Brain, Vol. 126, No. 7, 1713-1715,
July 2003
© 2003 Guarantors of Brain
doi: 10.1093/brain/awg135
Book Review |
THE DEVELOPMENT OF PSYCHOPATHOLOGY: NATURE AND NURTURE
Department of Psychological Medicine, University of Wales College of Medicine, Cardiff, UK
THE DEVELOPMENT OF PSYCHOPATHOLOGY: NATURE AND NURTURE
By Bruce Pennington
2002. London: Taylor & Francis Books Ltd
Price £34.50. pp. 380. ISBN 1-57230-755-2.
This is a book providing clarity on how developmental neuroscience has progressed, especially recently. It is one hundred years since Freud’s Interpretation Of Dreams was published and the important role of our unconscious processes first recognised. How excited he would have been, to read what neuroscience is now revealing about developmental psychopathology. Pennington begins his book pointing out that the twentieth century started with Freud’s comprehensive, if inadequate, theory of psychopathology, stating that what often seems irrational become rational given more understanding of a person’s early history. In contrast, the neuroscientific approach shows that some of the explanation for irrational behaviour is ‘sub-personal’, i.e. the causes lie outside the persons individual beliefs, e.g. in Alzheimer’s disease, schizophrenia and ADHD. It is unusual to find an account such as this book, which integrates with such mastery the biological and psychological mechanisms involved in the recent advances in genetics, epidemiology, neurobiology, neuropsychology and neuroimaging. (The author has even dipped into primate psychology). In just 380 pages, Pennington reduces the complexity into a four-level framework: aetiological; brain mechanisms; neuropsychology; and a surface or symptom level which addresses psychopathology as syndromal clusters of defining symptoms, for which an explanation is sought. He pays particular attention to the hazards of such categorisations.
Pennington’s first chapter dealing with fallacies of diagnosis, for instance the fallacy of reification (turning an abstract notion into a concrete entity), and cautions us to note that our taxonomy still have examples of inaccurate reifications and hypotheses. We have only recently moved out of the era of ‘OGOD’, (one gene, one disorder) and other single cause hypotheses.
After setting out fundamental issues facing the field, the second chapter, on methods of syndrome analysis, displays the author’s breadth of scholarships in behavioural and molecular genetics. Few reviews have been able to describe so plainly for the non-specialist, the processes of segregation analysis, twin and adoption, multivariate behavioural genetic, molecular linkage, and association methods with their complimentary strengths and weaknesses. Similarly, in his account of neurobiological methods he uses vivid descriptions and compelling metaphor. Pennington describes three broad classes of known genetic effects on brain development; on brain size, on neuronal migration and on neurotransmission he gives examples of each.
Pennington is most at home in the field of Developmental Neuropsychology and points out that an important gap in an integrated account of psychopathology is the lack of a strong theory for relating brain structure and function to underlying psychological functions. He points out that we need an intermediate level of analysis between brain structure/physiological, and psychological functions. He follows Luria’s (1966
) approach and divides the CNS into three functional systems: the arousal motivation system, which has cortical limbic and brain stem components; the perception memory system, which consists of the posterior neocortex and hippocampus; and the action selection system, chiefly the frontal neocortex, basal ganglia and part of the thalamus. This allows him to structure the rest of his book. Pennington emphasises the bi-directionality of neurodevelopment; for example, early stress experiences change the expression of the gene that produces glucocorticoids in the placenta. A child’s behaviour changes his experience, which in turn changes his brain development, which in turn affects the social environment’s response.
There is sympathy and sensitivity throughout his writing. At no point do we lose respect for the patient in impersonal classification or terminology (‘a person with autism’ is preferable to saying ‘an autistic’).
Traditional neuropsychology has given us a better understanding of visual perception and long-term memory than of the more clamant complex and immediate presentations of executive action and emotion. Traditional neuropsychopathology focused on parts of the brain that are less relevant for understanding psychopathology. Traditional psychology has not focused on development and had been too fixated on localisation of function. Localised function theories do not fit with what we know about brain development. Pennington throughout this book addresses a series of questions to drive neurodevelopmental research, and appends the relevant research designs. The book provides a research agenda for developmental medicine. Pennington shows how no single design is sufficient to conclusively establish a causal relationship between neuropsychological deficit and the symptoms of a disorder.
He does not confine himself to Developmental neuroscience. In a chapter on motivation, Pennington confidently discusses major depression, its theoretical basis and its treatments, and tackles anxiety disorders and bipolar disorders, clearly linking the topics together in a logical manner. This chapter contains less of his own work but his accounts are still particularly useful for non-psychiatrists.
In the subsequent chapter on action regulation, he returns to his most familiar territory of child development and expands on the problems of diagnostic criteria; in particular the way that over half of the children who meet diagnostic criteria for ADHD qualify for co-morbid diagnoses, and the unsatisfactory way in which DSMIV stipulates that the diagnosis of autism or schizophrenia excludes an ADHD diagnosis. His cutting edge knowledge of molecular research on ADHD focusing on the dopamine transporter gene (DAT 1) and one of the dopamine receptors (DRD4), and the work he cites, will ensure this review will serve us for some years as a reference source.
His writing on conduct disorder touches on moral behaviour, but an omission is that there is no mention of Piaget’s book, ‘ The Moral Judgement of the Child’. I can only find one reference to Piaget in this book. The book gives proper emphasis to the importance of Tourette syndrome and tic disorders, and is one of the first accounts to emphasise the very high prevalence of tic disorders, (in as much as 18% of boys in a US survey). Pennington interestingly suggests that tic disorders are the end of a normal distribution. Sadly, childhood Schizophrenia is not described in this book. Most child psychiatrists have faced, albeit rare, the onset of devastating cases of schizophrenia in early childhood, and had to ponder the difficulties of excluding schizoid children (Woolf, 1990) from early onset schizophrenia.
When Pennington discusses language and cognitive development, he is again on familiar ground and new thoughts, new speculations and intriguing ideas abound. He starts with the history of autism ‘being less than 60 years’. (This chapter was probably written before Houston and Frith’s book, 2000, establishing beyond reasonable doubt a case of autism in 1746). He deals again with the problem of DSM1V’s uneasy classification (in this case the ill-fitting conflation of the PDDs), and discusses very competently the inheritance patterns of the broader autistic phenotype, which is defined by social and cognitive deficit. Autism is one of the most heritable of psychiatric disorders. Again Pennington is very taken (and so am I) with the idea that the mild macrocephaly found in most cases of autism is associated with a progressive reduction of synaptic pruning, which would lead to an altered environmental experience. Pennington specifies what a successful neuropsychological theory of autism would require, and points out that there is no current overarching theory that can meet such specifications. The major current explanations are the theory of mind, (Baron-Cohen et al., 1986); the executive theory, (Ozonoff et al., 1991); praxis limitation theory (Meltzoff and Goprik, 1993); and the emotional theory (Hobson, 1993). His account of the genetics of autism predates the clock genes notion. (Wimpory et al., 2002).
His analysis of treatments and interventions for autism are sober and sensible, but it is a pity that he did not mention that some children and adolescents with autistic core deficits seem to improve with the ‘new’ generation of antipsychotics, in particular Risperidone. In the section on mental retardation he does not like the AAMR 1992 cut-off of IQ being increased to 75 any more than most practitioners. One hopes for its early replacement and return to a ceiling of IQ 70, allowing the problem of mental retardation numbers to be manageable again. Down’s, Williams and fragile X syndrome as key exemplar conditions are well chosen and illustrate how molecular geneticists and cognitive neuroscientists are working together to improve understanding.
Another syndrome to include in the next edition of this book (and I am sure this will be in demand), which would add to its richness, would be velocardio facial syndrome and its emerging relationship to psychosis. A regrettable omission is the concept of non-verbal learning disability and the insights it provides on autistic disorders and the non-dominant lobe. The section on dyslexia and other language disorders carries the authority of Pennington’s seminal work in 1994, rejecting several hypotheses about the transmission of dyslexia. Pennington comes down in favour on a small number of quantitative trait loci, which underlie the transmission of both dyslexia and normal variations in reading skills. There seems to be a continuum of severity; reading disorder is least severe, reading disorder plus phonological disorder more severe, and reading disorder plus phonological disorder plus specific language impairment more severe still. However, the section does not provide clear guidance to treatment. Many forms of intervention speech and language therapy appear to work to about an equal extent.
In summary, the main goal of this book is to propose, ‘a unified framework for studying the development of psychopathologies and to examine the current state of empirical knowledge in the light of this framework’. Pennington has done this very successfully. He has stressed the bi-directional nature of the relationships, he criticises forcefully the DSM IV classification and he provides an erudite summary of the neuroscience of psychopathologies. In the penultimate paragraph, he echoes Rutter (2001) in that there has been unprecedented gain in the physical health of children but a converse increase in psychological disorders. This book has helped to explicate many of the disorders responsible for this conundrum.
References
Baron-Cohen S, Leslie AM, Frith U. Does the Autistic child have a theory of mind? Cognition 1985; 21: 37–46.[CrossRef][Web of Science][Medline]
Freud S. Trans, The Interpretation of dreams. Standard Edition 1958. London & New York; 1955.
Hobson RP. Understanding persons, the role of affect. In: Baron-Cohen S, Tager-Flusberg H, Cohen DJ, eds. Understanding Other Minds. Oxford: Oxford University Press; 1993. p. 204–27.
Houston R, Frith U. Autism in History. The Case of Hugh Blair of Borgue. Oxford: Blackwells; 2000.
Luria A. Higher contact functions in man. New York: Basic Books; 1966.
Meltzoff A, Goprik A. The rule of imitation in understanding persons. In: Baron-Cohen S, Tager-Flusberg H, Cohen D, editors. Understanding other minds. Oxford: Oxford University Press; 1993. p. 335–66.
Ozonoff S, Pennington B, Rogers S. Executive function deficits in high functioning autistic individuals. J Child Psychol Psychiatry 1991; 32: 1081–1105.[Web of Science][Medline]
Piaget J. The moral judgement of the child. London: Routledge; 1968.
Rutter M. Nature, Nurture and Development. Preswald address to the Society for Research and Child Development. Minneanapolis MN; 2001.
Wimpory D, Nicholas B, Nash S. Social timing clock genes and autism: a new hypothesis. J Int Dis Res 2002; 46: 352–59.[CrossRef]
Woolf S. Loners. London: Routledge; 1990.
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