome Wakefield and Robert Spitzer build on a previously co-authored paper, "DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? (Am J Psychiatry, 156: 1856-1864, 1999). This response, "Why Requiring Clinical Significance Does Not Solve Epidemiology's and DSM's Validity Problem," is admirable for its explication of the central issues and the power of the argument. It is helpful to also compare these papers with that by Wakefield and First, "Clarifying the Distinction Between Disorder and Nondisorder: Confronting the Overdiagnosis (False-Positives) Problem in DSM-V," in Advancing DSM, edited by Katharine Phillips et al, (Washington, DC: American Psychiatric Association, 2002). Wakefield and Spitzer argue that the clinical significance criterion is riddled with problems. For example, they argue that the fact that a person seeks out mental health services is not a good measure of whether her symptoms are clinically significant. Furthermore, they argue that it is possible to have mental disorders that do not significantly interfere with one's life, and so the clinical significance criterion will lead to false negatives. They don't in this paper say much about how they propose to solve the false positives problem, because Wakefield has addressed his solution to the problem at length elsewhere.

The papers in the three other parts of the book are technical and will not be very accessible to those unfamiliar with the science and technology that they discuss. In Part II, Wayne Dreverts contributes the longest chapter in the book on "Neuroimaging Studies of Mood Disorders." Jane Epstein et al. report work on functional imaging, and conclude that, "This evolving neurobiological understanding does not supplant previous phenomenologic approaches to psychiatric taxonomy" (p. 67), and they draw a comparison between Charcot's description of the symptoms of Parkinson's disease and the later identification of its pathophysiological basis. Such work does tend to support the view of mental disorders as brain dysfunctions. While this is compatible with the existence of psychological, social and environmental causes of disorders, there is a real danger that most research will focus on trying to treat the disorder by trying to directly change the patient's brain function rather than using other approaches, and this may not always be the best solution. Those who are concerned with the increasing reductionism of psychiatry will not find much in these papers to allay their fears.

The third paper in this part, "Genetic Neuroimaging: Helping to Define Phenotypes in Affective Disorders" by Kelly Botteron, is one of the most methodologically sophisticated in the book. Botteron points out that, "It is increasingly clear that the factors hindering the identification of genes related to psychiatric disorders are not related to molecular genetic technology but to phenotypic description of disorders in order to accurately characterize taxonomy" (p. 109). She goes on to discuss in some detail how both neuroimaging and behavioral genetic analysis may help the project of describing the phenotype.

Part III of the book deals with longitudinal studies. It includes papers on longitudinal patterns of alcohol use, and another on ADHD comorbidity findings from te MTA study. There is a short paper by Thomas Achenbach setting out a proposal on empirically based assessment which builds and summarizes on his previous work. However, the paper by Stephen Buka and Stephen Gilman on "Psychopathology and the Life Course" stands out one of the more antireductionist in the book. Rather than simply seeing a mental disorder as an event that befalls a person as a particular time, they argue that "elements of life course human development are central to the valid classification of most forms of psychopathology in both childhood and adulthood" (p. 132). Their main proposal is that the life course of patients be used in distinguishing between different subtypes of mental disorders. They argue that doing this should lead to dramatic increases in the scientific understanding of mental disorders. (It is a little surprising that their paper never mentions one of the founders of American psychiatry, Adolf Meyer, who placed great emphasis on understanding a patient's whole life history in order to be able to properly understand his or her mental illness.)

The final part on "Exploring Alternatives" is mostly concerned with genetics. Both Kathleen Merikangas and Stephen Faraone have papers addressing the need for better phenotype definition. The clearest vision of how genetics might shape the future of psychiatry is provided by Hudziak's paper on "Importance of Phenotype Definition in Genetic Studies of Child Psychopathology." The central issue he addresses is how to get data on children's symptoms and the problem caused by the differences in different methods. The reports of parents, teachers, and children often fail to agree. However, it is the conclusion of the paper that is most striking. He writes, "As we refine our taxonomic approach, we may have more success identifying genetic and environmental risks for ADHD. Such an approach will most likely result in a taxonomy that is truly both phenotypic and genotypic. For example, in the future, children with ADHD may well be described as ADHD-Dopamine 4 Receptor Gene (7), ADHD-Dopamine Transporter Gene (10), and ADHD-Dopamine 3 Receptor Gene" (p. 227). This is of course an interesting suggestion, and it may be true that it will help treatment. Hudziak still envisages the continued use of behavioral and cognitive behavioral treatments in addition to other kinds. Nevertheless, such a change in psychiatric taxonomy will give many clinicians pause for thought, and many will probably wonder how such changes will affect our overall understanding of attention problems in children and adolescents.

The methodological discussion and research reported in this book are important work, and clearly, they need to be pursued. Diagnosing genetic susceptibility to serious mental disorder may aid clinicians in recommending preventative measures. However, it is also worth being clear about the limitations of such research. We are able to diagnose an increasing number of genetic disorders but we are a long way from having any cure or even effective palliative treatment. Diagnosis of genetic disorders is used for pregnant women in case they decide they want to abort a fetus that might develop disorders and in pre-implantation in vitro fertilization, for couples to select children who should have less likelihood of developing serious disorders. Diagnostic information has also been used by health insurance companies to refuse coverage to people who are at elevated risk of developing serious disorders, although there has been legislation to limit such actions. It is hard to see how these scientific advances in diagnosis will directly help patients in the short term, since we already have reliable methods of diagnosing ADHD, depression, anxiety, obsessive compulsive disorder, tics, and even schizophrenia and manic depression. Furthermore, treatments tend to be aimed at symptom alleviation rather than removal of the underlying cause, and so the diagnosis of the underlying disorder is of secondary importance. It is possible that future treatment may be able to get to the heart of the problem and even provide cures, but such treatment is still just a glimmer in researchers' eyes.

Defining Psychopathology in the 21st Century is a fascinating collection of papers, and represents some of the best research being done in current psychiatry. Nevertheless, it is striking as much for what it leaves uncovered as for what it includes. It contains no discussion of research on individual psychotherapy or family systems for the future of psychiatric taxonomy. It includes no discussion of the changes in our society or the comparison between different cultures as relevant to our classification of mental illness. This may be because no good research is being performed on such approaches. If so, one might wonder what why this would be. Whatever, the reasons, it does clearly suggest that the divide between medicalized psychiatry and other branches of clinical psychology is likely to deepen in coming decades.

 

2003 Christian Perring. All rights reserved.

Christian Perring, Ph.D., is Chair of the Philosophy Department at Dowling College, Long Island, and editor of Metapsychology Online Review.  His main research is on philosophical issues in medicine, psychiatry and psychology.

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