I spent this last summer rolling across America in a pickup driven by my unflappable hubby Phil, who I met twenty-five years ago at the South Pole Station in Antarctica. (This means I can’t resist quipping that I had to go to the end of the earth to meet that man.) Obviously, Phil is an adventuresome type, always game for the oddball undertaking. So when I received an email invitation for lunch with Dr. Robert Bilder, the Director of the Consortium for Neuropsychiatric Phenomics at the Semel Institute of UCLA, we pulled up camping stakes from Millard County, Utah, home of the loneliest road in America, and puttered over to tony Malibu, where we parked our pop-up trailer on the hillside at the Malibu Beach RV Park. I was nervous about meeting Dr. Bilder and his colleagues. All I knew was—the Consortium for Neuropsychiatric Phenomics is doing some highly original, ground-breaking work, and I wanted to find out more.
Contrary to common understanding, research has shown that personality dysfunctions such as paranoid or narcissistic personality disorders do not break themselves into distinct and tidy entities like those described in the “DSM” (the Diagnostic and Statistical Manual of Mental Disorders, which is the official dictionary of mental disorders).1 Instead, the various disorders often blend together, so that overlapping symptoms are the rule, not the exception. This is because thousands of genes help shape any one psychiatric condition—and many seemingly different conditions share some of the same underlying genetics.
Worse yet, syndromes that can arise from very different causes, such as antisocial personality disorder, are given the same label. A person may be inclined to commit crimes due to an abused upbringing, brain damage, or even genetics, but no matter what the cause, he will receive the same diagnosis, and often the same treatment. It’s a little like putting fish, goats, and windswept tumbleweeds in the same category because each can achieve the same speed.
Adding to the complexity, having a personality disorder isn’t as straightforward as a “yes” or “no” diagnosis might lead you to believe. Instead, the diseases and disorders—perhaps best thought of as syndromes—shade messily on an interwoven continuum from utterly incapacitating to barely there. More importantly, although neuroscience is giving us new insights into vital traits such as impulsivity, the current system of psychological categories doesn’t give us a very easy way of using this information to better understand a patient’s diagnosis.
Bob Bilder and his group are doing the unthinkable. They are boldly pointing out that not only is the current system of psychiatric diagnoses inaccurate, unreliable, and subjective—it actually prevents the research necessary to understand the basic causes and treatments of mental illness. In fact, trying to research personality-related syndromes and dysfunction using the officially recognized DSM diagnostic categories is a major reason why the era of personalized medicine—that is, the ability to use a person’s genetics to tell which therapies might be most effective—still seems so far in the future.
With all this in mind, and feeling more than a little intimidated, Phil and I soon found ourselves in Dr. Bilder’s waiting room at the Institute, where we were also to meet two of the Consortium’s researchers: data mining wizard Dr. Stott Parker and wunderkind neuroscientist Dr. Fred Saab.
The secretary ushered Dr. Bilder’s previous visitor out into the hallway. Bilder himself then appeared at the door. “Hi,” he beamed with an infectious grin. “I’m Bob.” Within moments, Stott and Fred had joined us, and we were off for Italian food.
The unassuming Bob, as it turns out, is as near as academia gets to having royal heritage. Bob’s doctoral advisor (“doctor-father,” in academic-speak), was the redoubtable Elkhonon Goldberg, whose doctor-father was in turn Alexandr Luria, author of the classic Mind of a Mnemonist, and one of the few shining psychological stars in Stalin’s Russia. (For a surprisingly personal account of how Luria navigated communism’s dangerous shoals, see Goldberg’s wonderful The New Executive Brain.)
Once in the restaurant, Bob, Stott, Fred, and of course the Hubby ate with gusto, while I nervously picked at a bowl of soup. As lunch unfolded, I learned how the current diagnostic gridlock has come about—and the fantastic new approaches that have been devised to get around it.
Next time: Surpassing the impasse.
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References
1. CR Cloninger, "A New Conceptual Paradigm from Genetics and Psychobiology for the Science of Mental Health," Australian and New Zealand Journal of Psychiatry 33, no. 2 (1999); N Haslam, "Categorical Versus Dimensional Models of Mental Disorder: The Taxometric Evidence," Australian and New Zealand Journal of Psychiatry 37, no. 6 (2003). As Bilder points out, citing Hempel’s earlier work: “Most sciences start with a categorical classification of their subject matter but often replace this with dimensions as more accurate measurement becomes possible.” CG Hempel, "Introduction to Problems of Taxonomy," Field Studies in the Mental Disorders (1961).
