The diagnosis of mental illnesses must be reviewed

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A study led by a psychologist from Trinity College Dublin raises important questions on how mental illness is currently diagnosed and whether these diagnoses accurately reflect the underlying neurobiology of mental illness.

The findings, just published in the leading peer-reviewed medical journal, JAMA Psychiatry, are significant in highlighting the need for more individualised approaches to defining mental illness.

In this study the researchers showed that a compulsive dimension of mental health maps onto various aspects of ‘cognitive flexibility’ better than an expert-assigned diagnosis. Cognitive flexibility reflects a set of brain processes that are thought to be essential for controlling our habits.

Prior research shows that habits play a role in a range of mental health conditions characterised by compulsive, repetitive behaviours.

These include obsessive-compulsive disorder, the focus of the present study, but also binge-eating, excessive shopping and forms of addiction.

Mental disorders are currently defined in terms of diagnostic and statistical manual (DSM) diagnoses.

They are labelled in categorical terms; patients either meet criteria or they don’t.

This is extremely important for making clinical decisions ? to treat, or not? but may not reflect the true nature of mental health and illness in the population.

There is now a substantial body of research suggesting that our existing categorical frameworks for mental illness need revision.

This is in part because there is substantial overlap across disorders, with most patients meeting criteria for multiple disorders and the fact that many disorders share commonalities, such as compulsiveness.

In the current study, patients met an average of 3.7 concurrent diagnoses. Disorders are also highly heterogeneous – which means that two patients might have the same diagnosis, but have little to no overlapping symptoms and might respond in entirely different ways to the same treatment.

Focusing on obsessive-compulsive disorder (OCD), the findings of this study suggest that self-reported levels of compulsive behaviour are a better predictor of alterations in cognitive flexibility than whether someone has a diagnosis of OCD.

Prior research shows that habits play a role in a range of mental health conditions characterised by compulsive, repetitive behaviours.

These include obsessive-compulsive disorder, the focus of the present study, but also binge-eating, excessive shopping and forms of addiction.

Commenting on the findings, lead author, Dr Claire Gillan said: “By defining mental health and illness in a way that is true to the biology of the brain and respects the reality that most mental illness varies in the population, it is hoped that we are charting a path towards a future where treatments can be prescribed on a more individualised basis, based on well-defined brain systems and circuits and crucially, with a higher rate of success.”

This study involved a collaboration between a team of researchers and clinicians at Trinity College Dublin, the Department of Psychology at New York University, New York State Psychiatric Institute, Harvard Medical School, the Warren Alpert Medical School of Brown University and the Hofstra Northwell School of Medicine.


In modern clinical medicine, a diagnosis is obtained through the crossover of symptoms, obtained by anamnesis or by a clinical interview, and signs of symptoms, obtained through a physical examination and laboratory or image tests (1).

The former is supposed to spark multiple hypotheses which the clinician then further investigates by looking at patient’s signs and symptoms.

Semiology has been described in many textbooks as Porto (2) or Bates (3), and was over time formalized as the paramount method of clinical examination in internal medicine.

Such standard foundational programs were made possible through Claude Bernard’s experimental medicine (4), confirmed by Alvan Feinstein one century later, whereby stating that recent clinical epidemiology belongs to the same epistemological strata (57).

The same method was implemented in most medical specialties, including psychiatry (89). With regard to general medical practice, physical examination (PE), lab, and image procedures provide the standard method to gather objective information, which is then used to refine the previously elaborated hypothesis through the anamnesis/interview method.

The very idea of a PE and semiology was strengthened by the transformations of modern medicine, and was consolidated with the Flexnerian reformation of medical schools (1011).

Psychiatry has tried to take part in this agenda and match such standards (12). Clinical interviews as a standard procedure for anamnesis in psychiatry, has been rigorously investigated.

An extensive bibliography, concerning how to improve an examiners agreement about symptoms, and a rising consensus about the need for a minimal structure for better clinician reliability, is now evident (1319).

Mental health practice often uses Mental State Examination (MSE) as an equivalent to PE from routine clinical examination and as a reliable method for objective data gathering (132022), since PE and MSE are logically correlated.

However, clinical interview/anamnesis is previous to, and also guides PE procedures and laboratory searches, but it is the core of the mental/psychic examination process and used predominately in most cases. However, the interview is a narrative, history taking method, and not an objective sign gatherer tool.

The interview should be a narrative, recollection method, not an objective investigative tool. PE is consistently mentioned throughout almost all propaedeutical textbooks in medicine, with minimal, if not aesthetical, variations.

MSE however has not achieved any international protocol or structured general tool, not even a minimal array of standard techniques and clinical report methods. Although MSEs widespread use as a PE correlative might not be suitable and may also be equivocated (92324), it still universally used to gather data, objective information and evidence in mental health practice.

MSE was simultaneously developed in different regions of the world, influenced by philosophically-oriented ideas on psychopathology (2526).

Many psychopathology textbooks have also been written in different languages, according to different traditions, which have resulted in vast variations in technique and nomenclature (2728). Nevertheless, mental semiology has been overlooked in most historiographical efforts, despite the importance of nosological history (29).

In the last 30 years, new trends in the history of psychiatry in Brazil developed, but none has considered mental examination. Estellita-Lins attempted to emphasize the phenomenology of living space (espace vécu) in Jaspers Psychopathology Textbook and its vital role concerning signs, “evidence” and examination (30).

Cheniaux (31) reviewed some of the Brazilian, and even foreign textbooks about “descriptive psychopathology,” searching for conceptual regularity or terminological “uniformity” among authors, but MSE was not addressed. Viotti Daker worked on the main Brazilian textbook by Nobre de Melo, examining its psychopathological models (32).

Again, the MSE was not mentioned, but Melo’s emphasis on fully assessing the person, before evaluating the particular functions subdivision, is noteworthy.

There is an increasing concern related to clinics and nosology in psychiatry. This concern might be traced back to Nancy Andreassen’s claim concerning the loss of psychopathological knowledge by younger psychiatrists, and to Parnas’ Danish group that contested the validity of the schizophrenia nosologic construct in DSM/ICD, further extended to the unreliability of diagnostic interview methods with structured diagnostic questionnaires (3334).

We should also mention Jacob’s questioning of MSE training in India (28), Aragona’s interrogation about the collaboration of neuroscience in psychiatric diagnosis, among many others (35). As Rodrigues and Banzato have stated, if a sound agreement concerning the “validity” of a concept in psychiatry had already been achieved, there would not be such confusion around it (36).

We foresee epistemological issues concerning psychiatry and mental health care, that have not yet been resolved, as the importance of examination skills and training in the evidence-based era. These themes are not simply classificatory issues but are fundamental psychopathological efforts demanding a discussion concerning the diagnosis process in mental health and psychiatry.

This study deals with modern psychiatry from a historical perspective but addresses some clinical problems such as MSE, examination reporting, patient records and psychopathology teaching/transmission.

A narrow comprehension of what evidence means may have been overlooked such as bedside skills and in particular phenomenological examining tradition (3739). Maybe ongoing “taxonomic issues” and “classification wars” in psychiatry (4042) are fair and useful, but we should also pinpoint some relevant matters that concern the examination, clinical reasoning and the diagnostic process itself (43).

Aiming to elucidate the origins, development, and methods of how MSE has been consolidated in Brazil, a review was carried out on the national literature.


Source:
TCD
Media Contacts:
Caoimhe Ni Lochlainn – TCD
Image Source:
The image is in the public domain.

Original Research: Closed access
“Comparison of the Association Between Goal-Directed Planning and Self-reported Compulsivity vs Obsessive-Compulsive Disorder Diagnosis”. Claire Gillan et al.
JAMA Psychiatry doi:10.1001/jamapsychiatry.2019.2998.

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