Limitations of the symptom-oriented approach to psychiatric research

Carving versus Stitching: The Concept of Psychic Function and the Continuity/Discontinuity Debate

BACKGROUND

The current debate on the continuity or discontinuity of psychotic symptoms and common psychic experiences has mainly dealt with methodological, epidemiological and clinical issues, but it has neglected epistemological research on the main concepts of the field.

METHODS

The implicit epistemic structure of continuity models of psychotic symptoms and its effect on research are addressed.

RESULTS

We explain how the seemingly commonsense, unproblematic concept of psychic function may explain the contradictions and paradoxes of research.

CONCLUSIONS

A new model of symptom individuation and symptom eliciting is proposed - based on the concepts of 'schemas', 'embodied affordances' and 'thick/thin descriptions'.

DEVELOPMENT OF DISRUPTIVE BEHAVIORS IN YOUNG CHILDREN: A PROSPECTIVE POPULATION-BASED COHORT STUDY

We know relatively little about the development of disruptive behaviors (DBs), and gender differences therein. The objective of this study was to describe the continuity and discontinuity in the degree to which young children in the general population are reported to exhibit specific DBs over time. Data came from the Québec Longitudinal Study of Child Development. First, the results show that relatively few children exhibit DBs on a frequent basis at 41 months of age. Second, the results show that a majority of children who exhibit a particular DB on a frequent basis at 41 months of age did not do so 1 year earlier. In addition, a majority of children who exhibited a particular DB on a frequent basis at 29 months of age no longer do so 1 year later. Third, gender differences in DBs (boys > girls) are either emerging or at least increasing in magnitude between 29 and 41 months of age. Consistent with the canalization of the behavioral development principle, children who exhibited DBs on a frequent basis at 29 months of age are less likely to stop doing so in the following year if they had exhibited the same behaviors at 17 months of age.

The development of prosocial behaviors in young children: a prospective population-based cohort study

Researchers know relatively little about the normative development of children's behaviors aimed at alleviating distress or discomfort in others. In this article, the authors aim to describe the continuity and discontinuity in the degree to which young children in the general population are reported to exhibit specific prosocial behaviors. Data came from the Québec Longitudinal Study of Child Development. Consistent with Hay's model of prosocial development, the results show that there were about as many children who stopped exhibiting prosocial behaviors between 29 and 41 months of age as there were children who started doing so during this period. Further, gender differences (girls > boys) in prosocial behaviors are either emerging or at least increasing in magnitude, with girls being more likely to start and boys being more likely to stop exhibiting these behaviors between 29 and 41 months of age. Consistent with the early-onset hypothesis, children who exhibit prosocial behaviors at 17 months of age are less likely to stop exhibiting the same behaviors between 29 and 41 months of age. Otherwise, if they did not exhibit prosocial behaviors at 29 months of age, they are also more likely to start doing so in the following year.

The 'continuum of psychosis': scientifically unproven and clinically impractical

The limitations of current diagnostic categories are well recognised but their rationale, advantages and utility are often ignored. The scientific support for a 'continuum of psychosis' is limited, and the examination of whether categories, a continuum or more than one continua, and alternatives such as subtypes or hybrid models, best account for the distributions of symptoms in populations has simply not been done. There is a lack of discussion, let alone consensus, about the critical aspects of psychosis to measure, the best ways to quantify those and how these would be applied in clinical practice. Systematic studies are needed to evaluate which of a range of plausible approaches to the classification of psychosis is most useful before change could be justified.

Madness explained: Why we must reject the Kraepelinian paradigm and replace it with a ‘complaint-orientated’ approach to understanding mental illness

This article is a synopsis of the argument outlined in my book Madness explained: Psychosis and human nature, in which I describe a new paradigm (which might be called a 'complaint-orientated' approach) for understanding the psychotic disorders, the most disabling forms of psychiatric illness. Despite extensive efforts to study the genetics, pathophysiology and neuropsychology of the psychoses, replicable findings have been rare. I argue that this is because the phenomena concerned have been poorly defined. Since the end of the 19th century, research into the psychoses has been dominated by the system of classification first proposed by the German psychiatrist Emil Kraepelin, which assumes that the severe mental illnesses fall into discrete types such as 'schizophrenia' and 'manic depression', and that there is a clear dividing line between madness and normal functioning. However, Kraepelinian diagnoses fail all empirical tests of their validity. For example, they do not identify patients with common symptoms, with common aetiologies, who respond to specific treatments. I suggest that we therefore need to abandon psychiatric diagnoses altogether and must instead attempt to explain the specific complaints ('symptoms') that patients bring to our attention. These include hallucinations, delusional beliefs, thought and communication disorders, which are much more widely experienced than was previously thought (for example, about 10% of the population have experienced hallucinations). I show that recent psychological research has revealed much about the mechanisms underlying each of these complaints. For example, auditory hallucinations occur when the individual mistakes inner speech for an external stimulus, and delusions appear to be the product of abnormal inferential processes. The new approach has implications for aetiology. For example, researchers working within the Kraepelinian paradigm have often assumed that the psychoses are endogenous. However, there is compelling evidence that the risk of experiencing psychotic complaints is influenced by adverse environmental factors such as insecure attachment relations and exposure to sexual and other kinds of trauma. These associations are relatively easy to understand once the psychological mechanisms leading to specific complaints are known. When all of the psychotic complaints have been explained, there will be no 'schizophrenia' or 'manic depression' left behind awaiting explanation. The approach that I advocate is not only more scientific than the Kraepelinian approach, but also more humane. In contrast to the Kraepelinian approach, which has encouraged disrespect for patients' experiences, it encourages us to treat patients as rational agents and to take what they say seriously.

Do different psychotic experiences differentially predict need for care in the general population?

INTRODUCTION

The pathway from subclinical psychotic experiences to need for care may depend on type of psychotic experience, level of associated distress, and previous experience of psychosis.

METHOD

In a general population sample with no previous Diagnostic and Statistical Manual of Mental Disorders , Revised Third Edition , psychotic disorder (n = 4722), 83 subjects displayed at least one psychotic experience. Within the group of 83, subjects with (n = 24) and without need for care (n = 59) were compared. Presence of psychotic experiences at younger ages had been assessed at earlier interviews.

RESULTS

Of 7 different psychotic experiences, only hearing voices, nonverbal hallucinations, and passivity phenomena were significantly associated with need for care. These associations were largely explained by the distress associated with the psychotic experience, but whether individuals had had psychotic experiences at earlier ages did not matter.

CONCLUSIONS

Different psychotic experiences differ in the associated level of need for care and the mediating role of distress. Longer prior exposure to psychosis may not influence the pathway from subclinical to clinical.

Clinical features and outcome in dogs and cats with obsessive-compulsive disorder: 126 cases (1989-2000)

OBJECTIVE

To determine clinical features and outcome in dogs and cats with obsessive-compulsive disorder (OCD).

DESIGN

Retrospective study.

ANIMALS

103 dogs and 23 cats.

PROCEDURES

Records of patients with OCD were analyzed for clinical features, medication used, extent of behavior modification, and outcome.

RESULTS

Most dogs affected with OCD had been obtained from breeders. Male dogs significantly outnumbered females (2:1). Female cats outnumbered male cats by 2:1 in a small sample. Most affected dogs lived in households with 2 or more humans and other dogs or cats, and had some formal training. Client compliance with behavior modification was high. A combination of behavior modification and medication resulted in a large decrease in intensity and frequency of OCD in most animals. Clomipramine was significantly more efficacious for treatment in dogs than was amitriptyline. Only 1 dog and 1 cat were euthanatized because of OCD during the study.

CONCLUSIONS AND CLINICAL RELEVANCE

OCD in dogs does not appear to be associated with lack of training, lack of household stimulation, or social confinement. In cats, OCD may be associated with environmental and social stress. Obsessive-compulsive disorder appears at the time of social maturity and may have sporadic and heritable forms. With appropriate treatment (consistent behavior modification and treatment with clomipramine), frequency and intensity of clinical signs in most dogs and cats may decrease by > 50%. Success appears to depend on client understanding and compliance and the reasonable expectation that OCD cannot be cured, but can be well controlled.

Functional brain mapping of psychopathology

In this paper, we consider the impact that the novel functional neuroimaging techniques may have upon psychiatric illness. Functional neuroimaging has rapidly developed as a powerful tool in cognitive neuroscience and, in recent years, has seen widespread application in psychiatry. Although such studies have produced evidence for abnormal patterns of brain response in association with some pathological conditions, the core pathophysiologies remain unresolved. Although imaging techniques provide an unprecedented opportunity for investigation of physiological function of the living human brain, there are fundamental questions and assumptions which remain to be addressed. In this review we examine these conceptual issues under three broad sections: (1) characterising the clinical population of interest, (2) defining appropriate levels of description of normal brain function, and (3) relating these models to pathophysiological conditions. Parallel advances in each of these questions will be required before imaging techniques can impact on clinical decisions in psychiatry.

Integrating psychopathological dimensions in functional psychoses: a hierarchical approach

Previous factor analysis studies of psychotic symptomatology have demonstrated three psychopathological dimensions: positive, negative and disorganization. However, few studies have analyzed non-schizophrenic samples and most use a syndrome-level of analysis or only schizophrenic symptom scales. This study examined how many dimensions underlie psychosis, and whether within psychosis there is a hierarchical organization of dimensions.A total of 660 inpatients with an acute psychotic episode were studied. Psychopathology was measured through a wide psychopathological assessment using the Manual for the Assessment and Documentation of Psychopathology (AMDP-system). Principal component factor analysis was carried out on 64 psychopathological symptoms scoring 1 or higher in at least 10% of the sample. A 15-factor solution was obtained which failed to depict a psychosis model on clinical and methodological grounds. Further predetermined factor analyses ranging from 1 to 15 factors were carried out to examine alternative factor solutions. A 10-dimensional model was the best model on clinical, statistical and conceptual grounds. Moreover, the examination of the 1 to 10 dimensional models allowed us to infer a hierarchical model of psychopathological dimensions, which can be represented in the frame of a tree-structure. The model permitted transitions between psychiatric categories and psychopathological dimensions, and it was able to integrate previous factor solutions with different numbers of resulting dimensions.The findings have implications for the design of future studies and for the hierarchical conceptualization of psychopathological dimensions.

Persecutory delusions: a review and theoretical integration

Persecutory (paranoid) delusions are a frequently observed clinical phenomenon. In recent years, an increasing volume of research has attempted to explain these types of beliefs in terms of psychological mechanisms. Theories have emphasized early experience, perceptual abnormalities, motivational factors, and information-processing deficits. In this article we review relevant findings, including our own studies of the role of causal attributions and theory of mind deficits. We propose a new integrative model that builds on this work. The core of the model is an account of the way that causal attributions influence self-representations, which in turn influence future attributions: the attribution--self-representation cycle. We argue that biases in this cycle cause negative events to be attributed to external agents and hence contribute to the building of a paranoid world view. These abnormalities are amenable to investigation by functional neuroimaging, and recent studies have implicated specific areas of neuroactivation. However, these findings do not necessarily suggest that paranoid delusions are entirely biological in origin, and there is evidence that adverse early experience may play a role in determining the development of a cognitive vulnerability to paranoid thinking.

Frequency of nonspecific clinical signs in dogs with separation anxiety, thunderstorm phobia, and noise phobia, alone or in combination

OBJECTIVE

To determine the frequency of nonspecific clinical signs in dogs with separation anxiety, thunderstorm phobia, noise phobia, or any combination of these conditions and determine whether these conditions are associated in dogs.

DESIGN

Case series.

ANIMALS

141 dogs.

PROCEDURE

Diagnoses were established using specific criteria. Owners of dogs completed a questionnaire on how frequently their dogs exhibited destructive behavior, urination, defecation, vocalization, and salivation when the owners were absent and the types and frequency of reactions to thunderstorms, fireworks, and other noises.

RESULTS

Associations of the 3 conditions and of various nonspecific clinical signs within and between diagnoses were nonrandom. The probability that a dog would have separation anxiety given that it had noise phobia was high (0.88) and approximately the same as the probability it would have separation anxiety given that it had thunderstorm phobia (0.86). However, the probability that a dog would have noise phobia given that it had separation anxiety (0.63) was higher than the probability that it would have thunderstorm phobia given that it had separation anxiety (0.52). The probability that a dog would have noise phobia given that it had thunderstorm phobia (0.90) was not equivalent to the converse (0.76).

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that dogs with any of these conditions should be screened for the others. Interactions among these conditions are important in the assessment and treatment of dogs with > 1 of these conditions. Responses to noise were different from those to thunderstorms, possibly because of the unpredictability and uncertainty of thunderstorms.

Natural animal models of human psychiatric conditions: assessment of mechanism and validity

1. The classic animal models for human psychiatric conditions involves rodents. As prey species, their normal behaviors of avoidance would be considered pathological in humans and dogs. Hence, such models may not be homologous for similar behaviors found in psychiatric pathology in humans. 2. Dogs exhibit pathological behavioral conditions that may be equivalent to certain human psychiatric conditions. These canine conditions appear spontaneously or endogenously in the absence of genetic or neurochemcial manipulation, and as such, may be homologous to the human condition. 3. If canine conditions approach homology with human conditions they should have excellent face, predictive, and construct validity. 4. The canine conditions of separation anxiety, obsessive-compulsive disorder, cognitive dysfunction, dominance aggression, and panic disorder have good to excellent validity at all explored levels for human generalized anxiety disorder, obsessive-compulsive disorder, Alzheimer's disease, impulse control disorders, and panic disorder. 5. Natural canine models can aid our understanding of human psychiatric conditions.