psychiatric diagnosis and classification

Psychiatric Diagnosis and Classification Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic) Psychiatric Diagnosis and Classification Edited by Mario Maj University of Naples, Italy Wolfgang Gaebel University of Du È sseldorf, Germany Juan Jose  Lo  pez-Ibor Complutense University of Madrid, Spain Norman Sartorius University of Geneva, Switzerland Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic) Copyright # 2002 by John Wiley & Sons, Ltd., Baffins Lane, Chichester, West Sussex PO19 1UD, UK National 01243 779777 International (+44) 1243 779777 e-mail (for orders and customer service enquiries): cs-books@wiley.co.uk Visit our Home Page on: http://www.wiley.co.uk or http://www.wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1P 0LP, UK, without the permission in writing of the publisher. Other Wiley Editorial Offices John Wiley & Sons, Inc., 605 Third Avenue, New York, NY 10158-0012, USA WILEY-VCH Verlag GmbH, Pappelallee 3, D-69469 Weinheim, Germany John Wiley & Sons Australia, Ltd., 33 Park Road, Milton, Queensland 4064, Australia John Wiley & Sons (Asia) Pte, Ltd., 2 Clementi Loop #02-01, Jin Xing Distripark, Singapore 129809 John Wiley & Sons (Canada), Ltd., 22 Worcester Road, Rexdale, Ontario M9W IL1, Canada Library of Congress Cataloging-in-Publication Data Psychiatric diagnosis and classification / edited by Mario Maj . . . [et al.]. p. cm. ``Based in part on presentations delivered at the 11th World Congress of Psychiatry (Hamburg, Germany, August 6±11, 1999)'' Includes bibliographical references and index. ISBN 0-471-49681-2 (cased) 1. Mental illnessÐDiagnosisÐCongresses. 2. Mental illnessÐClassificationÐCongresses. I. Maj, Mario, 1953±II. World Congress of Psychiatry (11th: 1999: Hamburg, Germany) RC469. P762 2002 616.89 0 075Ðdc21 2001057370 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-471-49681-2 Typeset in 10/12pt Palatino by Kolam Information Services Private Ltd, Pondicherry, India Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall, UK This book is printed on acid-free paper responsibly manufactured from sustainable forestry, in which at least two trees are planted for each one used for paper production. Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic) Contents List of Contributors vii Preface ix 1. Criteria for Assessing a Classification in Psychiatry Assen Jablensky and Robert E. Kendell 1 2. International Classifications and the Diagnosis of Mental Disorders: Strengths, Limitations and Future Perspectives T. Bedirhan U È stu È n, Somnath Chatterji and Gavin Andrews 25 3. The American Psychiatric Association (APA) Classification of Mental Disorders: Strengths, Limitations and Future Perspectives Darrel A. Regier, Michael First, Tina Marshall and William E. Narrow 47 4. Implications of Comorbidity for the Classification of Mental Disorders: The Need for a Psychobiology of Coherence C. Robert Cloninger 79 5. Evolutionary Theory, Culture and Psychiatric Diagnosis Horacio Fabrega Jr. 107 6. The Role of Phenomenology in Psychiatric Diagnosis and Classification Josef Parnas and Dan Zahavi 137 7. Multiaxial Diagnosis in Psychiatry Juan E. Mezzich, Aleksandar Janca and Marianne C. Kastrup 163 8. Clinical Assessment Instruments in Psychiatry Charles B. Pull, Jean-Marc Cloos and Marie-Claire Pull-Erpelding 177 9. Psychiatric Diagnosis and Classification in Primary Care David Goldberg, Greg Simon and Gavin Andrews 219 10. Psychiatric Diagnosis and Classification in Developing Countries R. Srinivasa Murthy and Narendra N. Wig 249 Index 281 Acknowledgements 295 Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic) Contributors Gavin Andrews School of Psychiatry, University of New South Wales at St. Vincent's Hospital, 299 Forbes Street, Darlinghurst, NSW 2010, Australia Somnath Chatterji Classification, Assessment, Surveys and Terminology, Department of Evidence for Health Policy, World Health Organization, Geneva, Switzerland C. Robert Cloninger Department of Psychiatry, Washington University School of Medicine, Campus Box 8134, 660 S.Euclid, St. Louis, Missouri 63110±1093, USA Jean-Marc Cloos Centre Hospitalier de Luxembourg, 4, rue Barble  , L-1210 Luxembourg Horacio Fabrega Jr. Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA Michael First NYS Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA David Goldberg Institute of Psychiatry, King's College, London, UK Assen Jablensky University Department of Psychiatry and Behavioural Science, University of Western Australia, MRF Building, Level 3, 50 Murray Street, Perth, WA 6000, Australia Aleksandar Janca Department of Psychiatry and Behavioural Science, Univer- sity of Western Australia, Perth, Australia Marianne C. Kastrup International Rehabilitation and Research Center for Torture Victims, Copenhagen, Denmark Robert E. Kendell University Department of Psychiatry and Behavioural Science, University of Western Australia, MRF Building, Level 3, 50 Murray Street, Perth, WA 6000, Australia Tina Marshall Division of Research, American Psychiatric Association, 1400 K Street N.W., Washington, DC 20005, USA Juan E. Mezzich Division of Psychiatric Epidemiology and International Center for Mental Health, Mount Sinai School of Medicine of New York University, New York, USA Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic) R. Srinivasa Murthy National Institute of Mental Health, Department of Psychiatry and Neuroscience, Post Bag 2900, Bangalore 56002-9, India William E. Narrow Division of Research, American Psychiatric Association, 1400 K Street N.W., Washington, DC 20005, USA Josef Parnas Department of Psychiatry, Hvidovre Hospital, Brondbyoestervej 160, 2650 Hvidovre, Denmark Charles B. Pull Centre Hospitalier de Luxembourg, 4, rue Barble  , L-1210 Luxembourg Marie-Claire Pull-Erpelding Centre OMS Francophone de Formation et de Re  fe  rence, 4, rue Barble  , L-1210 Luxembourg Darrel A. Regier American Psychiatric Institute for Research and Education, 1400 K Street N.W., Washington, DC 20005, USA Greg Simon Center for Health Studies, Group Health Cooperative, 1730 Minor Ave. #1600, Seattle, WA 98101±1448, USA T. Bedirhan U È stu È n Classification, Assessment, Surveys and Terminology, Department of Evidence for Health Policy, World Health Organization, Geneva, Switzerland Narendra N. Wig Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India Dan Zahavi Danish Institute for Advanced Studies in the Humanities, Vim- melskaflet 41 A, DK-1161 Copenhagen K, Denmark viii CONTRIBUTORS Preface The next editions of the two main systems for the diagnosis and classifica- tion of mental disorders, the ICD and the DSM, are not expected before the year 2010. The most frequently alleged reasons for this long interval are: (1) the satisfaction with the performance of the systems as they are now, since they are achieving their goals of improving communication among clini- cians and ensuring comparability of research findings; (2) the concern that frequent revisions of diagnostic systems may undermine their assimilation by clinicians, damage the credibility of our discipline, and hamper the progress of research (by making the comparison between old and new data more difficult, impeding the collection of large patient samples, and requiring a ceaseless update of diagnostic interviews and algorithms); (3) the presentiment that we are on the eve of major research breakthroughs, which may have a significant impact on nosology. There is a further reason, however, for the current hesitation to produce a new edition of the above diagnostic systems, which is seldom made explicit, but is probably not the least important: i.e. the gradually spreading perception that there may have been something incorrect in the assumptions put forward by the neo-Krae- pelinian movement at the beginning of the 1970s, which have guided the development of the modern generation of diagnostic systems. That current diagnostic categories really correspond to discrete natural disease entities is appearing now more and more questionable. Psychiatric ``comorbidity'', i.e. the coexistence of two or more psychiatric diagnoses in the same individual, seems today the rule rather than the exception. Thirty years of biological research have not been able to identify a specific marker for any of the current diagnostic categories (and genetic research is now providing evidence for the possible existence of vulnerability loci which are common to schizophrenia and bipolar disorder). Also the therapeutic pro- file of newly developed psychotropic drugs clearly crosses old and new diagnostic boundaries (e.g. new generation antipsychotics appear to be as effective in schizophrenia and in bipolar disorder, and new generation antidepressants are effective in all the various disorders identified by cur- rent classification systems in the old realm of neuroses). The fact that current diagnostic categories are unlikely to correspond to discrete natural disease entities has been taken as evidence that the neo- Kraepelinian (or neo-Pinelian) model was intrinsically faulty, i.e. that psy- chopathology does not consist of discrete disease entities. This has been Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic) recently maintained from several different perspectives, including the psy- chodynamic [1], the biological [2], the characterological [3], and the evolu- tionary [4] ones. Of note, Kraepelin himself, in his late years, questioned the validity of the ``discrete disease'' model, by stating that ``Many manifesta- tions of insanity are shaped decisively by man's preformed mechanisms of reaction'' and that ``The affective and schizophrenic forms of mental dis- order do not represent the expression of particular pathological processes, but rather indicate the areas of our personality in which these processes unfold'' [5]. A second possibility, however, is that psychopathology does consist of discrete disease entities, but that these entities are not reflected by current diagnostic categories. If this is the case, then current clinical research on ``comorbidity'' may be helpful in the search for ``true'' disease entities, leading in the long term to a rearrangement of present classifications, which may either involve a simplification (e.g. a single disease entity may underlie the apparent comorbidity of major depression, social phobia and panic disorder) or a further complication (e.g. different disease entities may correspond to major depression with panic disorder, major depression with obsessive-compulsive disorder, etc.) or possibly a simplification in some areas of classification and a further complication in other areas. There is, nevertheless, a third possibility: that the nature of psychopathol- ogy is intrinsically heterogeneous, consisting in part of true disease entities and in part of reaction types or maladaptive response patterns. This is what Jaspers [6] actually suggested when he distinguished between ``true diseases'', like general paresis, which have clear boundaries among them- selves and with normality; ``circles'', like manic-depressive insanity and schizophrenia, which have clear boundaries with normality but not among themselves; and ``types'', like neuroses and abnormal personalities, which do not have clear boundaries either among themselves or with normality. Recently, it has been pointed out [7] that throughout medicine there are diseases arising from a defect in the body's machinery and dis- eases arising from a dysregulation of defenses. If this is true also for mental disorders, i.e. if a condition like bipolar disorder is a disease arising from a defect in the brain machinery, whereas conditions like anxiety disorders, or part of them, arise from a dysregulation of defenses, then different classification strategies may be needed for the various areas of psycho- pathology. The present volume reflects the above developments and uncertainties in the field of psychiatric diagnosis and classification. It provides a survey of the strengths and limitations of current diagnostic systems and an overview of various perspectives about how these systems can be improved in the future. It is hoped that, at least for the eight years to come, the book will be of some usefulness to the many clinicians and researchers around the x PREFACE world who are interested in the future of psychiatric diagnosis and classi- fication. Mario Maj Wolfgang Gaebel Juan Jose  Lo  pez-Ibor Norman Sartorius REFERENCES 1. Cloninger C.R., Martin R.L., Guze S.B., Clayton P.J. (1990) The empirical struc- ture of psychiatric comorbidity and its theoretical significance. In: Comorbidity of Mood and Anxiety Disorders (Eds J.D. Maser, C.R. Cloninger), pp. 439±498. Amer- ican Psychiatric Press, Washington. 2. van Praag H.M. (1996) Functional psychopathology: an essential diagnostic step in biological psychiatric research. In: Implications of Psychopharmacology to Psy- chiatry (Eds M. Ackenheil, B. Bondy, R. Engel, M. Ermann, N. Nedopil), pp. 79±88. Springer, Berlin. 3. Cloninger C.R. (1999) Personality and Psychopathology. American Psychiatric Press, Washington. 4. McGuire M., Troisi A. (1998) Darwinian Psychiatry. Oxford University Press, New York. 5. Kraepelin E. (1920) Die Erscheinungsformen des Irreseins. Z. ges. Neurol. Psy- chiat., 62: 1±29. 6. Jaspers K. (1959) Allgemeine Psychopathologie. Springer, Berlin. 7. Nesse R. M. (2000) Is depression an adaptation? Arch. Gen. Psychiatry, 57: 14±20. This volume is based in part on presentations delivered at the 11th World Congress of Psychiatry (Hamburg, Germany, 6±11 August 1999) PREFACE xi Acknowledgements The Editors would like to thank Drs Paola Bucci, Umberto Volpe and Andrea Dell'Acqua, of the Department of Psychiatry of the University of Naples, for their help in the processing of manuscripts. The publication has been supported by an unrestricted educational grant from Pfizer, which is hereby gratefully acknowledged. Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic) [...]... as a common classification for different cultures and explores the issues around future revisions given the expectations of scientific advances in the fields of genetics, neurobiology, and cultural studies   Psychiatric Diagnosis and Classification Edited by Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor and Norman Sartorius # 2002 John Wiley & Sons, Ltd 26 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION. .. ``evidence-based'' imprimatur in psychiatric classification The theory and practice of psychiatric diagnosis and classification cannot be divorced from their social context [47] FUTURE SCENARIOS One Classification or Many? For the last 20 years, there have been two widely used classifications of mental disorders, the World Health Organization (WHO)'s ICD and the American Psychiatric Association (APA)'s... for the time being, a radical restructuring of psychiatric classification from a predominantly categorical 16 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION to a predominantly dimensional model However, if psychiatric classification ought to be unashamedly eclectic and pragmatic, such restructuring may not be necessary or even desirable Moreover, categorical and dimensional models need not be mutually exclusive,... important concern that needs to be taken 18 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION into account when developing, adapting, or translating diagnostic classifications Needs of Researchers Both DSM-III and its successors and, to a lesser extent, ICD-10 were welcomed and quickly adopted by researchers as rigorous diagnostic standards However, the performance of a classification as a research tool needs to... psychiatry is in a state of flux Advances in   Psychiatric Diagnosis and Classification Edited by Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor and Norman Sartorius # 2002 John Wiley & Sons, Ltd 2 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION neuroscience and genetics are setting new, interdisciplinary agendas for psychiatric research and the results to be expected within the next few decades are likely... disciplines where 22 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION molecular, imaging and computational tools have largely replaced traditional clinical skills in making a diagnosis In time, such developments might result in a completely redesigned classification of mental disorders, based on genetic aetiology [49] The categories of such a classification and their hierarchical ordering may disaggregate and recombine... experiment This term may be too demanding for psychiatry, where it may be more appropriate to speak of ``explicit'' rather than ``operational'' diagnostic criteria 14 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION and accessory symptoms of schizophrenia [37] and Schneider's distinction between ``first-rank'' and ``second-rank'' symptoms in the differential diagnosis of schizophrenia and affective psychoses [38]... demystifying psychiatric diagnosis and making its logic transparent to non-professionals While acknowledging such gains, it is important to examine critically the current versions of standardized diagnostic criteria and rule-based classification systems in psychiatry for conceptual and methodological shortcomings At present, the discipline of psychiatry is in a state of flux Advances in   Psychiatric Diagnosis. .. problems'' for worldwide use, and that every 20 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION country is obliged to report basic morbidity data to WHO using its categories, whereas the DSM is a stand-alone classification of mental disorders designed, at least in the first instance, for use by American health professionals For a variety of political and financial reasons, both classifications will continue... ``disorders'' in DSM-IV and ICD-10 do not form hierarchies and the current psychiatric classifications contain no supraordinate, higher-level organizing concepts DSM-IV and ICD-10 are certainly not systematic classifications in the usual sense in which that term is applied in biology A closer analogue to current psychiatric classifications can be found in the so-called indigenous or ``folk'' classifications . Simon and Gavin Andrews 219 10. Psychiatric Diagnosis and Classification in Developing Countries R. Srinivasa Murthy and Narendra N. Wig 249 Index 281 Acknowledgements 295 Psychiatric Diagnosis and. Theory, Culture and Psychiatric Diagnosis Horacio Fabrega Jr. 107 6. The Role of Phenomenology in Psychiatric Diagnosis and Classification Josef Parnas and Dan Zahavi 137 7. Multiaxial Diagnosis in. Psychiatric Diagnosis and Classification Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan Jose  Lo  pez-Ibor and Norman Sartorius Copyright