Book Review

Understanding Tourette Syndrome, Obsessive Compulsive Disorder, and Related Problems: A Developmental and Catastrophe Theory Perspective

N Engl J Med 1993; 328:144January 14, 1993

Article

Understanding Tourette Syndrome, Obsessive Compulsive Disorder, and Related Problems: A Developmental and Catastrophe Theory Perspective
By John M. Berecz. 318 pp., illustrated. New York, Springer Publishing, 1992. $44.95. ISBN: 0-8261-7390-X

John M. Berecz, a clinical psychologist who himself has Tourette's syndrome, has written a book with the goal of “spacious theorizing” about Tourette's syndrome and obsessive-compulsive disorder. He believes both have been overinterpreted from a specious biologic perspective that neglects psychosocial factors in considering etiology. From the premise that Tourette's syndrome and obsessive-compulsive disorder are actually the same “functional biopsychosocial” condition, he invokes catastrophe theory as a unifying and explanatory framework for his speculations. Catastrophe theory is based on topology, a branch of mathematics in which multidimensional geometric forms describe complex relations among variables. The approach is comparative and qualitative, rather than absolute and quantitative. The hallmark of Tourette's syndrome and obsessive-compulsive disorder is “ambitendency,” or the behavioral expression of contradictory emotional states. Ambitendency leads to a “bifurcated” self in which the opposition is of shame and anger or of the somatic and the intellectual. When these bimodalities are topologically mapped, the resulting Tourette's syndrome or obsessive-compulsive disorder is seen as due to abrupt and catastrophic changes as the topographic map makes abrupt and discontinuous turns. Catastrophe theory is also used to suggest therapeutic interventions.

In addition to supporting his premise with developmental theories, Berecz relies on case reports, accounts of historical figures with Tourette's syndrome or obsessive-compulsive disorder, descriptions of people with Tourette's syndrome in a nonclinical context, and clinical material. Medical treatment for Tourette's syndrome and obsessive-compulsive disorder is eschewed in favor of psychological treatments. Finally, the author attempts to address the perplexing theme of volition in Tourette's syndrome and obsessive-compulsive disorder, framing the issue of responsibility in multiple perspectives.

The book is engagingly written in an informal style and presents a number of provocative ideas that challenge established conventions about Tourette's syndrome and obsessive-compulsive disorder. The case reports make interesting reading, even though the conclusions do not clearly follow from the data presented. Catastrophe theory is explained in a lucid and interesting manner, although the defining variables of bimodality-bifurcation in Tourette's syndrome and obsessive-compulsive disorder are not convincingly supported by the data.

The author chastises the majority of clinicians and researchers on Tourette's syndrome for reductionism and for not adhering to an integrated biopsychosocial model of disease, but he himself falls into the trap of psychosocial reductionism. Adhering to an outmoded Cartesian dualism of mind versus body and functional versus organic, he summarily dismisses the amassed evidence of genetic, biochemical, neuropathological, neurophysiologic, developmental, psychological, and social studies of Tourette's syndrome. A true biopsychosocial analysis of this disease would focus more on the complementarity of processes occurring at different levels of organization in the human organism, rather than foster a spurious competition for causal status among these levels. The author's assignment of syndromal equivalence to Tourette's syndrome and obsessive-compulsive disorder ignores, among other things, instances of quantitative family-pedigree studies pointing to Tourette's syndrome and obsessive-compulsive disorder as distinct alternative expressions of common genetic factors. On the surface, many of the author's formulations of the causation of tics and the symptoms of obsessive-compulsive disorder are credible. He asserts that negative emotional experiences at critical points in development give form and substance to the tics they generate. Although these views may be enlightening in terms of the content of tics, such experiences are not necessarily the sole or pivotal initiators of the tic process.

I agree with the author's assertion that a work with a more “spacious” and encompassing view of Tourette's syndrome and associated disorders is needed at this time. Unfortunately, I cannot recommend this book as filling that need.

Jacob Kerbeshian, M.D.
University of North Dakota, Grand Forks, ND 58201