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Chapter 5 emphasizes the importance of examining attention at both the behavioral and cognitive levels. The current range of attention rating scales and more general Executive Function scales is assessed and it is argued that, although these scales are an important tool in capturing the range of severity of inattentive behaviors in ADHD, they are less effective in discriminating inattentive behaviors in disorders that also present with significant cognitive impairment. Thus more sensitive rating tools are needed to explore the range and severity of attention signatures at the behavioral level across different neurodevelopmental disorders and across development. Knowledge thus gained will complement the current cognitive research on disorders of attention. Attention must be regarded as a continuum, thus allowing a broader understanding of variation in attention phenotypes.

This chapter explores the concept of paraphilia as defined in the third and current fourth edition of the handbook of the American Psychiatric Association—the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). DSM-IV has excluded homosexual orientation from the sexual mental disorders, and eschewed the pejorative “perversion” in favor of the clinical “paraphilia” in naming other sexualities. It is argued that DSM-IV embodies cultural biases “masquerading” as scientific medical truth, but also expresses a more liberal view of human sexuality.

This chapter discusses the “official” definition of mental disorders found in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). It defends the DSM definition against criticisms and shows its virtues in contrast to Wakefield's influential alternative definition of mental disorder.

To express, explain, and validate their suffering and frame intervention, many people draw upon a “grammar” of institutionalized medical concepts and practices. The source of this grammar, the focus of the chapter, is a biomedical landscape of meaning—a “healthscape” of ideas, symbols, and institutionalized practices—that began to emerge in the 1950s with Freudian ideas about the neuroses and the explosive public reception of the “minor tranquilizers” like Miltown and Valium. By the early 1970s, people were using psychotropic drugs at rates comparable to today but doing so within a broadly psychosocial frame of reference, with little recourse to somatic theories, disease models, or even medical diagnoses. This began to change in the 1970s, when, especially in light of existing drug use, psychiatry began a decisive change centered in the development of a new diagnostic language of mental disorders. The 1980 edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, was shaped by biological rather than Freudian theories. Powered subsequently by Prozac and the SSRI class of antidepressants, it shifted practice decisively toward medication, including for children, and short-term behavioral therapies, and reoriented the field toward neuroscience. The new categories were powerfully institutionalized and effectively reified.

This chapter examines recent controversies over internet addiction and Chinese gold farmers, players of World of Warcraft who make a living acquiring in-game virtual currency and selling it for real money to (mostly Western) players looking to accelerate the tedious “grind” of the leveling-up process. The chapter shows how “cheap play” has been revived as a tool for condemning Chinese “cheap labor,” powerfully informing how internet game addiction is itself culturally and spatially represented in popular and psychiatric discourse. Using Cory Doctorow’s story “Anda’s Game” as a case study, it considers how twenty-first-century American anxieties about ludic immersion, compounded by the nation’s own destabilized position in the global economy, have led American game developers as well as medical professionals to pathologize gold farming as exclusionists had Chinese gambling: as symptomatic of an “Asian” psychosis that fails to respect normative boundaries between play and work, virtual and real world.

Diagnoses in psychiatry are based entirely on behavioral, not biological, criteria: though a small number of practitioners use functional brain imaging as a diagnostic tool, most psychiatrists believe that imaging has no role beyond potential medically apparent causes of a patient’s condition and make no use of this resource for routine clinical care. Although biological psychiatry has had a huge impact on the overall field since the 1960s, some tools are privileged over others. This chapter considers the plausibility and potential of imaging techniques as an aid for diagnosing, categorizing, and treating psychiatric illness by considering SPECT clinics, DSM classifications (and limitations), patient receptiveness, and other current developments. It evaluates to what extent neuroimaging can act as diagnostic agent, predictor of incipient illness, and even cure unto itself.

Interest in electricity in medicine, especially in psychiatric conditions, is as old as our knowledge of electricity as a controllable phenomenon. At the end of the eighteenth and the beginning of the nineteenth centuries, Benjamin Franklin and Anton Mesmer were among many students who used electric currents to stimulate paralyzed limbs and to relieve hysterical states. Giovanni Aldini, the nephew of Luigi Galvani, a principal early student of electricity, applied electric currents to mentally ill patients. In the original Aldini publication, the figures show one electrode applied to the top of the head and a second to the hand. The text states that the electrodes were connected to earrings. Much of Aldini’s work was done on fresh cadavers to show that electricity stimulated motor movements. There is no evidence that he produced seizures for therapeutic purposes. From the onset of the introduction of ECT, the importance of the grand mal seizure to the treatment has been questioned. Many people followed popular science beliefs in the potency of electricity alone and administered low-energy electric currents without inducing a seizure. When scientists compared sham treatments to real ECT in seeking benefits for patients, they found the sham currents to be ineffective. Low-energy electric currents delivered from a battery with electrodes on the scalp to either alert or sleeping subjects (electrosleep) were without benefit. Some applications of electricity in medicine have been truly innovative. At the end of every grand mal seizure, brain waves (measured by the EEG) flatten out, with markedly reduced rhythmic activity. Such activity can be simulated by anesthesia using a chemical called isoflurane. Isoelectric narcotherapy (isoflurane anesthesia therapy) is a brain-stimulation technique that seeks to induce long periods of electro-cerebral silence or markedly decreased electrical activity in the brain. An hour of isoelectric brain electrical activity under anesthesia was once thought to relieve depression in a fashion similar to ECT, but an attempt at replication in six subjects failed. Without independent confirmation, the technique has been abandoned. In the past two decades, three physical interventions have been enthusiastically promoted as replacements for ECT, that is, as ways to induce the same benefits without seizures.

Postnatal depression (PND) in Japan, despite a traditional support system for perinatal women and cultural differences, is no less common than in western countries. Our previous two studies, which began in the 1990s, found that PND was experienced by about 15% of Japanese women. First, 98 Japanese women living in England (Yoshida et al. 1997) and then 88 Japanese women living in Japan (Yamashita et al. 2000) were recruited into two prospective studies of PND from late pregnancy to 3 postnatal months. Using the same research protocol and diagnostic method, (Schedule for Affective Disorders and Schizophrenia, Research Diagnostic Criteria), the incidence of PND was 12% and 17% respectively. We have a traditional support system for perinatal women called Satogaeri Bunben. Satogaeri means returning to their home towns where their families of origin live and Bunben means delivery. Pregnant women return to their home towns several weeks prior to their delivery and remain there, with their babies, after delivery for a couple of months. It seems to be a very supportive system. However, Satogaeri Bunben itself did not lower the incidence of PND in either of the groups mentioned above. A disadvantage of Satogaeri Bunben is that a woman cannot be monitored by the same midwife or obstetrician and her husband has to work and live separately until their reunion in their marital home (Yoshida et al. 2001). Most mothers with PND are unlikely to access psychiatric care, even though their depressive symptoms are serious (Mclntosh 1993). Therefore neonatal home visits by health visitors were seen as a potentially useful opportunity for detecting mothers with PND. Luckily, a home visit system by community health visitors has been well organized throughout Japan since the late 1940’s. In the past, the focus was on reducing infant death and promoting infant growth and development. In our city, the neonatal home visit service is provided for mother–baby dyads where (a) a baby’s birth weight is less than 2500 g, (b) first-born babies with a birth weight of less than 2800 g, (c) babies with perinatal or pediatric physical health problems.

This Introduction refutes the claim that hoarding is a mental illness. It first surveys psychology texts and argues that hoarding has been incorrectly seen as a pathology whose classification can be found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Contrary to this reception, the Introduction suggests that hoarding in America is a modern moral panic over things such as clutter and inappropriate keepsakes. Examining the sensationalism that hoarders incite across media, the Introduction contests this depiction and outlines how to think critically and ethically about the psychopathology of material life. It maintains that we should not treat hoarding as a neurological malfunction or as a specialized anxiety disorder but that we must historicize why hoarding seems disreputable in the United States.

This chapter examines the diagnosis of personality disorder in general and narcissistic personality disorder (NPD) in particular. After reviewing the history of the construct of NPD, the reasons why it was targeted for elimination in the DSM-5 and the counter-arguments against its elimination are described. NPD was originally eliminated from the manual because it was not considered to be real, but was later reinserted. Opinions differ about whether it was reinserted because it had some clinical reality, or put back in for only political reasons. The chapter concludes by looking at why constructs for personality disorder such as NPD are included in the domain of psychiatry disorder. It is argued that competing versions of the essentialist bias interfered with the implementation in the DSM-5 of a competition between categories and dimensions that would have set up conditions in which progress would have had a better chance of occurring.

This chapter introduces the core thematic ideas of the present volume: that psychiatric research is in crisis, that it has entered a period of extraordinary science, and that a fully adequate response to the crisis should be responsive to the perspectives and interests of persons. We identify various sources of the crisis, drawing special attention to controversies concerning the role of the DSM in psychiatric research. And, we identify different strategies of response to the current crisis, including approaches that emphasize the importance of personal perspectives and the needs of the clinic and those that emphasize the important role of various scientific research programs. Further, we survey various developments (e.g., debates over fundamentals and a role for philosophical analysis, probing of the problems of the DSM framework, relaxation of standard forms of research practice, the introduction of the Research Domain Criteria initiative and other novel research programs) that are jointly suggestive of Thomas Kuhn’s characterization of periods of crisis that can arise in scientific research and of the “extraordinary science” that ensues. We suggest that this Kuhnian framework is useful for understanding the state of psychiatric research and it provides a framework for thinking about responses to the current crisis. We conclude with brief overviews of the contributions to the volume, each of which provides such a response.

Critics contend that the categories within the DSM are fueling the current crisis in psychiatry because they are not valid. As a remedy, NIMH has established RDoC, a framework of psychological and behavioral constructs that will — they believe — better guide the search for the biological mechanisms of psychopathology. Here, we assess the ability of RDoC to rescue psychiatry from its crisis, not only by 1) evaluating its promise of increased validity, but 2) recognizing that psychiatric diagnosis can have an impact on patients’ lives independent of its validity. To assess the former, we delineate possible interpretations of validity relevant to psychiatry, and argue that RDoC faces difficult challenges in achieving what is known as etiopathological validity. To assess the latter, we suggest how the very challenge RDoC faces with respect to validity may counterintuitively serve as a benefit to patients, by reducing the extent to which patients reductionistically re-shape their identities.

We criticize a worrisome trend in contemporary psychiatry that pathologizes normalcy on dubious epistemic grounds, on the naïve premise that mental health has some sort of clear, precise, and firm link to true belief and conversely that mental disease or disorder has some clear, precise and firm link to false or misbegotten belief. We deny this premise and show how it should make us worry that we understand what makes illusions, delusions, and hallucinations unhealthy or abnormal. In fact, we deny that illusions, delusions, and hallucinations are categorically or even typically unhealthy or abnormal.

Psychiatric epidemiology has for decades been searching for the environmental origins of psychiatric disorders. If it is ultimately determined that environmental correlates of disorders are causes, interventions targeting environmental risk factors could reduce the public health burden of psychopathology. This chapter systematically reviews the evidence linking exposures in the social environment over the life course with the risk of psychiatric disorders. Only those studies that are prospective and that define psychiatric disorders according to DSM-IV criteria have been included. The search identified 26 studies that met these inclusion criteria. These studies investigated the risk of mood, anxiety, and substance disorders following exposure to specific stressors (e.g. childhood maltreatment, parental divorce) and to the number of stressful life events during a given time-period (e.g. early childhood, past-year). Effect sizes reported in relative risk terms varied considerably across studies and ranged from 1.1 to 2.5. Topics discussed include the specificity of the associations between environmental exposures and subsequent psychiatric disorders, the consistency of associations with disorder onset and disorder recurrence, the clustering of environmental exposures, and the implications of these findings for clinical practice.

Psychiatric classifications categorize how patients present to mental health care professionals and are necessarily utilitarian. From the clinician’s perspective, the most important goal of a psychiatric classification is to assist them in managing their patients’ psychiatric conditions by facilitating the selection of effective interventions and predicting management needs and outcomes. Due to the field’s lack of understanding of the neurobiological mechanisms underlying the psychiatric disorders in both the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), diagnosis and treatment are only loosely related, thus limiting clinical utility. Both DSM and the chapter on mental and behavioral disorders in ICD adopted a descriptive atheoretical categorical approach that defines mental disorders according to syndromal patterns of presenting symptoms. This chapter discusses the fundamental challenges that underlie this decision. It then reviews the Research Domain Criteria (RDoC) project, a research framework established by the U.S. National Institute of Mental Health (NIMH) to assist researchers in relating the fundamental domains of behavioral functioning to their underlying neurobiological components. Designed to support the acquisition of knowledge of causal mechanisms underlying mental disorders, RDoC may facilitate a future paradigm shift in the classification of mental disorder.

This chapter proposes a new framework for diagnostic nosology based on Bayesian principles. This novel integrative framework builds upon and improves the current diagnostic system in psychiatry. Instead of starting from the assumption that a diagnosis describes a specific unitary dysfunction that causes a set of symptoms, it is assumed that the underlying disease causes the clinician to make a diagnosis. Thus, unlike the current diagnostic system, this framework treats both symptoms and diagnostic classification as consequences of the underlying pathophysiology. Comorbidities are therefore easily incorporated into the framework and inform, rather than hinder, the diagnostic process. Further, the proposed framework provides a bridge that links putative constructs related to pathophysiology and clinical diagnoses related to signs and symptoms. Crucially, this novel framework explicitly provides an iterative approach, updating and selecting the best model, based on the highest-quality available evidence at any point. It can account for and incorporate the longitudinal course of an illness. This chapter details its theoretical basis and provides clinical examples to illustrate its utility and application. It is hoped that the framework will enhance our understanding of individual differences in brain function and behavior and ultimately improve treatment outcomes in psychiatry.