Neurodevelopmental disorders are the new psychiatry. One of the tragedies of the 20th century, more particularly in child and adolescent psychiatry and to a lesser extent in adult psychiatry and psychology, was the tradition of blaming families, and mothers in particular, for psychiatric problems. Tragically we had, ‘schizophrenic mothers’ as causes of schizophrenia and, ‘refrigerated mothers’ as causes of autism.

These false theories caused untold distress to mothers and families. It does appear to me that attachment theorists could be in danger, using a different theory, of repeating some of these errors of the 20th century and causing more unnecessary guilt to mothers (see Table 1 opposite for differential diagnosis of neurodevelopmental disorders). 

At a clinical level I have seen many children described as having attachment disorders, who have classic Asperger syndrome, which is still listed in ICD-10, but has been incorporated into autism spectrum disorders in DSM-V.

Over many years, I have observed how it is almost impossible for professionals trained in the theories of Sigmund Freud and John Bowlby to take on board the neurodevelopmental disorders – attention deficit hyperactivity disorder (ADHD), autism and Asperger syndrome etc. 

Other neurodevelopmental disorders, including learning disability, bipolar disorder and schizophrenia, are now recognised as neurodevelopmental. The latter three cause less difficulty for clinicians, although Asperger syndrome is often misdiagnosed as bipolar disorder or borderline personality disorder or schizophrenia (see Table 1).  

All of these neurodevelopmental conditions overlap to a greater or lesser extent. They are not separate categories, that is not categorised in narrow diagnostic ‘boxes’. They are best seen along overlapping dimensional lines. 

If I was developing a classification system at this time from scratch, I would place patients on the following dimensions (note that patients may not score on every dimension):

• Anxiety
• Depression
• Abnormal thinking
• Relational
• Delusional
• Attentional
• Activity.

It is widely agreed that current classifications in psychiatry are unsatisfactory. People have been aware for some time of the overlap between bipolar and schizophrenia, in relation to the psychotic spectrum.¹ 

I have quite a number of patients on the autism spectrum who developed psychosis in later adult life, or indeed sooner. Overlap of conditions is extremely common and each element of the overlap must be identified and treated. 

It is very common for autism spectrum disorders to have other neurodevelopmental disorders also, including ADHD and learning disability. All of these disorders have major genetic underpinnings. Indeed, some genetic findings overlap between these developmental disorders, with other non-overlapping findings. 

The future of psychiatry will be neurodevelopmental. Psychiatrists will focus on these conditions. Mild psychiatric conditions will be dealt with by psychotherapists, counsellors and psychologists using psychotherapeutic interventions. This will allow psychiatrists to become child and adolescent neuropsychiatrists, which they are already moving towards anyhow. 

Much of adult psychiatry work by psychiatrists is already neuropsychiatric. Psychotherapy is not a uniquely medical skill or specialty, although it is part of all medicine. The more formal long-term psychotherapy is a non-medical skill and does not require expensive medical education and training. 

We have a long way to go before we achieve what Thomas Insel, former director of the National Institute of Mental Health in the US (NIMH), stated, that future diagnosis in psychiatry should be based on biomarkers, neuroimaging and laboratory tests.^2,3,4   This is only aspirational at this point. 

References

1. Fitzgerald M. Schizophrenia and Autism Clinical Overlap and Difference in Clinical Neuropsychiatry 2012; 10(4):171-176
2. McCarthy SE, Makarov V, Kirov G, Addington AM et al.  Micro duplications of 16P11.2 are associated with schizophrenia. Nat Genet  2009; 41:1,223-1,227
3. Craddock N, Mynors-Wallis L. Psychiatric Diagnosis: Impersonal, imperfect and important. Br J Psychiatr 2014; 204(2):93-95
4. Craddock N, Owen M. The Kraepelin dichotomy – going, going, but still not gone. Br J Psychiatr 2010; 196(2):92-95