Modern modularity and the road towards a modular psychiatry

The modular mind and psychiatry: toward clinical integration with a focus on self-disorders

One of the foundational tenets of evolutionary psychology, the modular view of the mind, offers promising applications for clinical psychiatry. This perspective conceptualizes the mind as a collection of specialized information-processing modules, shaped by natural selection to address adaptive challenges faced by our ancestors. In this paper, we propose several points of integration between the modularity framework and clinical psychiatric practice. First, we argue that the descriptive psychopathology of self-disorders provides evidence supporting the modular view, demonstrating how a dysfunctional minimal self may expose the mind's modular architecture to conscious awareness. Next, we will explore how the modular perspective can illuminate the nature of intrapsychic conflicts. Finally, we will discuss how evidence from neuropsychiatric syndromes supports the modular view of the mind and, in turn, how this perspective can provide a basis for classifying mental disorders.

Robust empirical data and clinical utility: the only drivers of change

We have arrived at our current descriptive classifications, with their many and varied array of categories, through the committee processes of DSM and ICD. To date, expert opinion, rather than solid science, has been the driver for change and this helps to explain the bewildering number of diagnostic categories and the fact that many patients meet criteria for several categories. Over the coming years, advances in neuroscience will offer the opportunity to base classification on robust evidence with diagnostic entities mapping more closely onto the workings of the brain. There are major shortcomings to the current classifications but all changes come at a cost to their users. We should be fully aware of the shortcomings and be thinking about the future. However, major changes to classification should await the emergence of robust empirical data and proven clinical utility. This will be the best way to benefit patients.

EPA guidance on improving the image of psychiatry

This paper explores causes, explanations and consequences of the negative image of psychiatry and develops recommendations for improvement. It is primarily based on a WPA guidance paper on how to combat the stigmatization of psychiatry and psychiatrists and a Medline search on related publications since 2010. Furthermore, focussing on potential causes and explanations, the authors performed a selective literature search regarding additional image-related issues such as mental health literacy and diagnostic and treatment issues. Underestimation of psychiatry results from both unjustified prejudices of the general public, mass media and healthcare professionals and psychiatry's own unfavourable coping with external and internal concerns. Issues related to unjustified devaluation of psychiatry include overestimation of coercion, associative stigma, lack of public knowledge, need to simplify complex mental issues, problem of the continuum between normality and psychopathology, competition with medical and non-medical disciplines and psychopharmacological treatment. Issues related to psychiatry's own contribution to being underestimated include lack of a clear professional identity, lack of biomarkers supporting clinical diagnoses, limited consensus about best treatment options, lack of collaboration with other medical disciplines and low recruitment rates among medical students. Recommendations are proposed for creating and representing a positive self-concept with different components. The negative image of psychiatry is not only due to unfavourable communication with the media, but is basically a problem of self-conceptualization. Much can be improved. However, psychiatry will remain a profession with an exceptional position among the medical disciplines, which should be seen as its specific strength.

Schizophrenia in 2020: Trends in diagnosis and therapy

Schizophrenia research is providing an increasing number of studies and important insights into the condition's etiopathogenesis based on genetic, neuropsychological and cranial neuroimaging studies. However, research progress has not yet led to the incorporation of such findings into the revised classification criteria of mental disorders or everyday clinical practice. By 2020, schizophrenia will most likely still be a clinically defined primary psychotic disorder. While there is some hope that treatment will be improved with new antipsychotic drugs, drugs addressing negative symptoms, more refined psychotherapy approaches and the introduction of new treatment modalities like transcranial magnetic stimulation, an additional hope is to improve early detection and prevention. As the results of new research into the etiopathogenesis of schizophrenia are promising to improve diagnosis, classification and therapy in the future, a picture of complex brain dysfunction is currently emerging requiring sophisticated mathematical methods of analysis. The imminent clinical challenge will be to develop comprehensive diagnostic and treatment modules individually tailored to the time-variable needs of patients and their families.

DSM-5 reviewed from different angles: goal attainment, rationality, use of evidence, consequences--part 1: general aspects and paradigmatic discussion of depressive disorders

DSM-5 was published in 2013 after about 10 years of preparation. Part 1 of this paper discusses several more general aspects of DSM-5 and offers a detailed, paradigmatic analysis of changes made to the chapter on depressive disorders. The background for the changes is analysed on the basis of a PubMed search and review papers on the classification of mental disorders in general and on empirical knowledge about individual disorders. Contrary to the original plans, DSM-5 has not introduced a primarily dimensional diagnostic system but has widely preserved the categorical system of disorders. Also, it has not adopted a more neurobiological approach to disorders by including biological markers to increase the objectivity of psychiatric diagnoses but has maintained the primarily symptom-based, descriptive approach. The criteria for some disorders have been changed, including affective, schizophrenic and addiction disorders, and a few new disorders have been added. A minimal version of the dimensional approach was realised through the introduction of several transnosological specifiers and the option to make symptom- or syndrome-related severity and dimensional assessments. These specifiers and assessments might allow a more individualised description of a patient's psychopathological state and more personalised treatment. However, most of the symptom- and syndrome-related assessments are not mandatory and therefore may not be used in clinical practice.

[Syndromal versus nosological diagnosis]

Against the background of the current preparation of ICD-11 and DSM-5, there is a discussion whether syndromal approaches should replace the traditional nosological diagnosis in psychiatry. From a historical point of view the syndromal approach results from a reaction to the nosological model of Emil Kraepelin. Later the syndromal diagnostic approach became more important because it enabled a quantitative-dimensional assessment and analysis of psychopathological data using modern statistical procedures. However, attempts to ascribe the traditional nosological categories to psychopathological syndromes using multivariate statistical methods have failed. The syndromal approach allows a differentiated recording of the cross-sectional symptomatology; however, a plurality of different syndromes might be registered without considering meaningful principles of classification and longitudinal aspects. The syndromal approach should be complemented by a nosological classification based mainly on the psychopathological course due to the absence of consistent neurobiological findings.

Characterization of spontaneous Parkinsonism in drug-naive patients with nonaffective psychotic disorders

Spontaneous Parkinsonism (SP) in schizophrenia-related disorders is poorly characterized. The objective of this study was to examine the concordance and clinical validity of alternative definitions of SP in patients with nonaffective psychotic disorders. Two-hundred drug-naive patients with nonaffective psychotic disorders were examined for core parkinsonian signs, including bradykinesia, rigidity, and tremor, and diagnosed of SP according to the Simpson-Angus Scale (SAS) cutoff criterion, the UK Parkinson's disease brain bank (UKPDBB) criteria, the National Institute of Neurological Disorders and Stroke (NINDS) criteria, and criteria requiring the presence of all three core features (full syndrome criteria). Parkinsonian signs and criteria were examined in relation to a number of relevant clinical variables. The most frequent sign was rigidity (33.5%) followed by bradykinesia (16%) and tremor (12%). The prevalence rate of SP according to the SAS cutoff criterion, the UKPDBB criteria, the NINDS criteria for possible and probable SP, and the full syndrome criteria were 20.5, 13, 25.5, 18.5, and 4%, respectively. Bradykinesia was specifically related to negative symptoms, rigidity to neurological soft signs, and tremor to dyskinetic movements. The set of criteria showing more associations with clinical variables were the NINDS criteria for probable SP. Patients fulfilling these criteria had higher ratings for poor premorbid adjustment, negative symptoms, dyskinesia, neurological soft signs, and poor global treatment response than those without that diagnosis. The NINDS criteria for probable SP, i.e., presence of any two of the three core parkinsonian signs, seem to be the most suitable for clinical and research purposes.

Integrative etiopathogenetic models of psychotic disorders: methods, evidence and concepts

Integrative models of the etiopathogesnesis of psychotic disorders are needed since a wealth of information from such diverse fields as neurobiology, psychology, and the social sciences is currently changing the concepts of mental disorders. Several approaches to integrate these streams of information into coherent concepts of psychosis are feasible and will need to be assessed in future experimental studies. Common to these concepts are the notion of psychotic disorders as brain disorders and a polythetic approach in that it is increasingly realized that a multitude of interindividually partially different pathogenetic factors interact in individual persons in a complex fashion resulting in the clinical symptoms of psychosis.

Modular networks involving the medial frontal cortex: towards the development of neuropsychiatry

OBJECTIVES

The pathophysiology of mental disorders is largely unresolved. We propose that the identification of abnormalities in brain modular networks will provide a promising approach for the understanding of mental disorders.

METHODS

We review the current discussion on the neuroscientific basis of psychiatric diseases and review recent studies in functional neuroimaging and systems physiology on mental functions of the human brain.

RESULTS

We propose that brain functional units are organized in modular networks. Modular networks allow for flexibility within the modular processing units and across interconnected modules affording optimization of task performance and deficit compensation in disease. As an example it will be shown that differentiated modules in medial frontal cortex play a critical role for the control of behaviour. This will be contrasted to recent studies in neurological and psychiatric patients revealing behavioural abnormalities due to lesions or reversibly deprived functions in the medial frontal cortex.

CONCLUSIONS

These findings are conceptualized as starting points for a neuroscience based diagnosis and treatment of brain diseases at the border of psychiatry and neurology.

Psychopathology in the 21st century

OBJECTIVES

The present publication sets out to evaluate the position of psychopathology in the 21st century and should also serve as a basis for defining the framework for the future tasks of the WFSBP Task Force.

METHODS

Review of publications on the various approaches of psychopathology in general and of different tasks, theories and tools of psychopathology approaches in particular.

RESULTS

The main tasks of psychopathology are, to record and describe experiential and behavioral abnormalities in their intersubjective context, to explain their origin from an objective scientific perspective, and to attempt to understand them from the subjective perspective of the patient. In order to provide stable fundaments for the work in clinical and scientific psychiatry all three components are indispensable.

CONCLUSIONS

The future of psychiatry hence lies in the hands of a type of psychopathology that we will call Integrative Psychopathology. The main tasks of psychopathology can only be pursued in close cooperation with other branches of science interested in studying psychiatric issues. Whereas contemporary psychopathology must lay the foundations for that cooperation, Integrative Psychopathology must be complemented by further advancements in Theoretical Psychopathology, so as to enable conceptual new developments, which can then be fruitful for cooperative research and psychiatric clinical practice.

The genetics of obsessive-compulsive disorder and Tourette syndrome: an epidemiological and pathway-based approach for gene discovery

OBJECTIVE

To provide a contemporary perspective on genetic discovery methods applied to obsessive-compulsive disorder (OCD) and Tourette syndrome (TS).

METHOD

A review of research trends in genetics research in OCD and TS is conducted, with emphasis on novel approaches.

RESULTS

Genome-wide association studies (GWAS) are now in progress in OCD and TS and will provide a platform for future discovery of common gene variants. Optimally, newer next-generation genome sequencing methods can also be used to detect larger effect genes (rare gene variants), taking advantage of pedigrees. Studies of gene networks or sets rather than individual genes will be required to elucidate biological etiology, as neural systems appear to act redundantly. Newer phenotyping strategies, such as symptom-based subtypes, cross-disorder latent class types, and intermediate phenotypes (endophenotypes) will need to be developed and tested to better align clinical and physiological measures with genetic architecture.

CONCLUSION

Although genetics research has made significant advances based on computational strength and bioinformatics advances, newer approaches to phenotyping and judicious study of gene etiological networks will be needed to uncover the genetic etiology of OCD and TS.

The Kraepelinian dichotomy - going, going... but still not gone

Recent genetic studies reinforce the view that current approaches to the diagnosis and classification of major psychiatric illness are inadequate. These findings challenge the distinction between schizophrenia and bipolar disorder, and suggest that more attention should be given to the relationship between the functional psychoses and neurodevelopmental disorders such as autism. We are entering a transitional period of several years during which psychiatry will need to move from using traditional descriptive diagnoses to clinical entities (categories and/or dimensions) that relate more closely to the underlying workings of the brain.

Future classification of psychotic disorders

Reclassifying psychotic disorders in the upcoming revisions of the mental disorders section of ICD-10 and DSM-IV will first necessitate the development of a unified and operationalized definition of the term "psychosis". Ideally, such a definition would be harmonized between both groups of diagnostic classification systems and become part of a glossary of terms. Conceptually and based on epidemiological and some genetic work, incorporating dimensional criteria and criteria for prodromal high-risk symptoms may become feasible. Considering the currently available evidence from genetic, neuroimaging and neurophysiological studies, none seems yet sufficiently validated to warrant major changes. However, further research in these areas promises to yield important new insights which may become relevant for the classification of psychotic disorders in the near future. Given the rapid progress in these fields, regular updates of the classification criteria at shorter intervals than in the past may become necessary.

Development of DSM-V and ICD-11: tendencies and potential of new classifications in psychiatry at the current state of knowledge

A reason for the necessity to revise ICD-10 and DSM-IV is the increase of knowledge in the past 20 years, especially neurobiological knowledge. But is this increase of knowledge, for example in the field of neurogenetics, of such magnitude that a revision of the psychiatric classification is necessary and promises to be fruitful? The current plans for DSM-V or ICD-11, respectively, focus on different improvements. In this context also the introduction of a purely syndromatic/dimensional approach without including etiopathogenetic hypotheses, is discussed. A switch to such a dimensional approach, which was discussed among others in the DSM-V task force Deconstructing Psychosis, would be the most radical development. It could avoid many theoretical pre-assumptions about causal hypotheses, which are still associated with ICD-10 and DSM-IV. This would indeed increase the validity of psychiatric classification, but it would also reduce the information as compared to traditional diagnostic categories with all the current implications concerning etiopathogenesis, therapy and prognosis. Such a dimensional approach would also mean that the syndromes would have to be assessed in a standardized way for each person seeking help from the psychiatric service system or for each person undergoing psychiatric research. This would have to be a multi-dimensional assessment covering all syndromes existing within different psychiatric disorders. Based on the different aspects that must be considered in this context, a careful revision seems more advisable than a radical change of classification.