Wednesday, July 22, 1998.
Dylan Evans, M.A., Ph. D. Candidate
Center for the Philosophy of Natural and Social Sciences
London School of Economics
London, U. K., WC2A 2AE
Notes by Jim Brody, 8/20/98. This was the 2nd in a series of 3 seminars. Notes for the 3rd, "Complexity Theory: Getting the Client to 'Maybe'" will be circulated in about a week.
The DSM seminar ran from 7-10 PM, accompanied by spaghetti and Chianti at Mitchell's Bistro on Cape Cod. 18 attended. The seminar was a supplemental offering to "Healing the Moral Animal: Lessons from Evolution," part of the 19th Cape Cod Institute.
Evans distinguished 3 kinds of disorders and postulated the existence of a 4th.
1) Defective modules e.g.: the Theory of Mind Module (ToMM) is defective in autism (Simon Baron-Cohen) such that an autistic person cannot imagine the viewpoint of another person or even that the other person has a viewpoint. (Also, a psychological adaptation for child care, reciprocity, kin recognition, mate selection, or any number of others is somehow impaired by developmental trauma such as pathogens or by developmental stress (or by genetic variance unless you believe in a "Universal Human Nature").)
2) Environmental mismatch e.g.: Depression, according to the social competition hypothesis of depression. (Also, changes in status or the death of a loved one are examples of this problem. EM probably occurs very often whenever people take on goals or tasks for which they have little aptitude or tolerance. An impulsive person who also has some difficulties with a bias in his systems for regulating appetite will have a difficult time in our culture.)
3) Protected polymorphisms. E.g., psychopathy, according to James Blair's model of "the psychopath as hawk." ( "Polymorphism" applies to two or more forms of a gene occurring in a population at levels greater than expected on the basis of mutation. Approximately synonymous with "allele." Eye color is a polymorphism; speculation is that schizophrenia may be one. "Protected" means that the less frequent form of a gene will increase in frequency over generations until it reaches a competitive equilibrium with its other form. For example, "hawk" social strategy is most effective when the rest of the population is not expecting it. Hawk tactics have a competitive advantage until they increase to the point that compensatory, protective shifts occur in non-hawks.
4) Adaptations. E.g., postnatal depression is an uncomfortable feeling for the mother but may have survival for her or for her newborn. Increased body temperature is often treated even though it often has protective functions. Nesse and Williams (1994, Why We Get Sick) lists many examples that may belong in this category.
Dylan raised several questions:
1) What's wrong with the DSM?
2) Can evolutionary psychology correct these faults?
3) Think of a disorder ... into which of the 3 categories does it go?
4) Are there disorders beyond the 3 types mentioned?
5) Are these distinctions useful?
Evans noted that he was more appreciative of the DSM after he had spent some time with it than he had been at the start of his research.
1) The DSM represents "research compilations" ... alternative models will have to account for the same data now summarized by the DSM.
2) The current DSM is functionally identical to an insect collector's display case. Judgments are made about the similarity and differences that are seen in complaints from or about different people. Clusters of complaints array into "disorders," arranged by intuitive schemes that involve variations of intensity, eliciting conditions, familial incidence, and behavior sequences. These arrays are often intuitive and certainly reflect the psychological adaptations and favorite preoccupations of the classifiers. For example, our primate heritage gave us marvelous avoidance systems but we, in our diagnostic searches, may detect more fear and danger than is actually present and may react more strongly to such distress in our clients than would be true for a non-primate observer.
3) Medications (particularly the SSRIs) jump existing classificatory schemes. Psychiatry moves, thus, into a phase of classifying disorders by their response to a medication or class of medications. For example, the term, "Serotonergic Spectrum Disorder" has appeared lately. This may be an advance; it is also analogous to the situation that occurs when a baseball is no longer classed as a spherical object or as a tool for use in a particular social arena but is included with other objects on which one uses a bat.
4) There is discord between #2 and #3. For example, serotonin has at least 15 different receptors identified and is involved in temperature regulation, digestion, eating, sleep, sex, and self esteem. Are all of these to be considered part of a "serotonergic spectrum disorder"? A client taking an SSRI "feels better" but may also be less attentive to their family. Current practice is to inquire about mood but not about all the ancillary activities that are also tied to SSRIs.
Stimulants help concentration in normal people and those with Attention Deficit Hyperactivity Disorder. The stimulants -- by an overwhelming mass of indirect (but little direct!) evidence -- exert the same effect on mania. Stimulants are thought to increase dopamine turnover; mania is thought to be characterized by an excess of dopamine availability. How can the stimulants sometimes reduce a manic pattern? Are ADHD and mania the same thing? They are probably different things but our "adaptations" are more sensitive to activity level than they are to impaired executive functions or to grandiosity.
5) Evolutionary information may highlight behavioral effects of medications, effects that are now unsuspected. Increasing serotonin availability raises self esteem, it also increases impulsiveness and can sometimes aggravate grandiosity. Rejection sensitivity may be excessive at work but a highly useful tool when ensuring that the children behave in public. Evolutionary theory and cross-species comparisons should give some information about the rank ordering of shifts in various behaviors as a function of the dose and type of SSRI.
6) Mania, ADHD, depression, and other disorders have "global" characterization. There is no attention given to the interaction between the severity of a disorder and the environment in which the client is located. For example, some children who have limited sustained attention in class have excellent sustained attention when caring for younger children. There may be a wealth of undiscovered interactions between psychopathology and social context, interactions that are now unsuspected because of the "complaint" model of making a diagnosis.
7) "Psychological Adaptations" promise a modular approach to client diagnosis, one that incorporates client assets and their complaints into a treatment approach, and views complaints as a product of both the client's particular set of mental adaptations as well as his/her setting.
An "Adaptations" approach has a greater promise of theoretical and applied links to proximal sciences such as biology, anthropology, and psychology. It also promises great power for understanding individual development; however, it must gain more systematic empirical support for its content before either promise is kept.
One contribution of an evolutionary model is that of recognizing pathology as sometimes being an adaptive response -- or an exaggeration of one -- that is in a nonsupportive niche. Assessment of the client's other talents as well as his environment become more important steps in forming treatment alliances and supplying temporally durable assistance.
8) There are barriers to changing anything. The current DSM represents a substantial financial and administrative apparatus, a growth that arose from research investment and funding (health insurance) needs. Those needs continue and should be respected, apart from considerations of client services. There is an army of professions and professionals whose livelihood and (more importantly) prestige depend on the current system. An alternative system might well have to be developed outside of established psychiatry.
Familial traits are probably important beyond that of finding comparable diagnoses for different members within a family tree. Identical mannerisms and habits have been noted often for twins reared apart. It's unlikely that special genetic laws restrict these phenomena to twins. Thus, interview parents & grandparents of details of behavior, not just their mental health diagnoses or temperaments.
Executive Functions ... their contributions to pathology and for prognosis are probably unappreciated, regardless of syndrome. Intact EFs should predict better treatment compliance, higher levels of insight, less impulsive behavior, greater success by the client in solving their own problems, and greater aptitude for inhibiting or magnifying affective response.
Complexity models of psychopathology (discussed further Thurs. night "Getting the Client to 'Maybe'") draw upon an analysis of the client's social, financial, and environmental setting to discover factors that stabilize or destabilize him or her. It is suggested that rapid changes in behavior represent developmental immaturity, trauma, or genetic impairment in the specific behaviors that exhibit rapid changes of intensity, direction, or duration.