In this concise book the authors (A. Farmer and P. McGuffin from the Social
Genetic and Developmental Psychiatric Research Centre, Institute of Psychiatry
in London, and Julie Williams, Professor of Neuropsychological Genetics from
University of Wales) bring out their wide expertise in research and diagnosis
of mental disorders. The contents commences with widely accessible chapters on
psychopathology and the history of its scientific investigation, proceeding
then to its symptoms and signs as well as issues of its definition and
classification. The subsequent chapters focus on more technical issues
pertaining mostly to diagnostics and evaluation of severity of mental
disorders, including specific subject groups. The book concludes with future
perspectives for research on psychopathology and its treatment in the 21st
century. It should also be noted that in 2002 the book was commended in the
Mental Health Category by the British Medical Association Awards.

The authors successfully combine widely accessible contents on mental
and personality disorders with highly specialized topics on the strategies and
instruments of measurement. The most widely used classification systems and
methods of diagnosis, with both general and specific range of application, are
characterized and usefully compared in tables. The authors elicit the relevant
historical background against which they codify their own phenomenological
approach to psychopathology and project future developments in its measurement
and treatment. They also adhere to the high methodological standards as
manifested by terminological and definitional issues discussed in the relevant
methodological and philosophical literature.

In general, the perspective on the measurement of psychopathology the
authors adopt throughout the text is a moderate bottom-up strategy aimed at
implementation in software packages. It starts with the checklist for
particular signs and symptoms. The results are then clustered into syndromes to
form a basis of diagnostic categories of a given mental disorder. The viability
of the top-down strategy that brings to the fore the results of research on
classification systems of psychopathology and the most recent scientific
evidence is also recognized. This moderate bottom-up strategy is implemented in
OPCRIT, a computerized diagnostic system, capable of diagnosis according to
multiple sets of criteria. A number of arguments could be cited in support of
this strategy. Of major importance to the authors, apart from leaning towards
the phenomenological attitude, is apparently the fact that this strategy seems
to match clinicians practice, but reliance on algorithms is presumed to set it
free from human error and prejudices.

The first chapter What is Psychopathology? familiarizes the
reader with the phenomenon of mental disorders, briefly summarizes the history
of scientific approach to the measurement of psychopathology, and recalls the
vexed questions. Three main approaches to psychopathology are shortly
discussed: phenomenological, psychodynamic and experimental. The
phenomenological approach aims at an objective description and categorization
of mental phenomena independently of any theories of possible causes of the
phenomena in question. To some extent, especially in the study of abnormal
behavior, this approach could gain in terms of reliability and validity of measurement
if combined with experimental approach consisting in testing hypothesis on the
relation between normal experiences and abnormal mental events. The lack of
testable hypothesis and spurious causal relationships offered as explanations
are the main arguments the authors cite in support of the claim that
psychodynamic approach stemming from Freud’s ideas seems driven far from the
ideal of scientific approach to psychopathology: "almost nowhere is
Freudian theory seen as part of the main stream in the study of
psychopathology". This counters the prevailing popular view while Freud
"remains the most prominent and famous of psychopathologists in the minds
of educated lay persons" (p. 7).

The major classification systems of mental disorders evolved either as promulgated
diagnostic systems of great clinicians and researchers or as consented upon by
a body of experts. In the second half of the 19th century ‘the great professor
principle’ gave way to the consensus of national and international committees
of experts. However, the principal change in research on psychopathology and
clinical practice took place after the 3rd edition of the Diagnostic and
Statistical Manual (DSM III) was published by the American Psychiatric
Association in 1980. The standard for this classification system was based on
scientific evidence and operational definitions of mental disorders which used
explicit criteria. The same methodology was then adopted in other
classification systems, especially in the International Classification of Diseases
produced by the World Health Organization.

Description of symptoms and signs is the first stage in the measurement
of psychopathology as they combine then to form diagnostic categories. The
version of the phenomenological approach the authors propound focuses on an
objective description of symptoms and signs rather than on empathy with a
patient; although informant’s self-report, even in the case of children, is in
many cases acknowledged as revealing. Moreover, clinicians, observers and
interviewers should be wary of using technical terms and "avoid altogether
those that one is not prepared to define in plain English" (p. 18).

In examination of mental health the description of appearance and
behavior draws upon observer report and, as the authors emphasize, this usually
is the poorest part of the interview in terms of the inter-rater agreement. In
order to standardize it they recall the following topics to be covered in the
description: manner, dress and self-care, posture and movement, appropriateness,
facial appearance, abnormalities of movement and behavior. The authors
delineate in detail some other sings and symptoms: abnormalities of speech (its
form and content) and of mood (depression, anxiety, mania and hypomania),
abnormal beliefs and ideas (especially different kinds of delusions and
hallucinations), abnormal perceptions (coming in different modalities) and
cognitions (orientation, attention and concentration, memory, language,
visuospatial and constructional abnormalities). The introduction of operational
diagnostic criteria for childhood disorders as well as structured interviews
and rating scales for their evaluation enable the kind of descriptive approach
in children and adolescents the authors outline in the preceding chapter.

How these symptoms and sings combine to form syndromes and diagnostic
categories is further discussed in chapter three Defining and Classifying
Disorder. Of the recent changes in classification systems the major one was
to avoid any theoretical bias (especially psychoanalytical etiologies as the
etiology of many disorders in not yet known) and develop functional
classifications instead. This kind of classification, however, deters from
using diagnostic tests to confirm the presence of a particular disorder.

The authors point out that in contrast to the past there is a growing
convergence between the most recent editions of DSM and ICD what is amply
illustrated in the book by tables comparing diagnostic categories of both these
systems. The reliance of the systems upon operational definitions, apart from
standardized interviews, is crucial in enhancing reliability of the measurement
of psychopathology. In their conclusion, however, the authors go further to
claim that "Essentially this requires that diagnoses are formulated as a
series of explicit algorithms" (p. 55). This strong claim reworded on page
97: "one logical consequence of using fully operationalized criteria for
research is that the diagnostic method becomes purely algorithmic" would
require more careful exposition and defense as — apart from being vulnerable
to more serious challenges — it might seem to be at odds with the following
commitment on the part of the authors: "we favour the probing approach so
that the trained interviewer relies on a template that they have developed in
their head rather than the exact words, and only those words, on a page or
laptop computer screen" (p. 88).

The undisputable advantage of operational definitions is the enhancement
of reliability (when two different researchers receive similar results) as well
as easy application and construction of structural interviews based thereupon.
On the other hand, however, they use ‘pre-determined’ rules which are sometimes
satisfied incompletely by a given individual, they neglect — important from
the point of view of clinical practice — factors as family history or
pre-morbid functioning, and that some institutions (esp. insurance companies)
force clinicians to use regardless of their applicability to a given case.

The main features of the measurement instruments are generally
characterized in chapter four Validity, Reliability, and Utility.
Questionnaires addressed to subject or observer are the simplest method of
measurement. More complex ones are standardized clinical interviews (structural
or semi-structural) when a clinician or researcher elicits descriptions of an
individual’s experience, her or his cognitive and emotional states. In
experimental methods individual’s responses to strictly controlled conditions
(memory test, attention, perception, emotional processes) are investigated.
What matters, however, is not only a method of measurement, but also the
characteristic of a given measure, most importantly its validity (it measures
what it is supposed to measure) and reliability (the results are repeatedly
consistent). The authors discuss the basic kinds of these characteristics of
measures, shortly specify the range of their application and statistical
methods of their evaluation. They also provide ample references to the
literature. Although this chapter largely recalls known material, it nicely
complements the content preceding more advanced topics.

Chapters 5 to 8 focus on more specialized topics: Diagnostic
Interviews; Polydiagnostic Approaches, Computerized Methods, and the
Best Estimate Diagnoses; Rating Scales: Screening, Observer, and
Self-rating Questionnaires and Measuring Psychopathology in Specific
Subject Groups. In this part of the book, written in the same very readable
style as the others, the authors exploit their vast experience and knowledge in
bringing together wealth of material of interest to a wide range of
specialists: from undergraduate students of clinical psychology and junior
psychiatrists to clinical practitioners and researchers. The topics covered
include the essential characterization of the most widely used general and more
specific questionnaires, structured and semi-structured interviews and rating
scales. The key points of this characterization are comprehensively summed up
in tables indicating authorship, date of origin and initial purpose, comparing
symptoms covered, the range of application, time to administer etc.

In view of enhancing validity of measure the authors advocate
polydiagnostic approaches which allow to apply multiple sets of criteria to the
same subjects and choose the one with the most satisfactory validity. Their own
computerized checklist OPCRIT contains the items from multiple sets of criteria
for psychosis. The researcher can follow the bottom-up strategy rating each
item on the checklist, which are then reassembled by using algorithms based on
the diagnostic criteria. A number of studies comparing the standard procedure
of the collective review of all available material and arriving at consensus
decision about the diagnosis by the researchers involved with OPCRIT
demonstrate agreement from good to excellent.

A separate chapter is devoted to the measurement of psychopathology in
specific subject groups which include: children, adolescents, people with
learning disability, the elderly (especially cognitively impaired), addicted to
street drugs and alcohol, with eating disorders, and after childbirth. Some of
these groups have specific classification of psychopathology tailored to them
and diagnostic interviews and rating scales which are shortly characterized and
compared in tables.

In chapter 9 Personality and Personality Disorders the authors
attempt to integrate two major approaches to the measurement of normal
personality and personality disorders and relate them to mental disorders. They
discuss the main features of dimensional description of personality (esp. the
‘Big Five’ factors) and contrast it with theory of person-situation interaction
and bio-psychosocial approach in order to pin down problems with dimensional
approach to personality.

The diagnostic terms and categories of personality disorder in the two
major classification systems ICD10 and DSMIV are found to be similar with minor
— and sometimes merely terminological — differences carefully indicated in
the text and depicted in a table. What is more problematic is how to proceed
with measurement of personality disorder based on these highly convergent
classification schemes: top down (emphasis on the structure of the criteria) or
bottom up (focusing on definition of component behaviors) strategies. The
authors indicate also that the general disadvantage of the categorical approach
to personality disorder is that "individuals who fulfil the general criteria for having a personality disorder also tend to fulfil the criteria for more than one specific category" (p. 155). This
general discussion is followed by a detailed study and comparison of the
measurement instruments available and indication on how to choose the most apt
one for a given study or diagnosis.

In the closing chapter Psychopathology in the Twenty-First Century
the authors evaluate the present state of affairs in the measurement of
psychopathology from a more distant perspective. Among the crucial factors
influencing the change in the past fifty years they identify three types:
scientific and technological progress (development in functional and structural
neuroimagining, pharmacology, genetics, cognitive science, molecular genetics),
improvement of service and medication as well as modification of the methods of
measurement. These factors are projected to continue their influence as regards
the identification of the causes of psychopathology and according changes in
new editions of DSM and ICD classifications.

The recurrent theme of the book, namely dimensions versus categories, is
concluded in this chapter. The operational definitions — a standard in modern
classification systems — impose thresholds on dimensions, but — as the
authors emphasize — many diagnostic interviews include additional dimensional
ratings of different symptom groups. The range of application of categorical
and dimensional approaches may further be discriminated when etiology of
psychopathologies will be discovered and this should be expected in particular
of neuroimaging and genetics which are "the joint royal routes to
understanding of the neurobiological substrata of psychopathology" (p.
185).

Finally, in the appendix there are references to further information on
interviews, training centers and software packages available on the Internet
with useful indication of their accessibility.

My critical remarks concern apparently minor points. In characterizing
psychopathology as "the study of abnormal states of mind" the authors
admit that the classification of given signs and symptoms as pathological
depends, among others, upon language, education, religious beliefs or ideology,
and is therefore culture relative. The nature of this dependence is not much
elicited in the book, except perhaps for mentioning the case of "sluggish
schizophrenia" — a category of purported mental disorder diagnosed on the
basis of ‘abnormal’ political views ascribed to political dissidents in the
Soviet Union. This topic seems to deserve more space as in many points the
authors address reliability and validity of studies on the international level.

A number of typographical errors occur in the text, which one would not
expect in a book edited by such a renowned publishing house.

This practical and wide-ranging précis of the measurement of
psychopathology will be well appreciated not only by someone already familiar
with the field, but also by students and educated laypersons. Conceived as a
textbook, it functions not so much as a freestanding survey of the field, but a
clear and elaborate skeleton upon which one could hang supplementary material
when teaching an introductory course.

           

© 2003 Pawel
Kawalec

 

Pawel Kawalec Ph.D., Faculty of
Philosophy, Catholic University of Lublin, POLAND

Categories: Philosophical, MentalHealth