The Psychobiological Modules as a Clinical Compass
by Sarah Perrin, OMS III, Touro University-CA
Finding health should be the object of the doctor. Anyone can find disease.
-Dr. A.T. Still (1828-1917)
Classification of disorders in psychiatry began in the mid-1800s as a means for the collection of statistical data. The first Diagnostic and Statistical Manual of Mental Disorders was published in 1952. In 2013 the transition from DSM-IV to DSM-V was made but with few appreciable differences. Some arbitrary lines were erased-the bereavement exclusion was removed from the criteria of Major Depressive Disorder. Some new differentiating designations were made-Panic Disorder and Agoraphobia are now two separate entities with separate codes as opposed to overlapping ones as in DSM-IV. The diagnostic sensitivity for some disorders has been increased by removal of a criterion or by increasing the applicable age (as with ADHD). Other significant changes included disposing of the subtypes of schizophrenia and the lumping together of Autism Spectrum Disorders.
Like the DSM-IV, the DSM-V serves as a guide for ICD-coding and to provide labels that allow providers to communicate a patient’s history efficiently. What the current classification system does not provide is insight into the nature and pattern of the dysfunction. The DSM is not as useful for making clinical diagnostic and treatment decisions as it could stand to be.
In Dr. Levin’s AMPERIC Model, seven psychobiological modules are identified. They include the Arousal system, the Mood and Reward system, Perseveration system, Executive function network, Reality testing system, Interpersonal skills system and cognitive system. Simply put, a deficit or abnormally high activity in one or more systems can lead to symptoms. If the symptoms are such that the patient has difficulty functioning in their environmental contexts, a disorder is present. The closest we have come to looking through the psychobiological lens in DSM-V was the placement of Gambling disorder among the Substance-related disorders, because the shared feature is implication of the Reward system. The details of the healthy and dysfunctional states of the seven brain modules can be found in Dr. Levin’s proposal of the new classification system. Here we consider how this model aids the physician in finding the health of the patient. Health can be described as when the constellation of symptoms are so well controlled that they do not interfere with functioning in the patient’s environments.
Though there are disorders that involve patterns of dysfunction in more than one of the seven modules, it is rare that a patient would have deficits or dysfunction in all systems. In fact, patients can sometimes compensate in one system, to some extent, for deficits in another. An example of this might be a child who has symptoms of ADHD with high arousal (hyperactivity) and low executive function (regulation control, attention) but with robust enough interpersonal and cognitive skills to navigate his environment somewhat effectively. With a thoughtful patient interview both dysfunctional and healthy modules can be elucidated. In the intake interview purposeful questions are aimed not only at finding out which systems are contributing to the patient’s difficulty functioning in their environmental contexts, but also at finding out which ones do not. Questions like, “What are you good at?” and “What do you like to do?” can be as telling as “What would like to change about yourself?” The patient benefits from having both what is disordered and what is healthful identified.
The way in which the current classification scheme of the DSM describes disorders presents a twofold problem for treatment. It is not organized in a way that lends itself to clinical extrapolation about potential pharmacologic or other therapeutic treatment intervention. Furthermore, once a diagnosis is received, the treatment administered will often be a response to the diagnosis rather than a response to the dysfunctional system. While the particular medication that will work best for an individual patient cannot be determined by establishing which system is malfunctioning, we will be guided to potential pharmacologic interventions because we know enough about the structure and function of those systems. Clinical judgment and our interpretations of the literature will take us the rest of the way to the treatment plan and ultimately the patient’s health. Presently it is all we have because DSM-V makes no attempts to guide us there. Classifying dysfunction in terms of Psychobiological Module it manifests from shifts the goal of “finding the health” into focus which, after all, is the object of good medicine.