The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM ?C whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.     

The six most essential questions in psychiatric diagnosis: a pluralogue. Part 4: general conclusion

In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined.     

Fundamental properties of the N2pc as an index of spatial attention: effects of masking.

Masking is an important tool in many paradigms used to study the cognitive architecture. The N2pc is an electrophysiological event-related potential (ERP) that has been used as a tool to study the deployment of visual spatial attention. The aim of this paper was to study the effects of masking on the N2pc. Two stimuli were presented on the screen, one to left and one to right of fixation, and subjects reported the identity of one of them. The targets could be discriminated both by their category (letters vs. digit) and by their colour (pink vs. green). Backward masking was produced by presenting a second pair of bilateral stimuli after the offset of the first pair. The second pair of stimuli consisted of characters of the same colour and category as in the first pair. Forward masking was produced by using the very same stimuli as in the backward masking condition, but by instructing subjects to report the second stimulus. The forward mask trials had longer response times compared to no-mask trials, and backward mask trials had even longer response times, and also a higher error rate. Although the different masking procedures lead to clear behavioural effects, the N2pc was not affected, suggesting that the deployment of visual spatial attention, per se, was not affected by pattern masking. A sustained posterior contralateral negativity (SPCN) following the N2pc was also found (300 ms post-target, and beyond), and the amplitude of the SPCN was strongly modulated by the number of presented stimuli and the duration of the SPCN was positively correlated with RT in the behavioural task. We hypothesize that the SPCN reflects neural activity associated with the passage of information through visual short-term memory.     

Correlational analyses of explicit and implicit memory performance

Sixty-four subjects were administered two tests of explicit memory (selective recall and recognition) and four tests of implicit memory (identification in a perceptual clarification procedure, word-fragment completion, tachistoscopic identification, and anagram solution). Each test drew on a different subset of a long list of previously displayed words. Although the four implicit memory tests showed sizable priming effects, correlational and factor analyses showed striking dissociations. On the one hand, performance on the perceptual clarification procedure and word-completion tests were related to one another, as well as to recall and recognition. On the other hand, performance on tachistoscopic identification and anagram solution were related to one another, but not to the measures for the other tasks. A framework is proposed to reconcile these new results with current knowledge on the explicit/implicit memory distinction, based in particular on studies of amnesic subjects. It is argued that a small number of tasks, especially tachistoscopic identification, may serve as relatively uncontaminated and ubiquitous indicators of implicit memory. However, explicit remembering could affect performance in so-called implicit memory tasks that allow for a strategy of controlled selection of candidate responses from accumulating cues, in experimental conditions that make the explicit remembering of relevant events possible.     

A pitfall for the expectancy theory of human eyelid conditioning

Two simple eyeblink conditioning experiments with random intermittent reinforcement schedules were performed. In Experiment 1, subjects had to rate their expectancy for an unconditioned stimulus (US) on a seven-level scale prior to each trial. As anticipated, expectancy for US increased with a successive conditioned stimulus (CS) alone, and decreased with successive CS-US pairings. However, Experiments 1 and 2 showed that the frequency of eyeblink conditioned responses (CRs) evolved in a direction opposite to that of expectancy changes: CRs increased, whereas expectancy for US decreased, and vice versa. The possible effect of sensitization on eyeblink response was ruled out by the lack of a run effect in an unpaired control group in Experiment 2. These results tend to disconfirm the expectancy theory of conditioning. Although they were explicitly predicted by the conventional “strength” theory of conditioning, an alternative interpretation is proposed within a cognitive framework.     

Is time to scan visual images due to demand characteristics?

The time to scan across an object in a mental image increases with the distance scanned. Does this finding reflect the operation of underlying mechanisms or the effects of demand characteristics? Two types of demand characteristics were considered here. First, the scanning effects were shown to persist even when they conflicted with the experimenters' expectations. Experimenters were led to expect different rates of scanning and different effects of distance on scan times, but the results in all cases showed no hint of experimenter effects, instead displaying the usual increase in time with distance scanned. Second, the scanning effects were shown to persist in the absence of implicit task demands. Effects of distance were observed in an experiment in which subjects were never asked to scan the image; furthermore, such effects were observed only for items that should require spontaneous scanning even though they were randomly intermixed with items that should not, and this distinction was never mentioned nor alluded to in the instructions. Thus, experimenter effects and task demands are not sufficient explanations for the increase in the time to scan across an image as distance is increased.     

The time to name disoriented natural objects

A series of experiments revealed systematic effects of orientation on the time required to identify line drawings of natural objects. Naming time increases as patterns are rotated further from the upright. With practice, however, the effect of orientation is reduced considerably. Furthermore, the reduced orientation effect with practice on a set of objects does not transfer to a new set of objects, suggesting that the acquired ability to reduce the orientation effect is specific to particular patterns. Finally, for departures in orientation from the upright between 0° and 120°, the magnitude of the orientation effect on identification for patterns seen for the first time is equivalent to that found in a mental rotation task using the same patterns (making left/right decisions about rotated patterns). This final result suggests that novel depictions of a known class of objects may be identified by a process of mental rotation.     

Curve tracing: A possible basic operation in the perception of spatial relations

The two experiments in this study suggest that fast internal tracing of curves is employed by the visual system in the perception of certain shape properties and spatial relations. The experimental task in the first experiment was to determine, as rapidly as possible, whether two Xs lay on the same curve or on different curves in a visual display. Mean response time for “same” responses increased monotonically with increasing distance along the curve between the Xs. The task in the second experiment was to decide either that a curve joining two Xs was unbroken or that the curve had a gap. Decision times again increased as the length of the curve joining the Xs was increased. The results of both experiments suggest that people can trace curves in a visual display internally at high speed (the average rate of tracing was about 40° of visual angle per second). Curve tracing may be an important visual process used to integrate information from different parts of a visual display.     

A critical reappraisal of the evidence for unconscious abstraction of deterministic rules in complex experimental situations

In a recent experiment (Lewicki et al., 1988) subjects were submitted to a four-choice RT paradigm for 3600 trials. On each of the successive logical blocks of five trials, the first two locations of the target were randomly distributed, and the last three locations were determined by complex rules. Although subjects were unable to verbalize the actual nature of the manipulation, performance on the last trials of each block improved at a faster rate and was better overall than performance on the first trials. In addition, subsequent rules changes on 480 additional trials only affected performance on the last three trials of each block. The present paper demonstrates that contrary to Lewicki et al's assertions this performance pattern requires neither acquisition of tacit knowledge of the composition rules, nor partitioning by the subjects of the sequence into logical blocks of five trials. Rather, the results can be accounted for by the relative frequency of a few simple sequences of target locations. Moreover, this alternative explanation alone correctly anticipates some striking features of fine-grained performance (Lewicki et al., 1988). The discussion focuses on methodological implications of these findings for investigation of unconscious learning, and speculates on what and how people learn when they encounter a complex and structured situation.