Psychiatric Genetic Counseling Research Articles

Genetic Risk Assessment in Psychiatry.

Most psychiatric disorders of pediatric and adult onset are caused by a complex interplay of genetic and environmental risk factors. Risk assessment in genetic counseling is correspondingly complicated. Outside of neurodevelopmental conditions, genetic and genomic testing has not achieved clinical utility. Genetic counselors most often base risk assessment on the client's medical and family history and empiric recurrence risk data. In rare cases significant familial risk may arise from variants of large effect. New approaches such as polygenic risk scores have the potential to inform diagnosis and management of affected individuals and risk status for at-risk individuals. Research on the genetic and environmental factors that increase risk for schizophrenia and etiologically related disorders are reviewed, guidance in determining and communicating risks to families is delivered, and new opportunities and challenges that will come with translating new research findings to psychiatric risk assessment and genetic counseling are anticipated.

Evidence-Based Genetic Counseling for Psychiatric Disorders: A Road Map.

Psychiatric disorders, such as schizophrenia, depression, anxiety, and bipolar disorder, are common conditions that arise as a result of complex and heterogeneous combinations of genetic and environmental factors. In contrast to childhood neurodevelopmental conditions such as autism and intellectual disability, there are no clinical practice guidelines for applying genetic testing in the context of these conditions. But genetic counseling and genetic testing are not synonymous, and people who live with psychiatric disorders and their family members are often interested in what psychiatric genetic counseling can offer. Further, research shows that it can improve outcomes like empowerment for this population. Despite this, psychiatric genetic counseling is not yet routinely or widely offered. This review describes the state of the evidence about the process and outcomes of psychiatric genetic counseling, focusing on its clinical implications and remaining research gaps.

Psychiatric genetic counseling: A mapping exercise.

Psychiatric genetic counseling (PGC) is gradually developing globally, with countries in various stages of development. In some, PGC is established as a service or as part of research projects while in others, it is just emerging as a concept. In this article, we describe the current global landscape of this genetic counseling specialty and this field's professional development. Drawing on information provided by expert representatives from 16 countries, we highlight the following: (a) current understanding of PGC; (b) availability of services for patients; (c) availability of training; (d) healthcare system disparities and cultural differences impacting practice; and (e) anticipated challenges going forward.

Patient perspectives on the process and outcomes of psychiatric genetic counseling: An "Empowering Encounter".

Genetic counseling (GC) for individuals with mental illness (MI) has been shown to improve patient outcomes, such as increased empowerment and self-efficacy. However, we do not understand how the process of GC results in these improvements or what aspects of the process are critical. In this qualitative study, we explored the process and outcome of psychiatric GC from the patient's perspective. Ten Canadian adults with a diagnosed MI were interviewed prior to, and 1month following, psychiatric GC. Interview transcripts were analyzed using Grounded Theory methodology and generated a theoretical framework that describes the process and outcomes of psychiatric GC from the patient's perspective. Participants described the counseling process to be an "empowering encounter" and identified specific attributes of the process and characteristics of the counselor that contributed to their empowerment. Participants gained a new perspective on the cause and management of their MI, which seemed to facilitate a deeper acceptance of their condition. Consequently, participants reported being empowered and feeling less shame, blame, and guilt; which reportedly made them more able to manage their MI and protect their mental health; and more open to talking about their condition with family and friends. This study provides a better understanding of how the process of GC influences patient outcomes and highlights features of the process that maximize patient benefit.

Impact of the physical environment on patient outcomes of genetic counseling: An exploratory study.

The psychology literature shows that the physical space in which counseling sessions are conducted influences outcomes of the interaction. However, this phenomenon has not been quantitatively explored in genetic counseling (GC). Through retrospective review of naturalistic data from a psychiatric GC clinic (where data on patient outcomes are routinely tracked from pre- to 1month post-appointment using the Genetic Counseling Outcome Scale (GCOS, empowerment) and the Illness Management Self Efficacy Scale (IMSES), we tested the hypotheses that patients seen in comfortably furnished counseling (C-type) rooms would have greater increases in (a) empowerment and (b) self-efficacy after GC than patients seen in medically oriented (M-type) rooms. We matched each patient with complete GCOS and/or IMSES who was seen in a C-type room between February 2012 and December 2017 to four M-type room controls where possible. We used t tests to compare change in outcome scale scores between groups. There were no significant differences in change in scores between patients seen in M-type (GCOS n=84, IMSES n=56) and C-type rooms (GCOS n=22, IMSES n=18) (p=0.241, d=0.26, and p=0.602, d=0.14, respectively). The effect sizes we demonstrate allow estimation of sample size calculations for the design of future prospective studies.

SU47 - BEHAVIOURAL CHANGES AFTER PSYCHIATRIC GENETIC COUNSELING: AN EXPLORATORY STUDY

Background Though often thought of as an intervention exclusively concerned with delivering information about genetic testing/recurrence risk, Genetic Counseling (GC) is actually “a process of helping people to understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease.” There is currently limited data relating to the effect of genetic counseling (rather than information) on patients’ health behaviors. With its focus on strategies to protect mental health, Psychiatric Genetic Counseling (PGC) is conceptually positioned to produce health behavior changes. Indeed, research shows that PGC leads to increased patient empowerment and self-efficacy – both of which are necessary for patients to engage in behavior change. No studies have yet examined if PGC can evoke patient health behavior changes. Methods We conducted semi-structured interviews with eight patients with a personal history of psychiatric illness who had received PGC in Vancouver, Canada within the previous year, to explore its effect on health behaviors. Interviews focused on (i) experience with PGC services, (ii) perception of the etiology of mental illness and risk of developing symptoms, (iii) views on their past and current behavior and ability to change, and (iv) changes in their behavior since their PGC session. Guided by grounded theory, we used a constant comparative approach to data analysis. Results Participants reported increases in use of protective behaviors such as exercise, improving sleep habits, adhering to prescribed medication, seeking professional help and engaging in self-care. Participants reported increased sense of control, confidence and acceptance of their psychiatric disorder after PGC. This arose from having their feelings of guilt, shame, fear and hopelessness, and misconceptions and/or uncertainties about the etiology of psychiatric disorders and recommended risk-reducing behaviors addressed. PGC reframed participants’ initial perception of mental illness by separating cause into controllable and uncontrollable factors, discussing strategies to address the controllable factors and reiterating that everyone has a varying degree of susceptibility –some may be higher than others- but symptoms of mental illness are not predetermined. Discussion Overall, participants reported health behavior changes and improved mental health outcome after PGC. Future studies could explore these changes quantitatively.

M44 - PATIENT OUTCOMES OF PSYCHIATRIC GENETIC COUNSELING: ASSESSING THE IMPACT OF DIFFERENT FAMILY HISTORY COLLECTION MODALITIES

Background Though often thought of as an intervention exclusively concerned with delivering information about genetic testing/recurrence risk, Genetic Counseling (GC) is actually “a process of helping people to understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease.” Documentation of family history (Fhx) is fundamental to this process for GC; it provides a basis for genetic risk assessment, and for personalizing conversations about illness etiology. The process of Fhx documentation can also build rapport, which is key to optimal patient outcomes of GC. Various approaches for obtaining the Fhx have been employed, often motivated by a desire to increase the efficiency of generating an accurate pedigree. However, no studies have evaluated whether different modalities for collection of Fhx data influence patient outcomes. Pre-appointment phone calls have the theoretical advantages of helping to clarify expectations and initiate rapport-building prior to the appointment, and allowing the patient and counselor to more fully attend to the content of the GC session if Fhx has been documented in advance. Methods We sought to test the hypothesis that patient outcomes of psychiatric GC would demonstrate more dramatic improvements when Fhx was collected via telephone prior to their appointment (FhxPrior) as compared to when Fhx was collected during the appointment (FhxDuring). We used data from our specialist psychiatric GC clinic, where as routine clinical practice, patients complete the GC outcomes scale (GCOS, measuring empowerment) and Illness Management Self Efficacy Scale (IMSES) immediately prior to GC (T1) and at one-month follow-up (T2). Because of the hypothetical advantages of collecting Fhx before the appointment, this is standard practice for the clinic. However, when a patient cannot be reached by telephone before the appointment, Fhx is collected during the appointment. Study inclusion criteria required: 1) that both T1 and T2 assessments were completed between 1 Feb 2012 - 31 Jan 2017, 2) that the Fhx was obtained from the patient him/herself, and 3) that the psychiatric GC appointment was conducted in person (rather than by telephone or videoconference). Change in scale scores between T1 and T2 were compared between groups using Mann-Whitney U tests. Results Of 573 patients who had completed T1 questionnaires, 240 met inclusion criteria and were included in the analysis (FhxPrior, n=206; FhxDuring, n=34). Overall, patient GCOS and IMSES scores increased significantly from T1-T2 (p=0.000, d=1.2 and p=0.004, d=0.24 respectively). The increase in IMSES scores from T1-T2 was significantly greater for the FhxPrior group than for the FhxDuring group (p=0.014, d=0.64). There was no difference in the increase in GCOS score between groups (p=0.649). Discussion Our data support previous findings regarding the important positive outcomes of psychiatric GC for patients, and suggest that obtaining Fhx via telephone prior to a psychiatric GC appointment may lead to greater increases in patient self-efficacy as compared to obtaining Fhx during the GC appointment. Future research will include prospective evaluation of alternate Fhx collection methods to maximize patient outcomes in our clinic.

Genetic Counseling For Psychiatric Disorders: Establishing A Framework In The Genomic Era

Overall Abstract Following on from a Banbury meeting in the Fall of 2016: Genetic counseling for psychiatric disorders: challenges in the genomic era, this symposium will address how we establish a framework to support effective co-operation between psychiatrists, clinical geneticists and genetic counselors. We established that differences in semantics between clinical geneticists and researchers in psychiatric genetics focused around explanatory or diagnostic and predictive or susceptibility testing. The divergent ways in which genetic testing is applied to autism in comparison to other psychiatric disorders, through microarray and CNV testing, raises important considerations for examining the impact of CNV identification on patients and their care. In addition, there is an urgent need to educate psychiatric residents about genetic syndromes and we will discuss how future efforts will focus on integrating genetic discoveries into patient care. Similarly, pharmacogenetic testing on all psychiatric conditions is not warranted at this time; however, there are clear circumstances when it should be considered. Specifically, the elderly and youth may be more at risk and testing for variants that are known to increase risk for adverse outcomes should be encouraged. Finally, in complimenting current and future (pharmaco)genetic testing, psychiatric genetic counseling should be made available to all who request it. We will highlight the global effort for implementing this, discuss how best to bring clinical genetics and psychiatry closer together and consider ways to develop evidence based studies in psychiatric genetic counseling, to keep abreast with the fast pace of genetic discovery in mental illness.

Counseling Families About Recurrence Risks of Psychiatric Disease

Members of families affected with psychiatric conditions seek genetic counseling to understand the risks to themselves and/or their offspring. Often their risk perceptions exceed absolute risk estimates as fears may be based on assumptions of Mendelian risks rather than common complex disease risks. Yet, regardless of the often reassuring empiric risk information, the challenges to this work include: advocating for improved family communication where secrets may prevail to learn diagnoses, assessing risks/benefits of remaining on medications during pregnancy, and identifying families where genetic testing for copy number variants may be appropriate. This presentation will provide an overview of the state of psychiatric genetic counseling, its assets and potential pitfalls, with a hopeful view toward the future of personalized medicine and enhanced risk assessment.

Patient outcomes of genetic counseling: Assessing the impact of different approaches to family history collection.

No studies have yet evaluated whether different modalities for the collection of family history data influence patient outcomes of genetic counseling. We retrospectively compared outcomes of genetic counseling between patients whose family history (Fhx) was collected (1) via telephone prior to their appointment (FhxPrior) or (2) during the appointment (FhxDuring). We used a psychiatric genetic counseling clinic database, where information about demographics and Fhx timing is recorded, and patients complete the Genetic Counseling Outcomes Scale (GCOS, measuring empowerment) and Illness Management Self-Efficacy Scale (IMSES) immediately prior to (T1) and 1 month after their appointment (T2). We used ANCOVA to evaluate the effect of the Fhx method on patient outcomes at T2. Complete data were available for 240 patients and were used for analysis (FhxPrior, n = 206; FhxDuring, n = 34). GCOS and IMSES scores increased from T1 to T2 (P < .0005 and P = .004, respectively). Although there was no difference between groups for GCOS (P = .412), T2 IMSES scores were significantly higher for FhxPrior than FhxDuring after controlling for T1 scores (P = .011). Our data suggest that obtaining Fhx via telephone prior to genetic counseling may lead to greater increases in patients' self-efficacy as compared to obtaining Fhx during the genetic counseling appointment.

Training to Provide Psychiatric Genetic Counseling: How Does It Impact Recent Graduates' and Current Students' Readiness to Provide Genetic Counseling for Individuals with Psychiatric Illness and Attitudes towards this Population?

Mental illness is extremely common and genetic counselors frequently see patients with mental illness. Genetic counselors report discomfort in providing psychiatric genetic counseling (GC), suggesting the need to look critically at training for psychiatric GC. This study aimed to investigate psychiatric GC training and its impact on perceived preparedness to provide psychiatric GC (preparedness). Current students and recent graduates were invited to complete an anonymous survey evaluating psychiatric GC training and outcomes. Bivariate correlations (p<.10) identified variables for inclusion in a logistic regression model to predict preparedness. Data were checked for assumptions underlying logistic regression. The logistic regression model for the 286 respondents [χ2(8)=84.87, p<.001] explained between 37.1% (Cox & Snell R2=.371) and 49.7% (Nagelkerke R2=.497) of the variance in preparedness scores. More frequent psychiatric GC instruction (OR=5.13), more active methods for practicing risk assessment (OR=4.43), and education on providing resources for mental illness (OR=4.99) made uniquely significant contributions to the model (p<.001). Responses to open-ended questions revealed interest in further psychiatric GC training, particularly enabling "hands on" experience. This exploratory study suggests that enriching GC training through more frequent psychiatric GC instruction and more active opportunities to practice psychiatric GC skills will support students in feeling more prepared to provide psychiatric GC after graduation.

The current state of genetic counseling and newborn screening: an interview with Megan Tucker.

Megan Tucker talks to Francesca Lake, Managing Editor: A certified genetic counselor for over 10 years, Megan is currently the director of the Indiana State University Genetic Counseling Graduate Program and the Genetic Counseling Clinic at Union Hospital (Terre Haute, IN, USA). She began her career split between the Center for Prenatal Diagnosis and the Medical Genetics and Neurodevelopmental Center at St Vincent Hospital (Indianapolis, IN, USA). During this time she was instrumental in both the development of the statewide Perinatal Loss Evaluation Program and a hospital protocol to ensure collection of cord blood to allow time to effectively genetically evaluate babies. Her current clinical focus is in cancer and psychiatric genetic counseling.

How do Physicians Decide to Refer Their Patients for Psychiatric Genetic Counseling? A Qualitative Study of Physicians' Practice.

Psychiatric genetic counseling (PGC) is an emerging specialty discipline within the genetic counseling profession. A specialist PGC service was founded in 2012 in Vancouver, Canada, and though patient benefits have been demonstrated, many physicians do not regularly refer patients to the service despite awareness of its availability. We conducted a qualitative study involving semi-structured telephone interviews with Vancouver-based physicians who were aware of the PGC service to explore this phenomenon. Interviews were audio-recorded, transcribed verbatim, coded, and analysed for emergent themes. Consistent with a grounded theory approach, constant comparison was employed throughout data collection and analysis. Analyses of interviews conducted with 12 physicians revealed that referral practices were informed by perceptions about the purpose of PGC and interpretation of patient cues. Physicians perceived PGC as an information-focused intervention, and considered referral when patients explicitly expressed desire for information about recurrence risk or etiology that they felt unable to adequately address themselves. Even when physicians identified psychotherapeutic benefits of PGC, patient needs of this nature were not perceived as cues prompting referral to PGC. These data suggest that further work is necessary to position PGC in physicians' minds as a service that could potentially benefit most individuals with psychiatric disorders and their families, and that it encompasses more than information provision. It is important to increase physicians' awareness of the complementary role that genetic counselors can play to that of the physician in providing psychotherapeutically oriented counselling about illness etiology.

Evaluating a unique, specialist psychiatric genetic counseling clinic: uptake and impact.

People with psychiatric disorders and their family members have expressed interest in receiving genetic counseling (GC). In February 2012, we opened the first (to our knowledge) specialist psychiatric GC clinic of its kind, for individuals with non-syndromic psychiatric disorders and their families. Prior to GC and at a standard 1-month follow-up session, clinical assessment tools are completed, specifically, the GC outcomes scale (GCOS, which measures empowerment, completed by all clients) and the Illness Management Self Efficacy scale (IMSES, completed by those with mental illness). Consecutive English-speaking clients attending the clinic between 1 February 2012 and 31 January 2013 who were capable of consenting were asked for permission to use their de-identified clinical data for research purposes. Descriptive analyses were conducted to ascertain demographic details of attendees, and paired sample t-tests were conducted to assess changes in GCOS and IMSES scores from pre- to post-GC. Of 143 clients, seven were unable to consent, and 75/136 (55.1%) consented. Most were female (85.3%), self-referred (76%), and had personal experience of mental illness (65.3%). Mean GCOS and IMSES scores increased significantly after GC (p < 0.0001 and p = 0.011, respectively). In a naturalistic setting, GC increases empowerment and self-efficacy in this population.

New Ethical Issues for Genetic Counseling in Common Mental Disorders

Recent genetic findings of high-impact genetic variants in bipolar disorder, schizophrenia, and autism spectrum disorder (ASD) must lead to profound changes in genetic and family counseling. The authors present risk calculations, discuss the ethical implications of these findings, and outline the changes now required in the risk counseling process. The authors use data from recent mega-analyses and reviews of common and rare risk variants in bipolar disorder, schizophrenia, and ASD to calculate risks of illness based on genetic marker tests. They then consider new ethical issues in mental disorders presented by these risks, including within-family conflicts over genetic testing; effects of genetic discoveries on stigma, abortion, preimplantation procedures, and population screening for susceptibility; and genetic tests as a factor in marital choice. New structural mutations (de novo copy number variants [CNVs], which are chromosomal microdeletions and micro-duplications) are present in 4%27% of patients with bipolar disorder, schizophrenia, or ASD and can occur almost anywhere in the genome. For a person with a de novo CNV, the absolute risk of bipolar disorder, schizophrenia, or ASD is 14%, much higher than the population risk. Rare CNVs have also been identified that are generally not new mutations but constitute very high-effect risk factors, ranging up to 82%. A substantial minority of patients with bipolar disorder, schizophrenia, and ASD have high-impact detectable genetic events. This greatly changes psychiatric genetic counseling for these patients and families. A psychotherapeutic approach may be needed as a routine part of risk counseling, particularly for resolution of ethical issues and for within-family stigma and conflicts over genetic test results.

“Nothing is Absolute in Life”: Understanding Uncertainty in the Context of Psychiatric Genetic Counseling from the Perspective of those with Serious Mental Illness

No genetic tests are currently clinically available for serious mental illnesses such as schizophrenia and bipolar disorder. Rather, the full spectrum of genetic variants that confer susceptibility remain unknown, and estimates of probability of condition recurrence typically have the form of ranges rather than single absolute numbers. Genetic counselors have been shown to feel that the information that can be provided for patients with serious mental illness could be more confusing than helpful. However, how those with serious mental illness perceive this uncertainty remains unknown. So, to investigate this, individuals with serious mental illness participated in a psychiatric genetic counseling (GC) session and responded to a single open ended question about their reactions towards the uncertainty that they encountered in their GC session immediately and one month post-counseling (from which themes were identified), and completed the Genetic Counseling Satisfaction Scale immediately post-session (descriptive statistics applied). While some of the 37 participants were disappointed with the uncertainty, twice as many were unconcerned. Overall, responses from immediately and one month after GC were very similar; participants were very satisfied with, and found value in GC despite uncertainty, and four approaches to coping with uncertainty emerged. Ultimately, these findings offer insight into providing GC for those with serious mental illness, and potentially could be applied to other areas of GC where uncertainty lies, with downstream impact on GC practice and future research.

Evaluating Genetic Counseling for Individuals With Schizophrenia in the Molecular Age

Recent advances in schizophrenia genetics are shedding new light on etiopathogenesis, but issues germane to translation of findings into clinical practice are relatively understudied. We assessed the need for, and efficacy of, a contemporary genetic counseling protocol for individuals with schizophrenia. After characterizing rare copy number variation in a cohort of adults with schizophrenia, we recruited subjects from the majority of individuals who had no clinically relevant structural genetic variant. We used a pre-post study design with longitudinal follow-up to assess both the profile of need and the impact of general genetic counseling on key knowledge-based and psychological factors. Thirty-nine (60.0%) of 65 patients approached actively expressed an interest in the study. At baseline, participants (n = 25) tended to overestimate the risk of familial recurrence of schizophrenia, express considerable concern related to this perceived risk, endorse myths about schizophrenia etiology, and blame themselves for their illness. Postcounseling, there was a significant improvement in understanding of the empiric recurrence risk (P = .0090), accompanied by a decrease in associated concern (P = .0020). There were also significant gains in subjective (P = .0007) and objective (P = .0103) knowledge, and reductions in internalized stigma (P = .0111) and self-blame (P = .0401). Satisfaction with genetic counseling, including endorsement of the need for such counseling (86.4%), was high. These results provide initial evidence of need for, and efficacy of, genetic counseling for individuals with schizophrenia. The findings may help facilitate development of a contemporary genetic counseling process that could optimize outcomes in the nascent field of evidence-based psychiatric genetic counseling.

Genetic Counseling for Schizophrenia: A Review of Referrals to a Provincial Medical Genetics Program From 1968 to 2007

Although previous studies reported that a majority of individuals with schizophrenia and their family members are interested in genetic counseling, few in each group had ever been offered genetic counseling. Although some individuals with genetic syndromes that include schizophrenia have received psychiatric genetic counseling, genetic syndromes account for only a very small proportion of patients with schizophrenia. There are little data on the characteristics of individuals/families who have received psychiatric genetic counseling. This exploratory retrospective study examined the population of individuals referred for genetic counseling in British Columbia for a primary indication of nongenetic schizophrenia, and assessed trends in the annual number of such referrals over time. All charts in the database of the provincial medical genetics program were reviewed to obtain information on demographics, psychiatric diagnosis, discipline of referring physician, referred individual's and partner's (where applicable) family history, and pregnancy history. Data were analyzed using descriptive statistics. Between 1968 and 2007, 288 individuals were referred for a primary indication of schizophrenia. The proportion of referrals (69%) was highest for family members with an affected first-degree relative not for individuals personally affected (25%). Most referrals were for preconception counseling. Family physicians accounted for 69% of the referrals, whereas obstetricians accounted for 9% and psychiatrists 2%. These findings show that only a small proportion of individuals with schizophrenia and their family members receive referrals for psychiatric genetic counseling in British Columbia. Future strategies to improve access to genetic counseling include outreach (showing the need of such counseling) to both this population and to healthcare professionals, especially psychiatrists and obstetricians.

Genetic counseling for schizophrenia: A review of referrals to a provincial medical genetics program from 1968 to 2007

Recent studies have shown that individuals with schizophrenia and their family members are interested in genetic counseling, but few have received this service. We conducted an exploratory, retrospective study to describe (a) the population of individuals who were referred to the BC provincial medical genetics program for genetic counseling for a primary indication of schizophrenia, and (b) trends in number of referrals between 1968 and 2007. Referrals for a primary indication of schizophrenia were identified through the provincial program database. Charts were reviewed and the following information was recorded: discipline of referring physician, demographics, psychiatric diagnosis, referred individual's and partner's (if applicable) family history, and any current pregnancy history. Data were characterized using descriptive statistics. Our results showed that between 1968 and 2007, 288 referrals were made for a primary indication of schizophrenia. Most referrals were made: (a) for individuals who had a first-degree family member with schizophrenia, rather than for affected individuals, (b) for preconception counseling, and (c) by family physicians (69%), with only 2% by psychiatrists. In conclusion, for British Columbia, individuals affected with schizophrenia and their family members are rarely referred for psychiatric genetic counseling. There is a need to identify barriers to psychiatric genetic counseling and develop strategies to improve access.

Psychiatric Genetics: Applications in Clinical Practiceedited by Jordan W. Smoller, M.D., Sc.D., Beth Rosen Sheidley, M.S., C.G.C., and Ming T. Tsuang, M.D., Ph.D., D.Sc. Arlington, Va., American Psychiatric Publishing, 2008, 337 pp., $60.00.

Psychiatric Genetics: Applications in Clinical Practiceedited by Jordan W. Smoller, M.D., Sc.D., Beth Rosen Sheidley, M.S., C.G.C., and Ming T. Tsuang, M.D., Ph.D., D.Sc. Arlington, Va., American Psychiatric Publishing, 2008, 337 pp., $60.00.