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Related Topics
Psychiatric Diagnosis and ClassificationReview - Psychiatric Diagnosis and Classification
by Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor, and Norman Sartorius (editors)
John Wiley & Sons, 2002
Review by Peter B. Raabe Ph.D.
Jun 20th 2002 (Volume 6, Issue 25)

This book is based in part on presentations delivered at the 11th World Congress of Psychiatry  (Hamburg, Germany, 1999).   Consequently, the writing is scholarly and most passages are saturated with technical terminology.  Readers not accustomed to academic works will find these essays challenging.  The ten chapters of this book discuss various answers to the question, Has the description and classification of mental disorders or diseases, as found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders  (DSM) and the World Health Organization’s ICD-10 Classification of Mental and Behavioural Disorders, Clinical Descriptions and Diagnostic Guidelines, part of the International Classification of Diseases  (ICD), been accurate, functional, and effective both in clinical treatment and in teaching psychiatry and psychotherapy?

Topics considered include the criteria on which classifications of mental disorders are and ought to be based, the strengths and limitations inherent in an international classification system, the effects of the recent rise of “comorbidity”  (the diagnosing of several mental disorders within one patient) on classification, the role of phenomenology in psychiatric diagnosis, the efficacy of clinical assessment instruments in diagnosing, and the difficulties encountered in the diagnosing and classification of mental disorders across cultures and within developing countries.  The authors courageously discuss various problems inherent in any attempt to define mental disorders such as problems with the way research into mental disorders is conducted and the way data is then interpreted, difficulties encountered in classifying overlapping symptoms and so-called “threshold cases” in which a patient doesn’t meet the criteria of exhibiting severe symptoms, the problem of vagueness in the concept of harm to self or others as a criteria for diagnosis, and the ubiquitous risk of pathologizing the normal when classification is too broad and general, or omitting disorders when classification is too narrow and specific. 

Chapter 4, which deals with comorbidity, is particularly interesting.  In it the authors argue that the diagnosis of discrete mental diseases according to various diagnostic manuals has always been difficult.  They point out that  “for mental disorders, comorbidity, defined as the increased risk of multiple disorders occurring together, is the rule rather than the exception.”  They argue that disorders are polygenic, multifactorial and developmentally complex, and that it is an “inescapable fact of life for clinicians that most patients who satisfy the criteria for one particular category of mental disorders usually satisfy the criteria for others as well”  (pp. 80-81).  The question this raises for the clinician is, Which diagnosed disorder should be treated?  Or are the combination of disorders, in other words the sum of the comorbidity, a new and discrete disorder requiring yet another treatment not mentioned in the manuals?  The authors say that in cases of comorbidity clinicians make treatment choices based on a number of criteria:  they limit assessment to only a few of the disorders due to time constraints and resources limitations, they choose to treat only those disorders about which the patient is complaining, they treat those with which they are most familiar and feel most competent in treating, and they treat only those disorders the patient’s insurance provider has agreed to cover.  The analysis in this chapter reveals many common clinical biases and a shocking economic pragmatism among mental health providers that many patients may not be aware of. 

This book can be read from two perspectives.  If it is read from a psychotherapist’s point of view then the discussion is interesting, thought provoking, and often enlightening.  But if the reader has the slightest doubts about the fundamental assumptions on which psychotherapy is based then these discussions of diagnosis and classification will seem like watching a tailor expend his energy on sewing the perfect buttonhole before he has even begun to construct the suit.  In effect the writers of these chapters are attempting to justify the systematic methods they use for recognizing and cataloging that which their critics say doesn’t exist, namely individual markers, symptoms, or traits which clearly identify discrete mental illnesses. 

For example, the editors are careful to point out at the very beginning of the book, “That current diagnostic categories really correspond to discrete natural disease entities is appearing now more and more questionable. . . Thirty years of biological research have not been able to identify a specific marker for any of the current diagnostic categories”  (p. ix).  This will raise a number of questions in any inquiring mind such as,  Is it realistic to expect that mental distress will ever be defined in terms of specific biological “markers”?  Isn’t it the case that whenever a biological marker—a physical cause—is found for a so-called mental disorder the classification of “mental disorder” is then dropped and it becomes, by definition, a medical disease, as in the case of Alzheimer’s disease?  If the answer is “yes” then it would mean that for any non-physical distress to remain classified as a  “mental disorder” it must necessarily continue to remain free of any biological cause that is verifiable by the empirical means employed in medical science. 

And what about those other cases in which a “condition” becomes “normalized,” such as when, in 1973, a board of prominent American mental health professionals simply voted homosexuality off their list of mental illnesses?  These type of questions challenge the very foundation on which diagnosis and classification are based.  They lead to the conclusion that psychotherapy will continue to exist only so long as there are enough “mental disorders” not attributable to biological causes and not voted into normalcy.  Is it any wonder then that, in order to sustain the profession, new “mental disorders” are “discovered” by mental health professionals on an almost daily basis?  And is it any wonder that critics of the mental health professions argue that it’s not enough to merely discuss how to effectively diagnose and classify but that the very processes of diagnosing and classifying itself should come under both moral and scientific scrutiny?

Interestingly, the editors hail from universities in Italy, Germany, Spain, and Switzerland, while the contributors are literally from all over the world.  This may give the reader the comforting feeling that there is universal consensus among professionals about psychiatric diagnoses and classifications—a feeling that these essays reveal to be quite unfounded.     

An interesting read in strongly technical language, this book gives penetrating insights into the kinds of consequential issues with which contemporary mental health services providers are currently struggling.  It succeeds in answering many questions about how non-physical distress is perceived by professionals at the same time that it raises many more.  I would recommend this book to anyone practicing in the mental health field, and to consumers of mental health services who are comfortable reading academic works. 

 

© 2002 Peter B. Raabe

Peter B. Raabe teaches philosophy and has a private practice in philosophical counseling in North Vancouver, Canada. He is the author of the book Philosophical Counseling: Theory and Practice (Praeger, 2001).


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