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Measuring PsychopathologyReview - Measuring Psychopathology
by Anne Farmer, Peter McGuffin, and Julie Williams
Oxford University Press, 2002
Review by Pawel Kawalec, Ph.D.
Jul 18th 2003 (Volume 7, Issue 29)

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


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