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Human Nature Review 2002 Volume 2: 413-415 ( 9 October )
URL of this document http://human-nature.com/nibbs/02/perring.html
Psychiatric Diagnosis and Classification
Edited by Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor and Norman Sartorius
John Wiley & Sons, 2002
Reviewed by Christian Perring, PhD., Department of Philosophy, Dowling College, Oakdale, NY 11769, USA.
Psychiatric Diagnosis and Classification is a collection of ten papers on psychiatric diagnosis based in part on presentations delivered at the 11th World Congress of Psychiatry in 1999. The international list of contributors approach the topic from a variety of perspectives with the aim of setting out the important issues for the next editions of the ICD and the DSM, which are not expected to be published before the year 2010. For the most part, these papers provide a survey of a fairly wide variety of relevant perspectives rather than a thoroughly detailed investigation of particular topics. The table of contents provides a clear guide to the topics covered. The first three papers provide an excellent introduction to the recent history and the current state of psychiatric diagnosis as well as some issues faced by the creators of future classification schemes.
Some of the chapters are the repositories of many facts. For example, “Clinical Assessment Instruments in Psychiatry” by Charles Pull et al. surveys the literature on its topic, but provides very little discussion of the relevance of the information to the revision of our classification systems for mental disorders. David Goldberg et al. give a very practical and much more readable survey of the use of psychiatric classifications by primary care physicians; their main conclusion is that “primary care needs to use a simplified system of classification” (p. 243). Juan Mezzich et al. survey the history of multiaxial diagnosis and outline some issues for the future in a well-organized chapter on the topic.
Other chapters are much more speculative in their approach. Robert Cloninger writes about the implications of comorbidity for the classification of mental disorders, but it soon becomes clear that his approach does not start from the same assumptions as the editors of the DSMs. Instead, he argues that the fact that comorbidity is so prevalent in psychiatric illness indicates that the classification scheme requires a fundamental shift in perspective to an integrative psychobiological approach and away from using narrowly defined categories. He argues that quantum processes are necessary to understand the features of human psychology such as subjectivity, creativity and intuition. In a remarkable table he asserts that there are important analogies between properties of human beings and quantum phenomena: between creativity and non-causality, freedom of the will and the uncertainty principle, serenity/fluidity and distributed coherence, intuitive awareness and non-locality, and sense of unity of being and the universality of Higgs field. Cloninger briefly outlines what he means in suggesting these analogies, and it is possible that some readers will find such an approach promising. But most readers will quickly see that such claims are both implausible and show little sign of leading to a productive research program. Cloninger goes on to outline what he calls “Coherence Therapy,” which seems to be somewhat influenced by psychodynamic theory and especially some elements of psychoanalytic theory. There certainly should be some place within psychiatric theory for the kind of grand synthesizing schemes favored by Cloninger, but especially problematic is the lack of acknowledgement of the need for an approach secured by a strong evidential basis and the lack of evidence for the assertions within this chapter.
Josef Parnas and Dan Zahavi provide a more systematic and focused argument, for the importance of phenomenology in psychiatric diagnosis and classification. Most of their chapter is exposition, sketching the philosophical tradition of phenomenology and its relation to other stances on the relation between the mind and the body. They explain phenomenal consciousness and self-awareness, temporality, intentionality, embodiment, intersubjectivity and objectivity. But the chapter is disappointing in that it does little to spell out how taking phenomenology seriously would change psychiatric practice; it would have been helpful to discuss at least one kind of mental disorder in detail to give the reader a clearer understanding of what a “prototypical, phenomenologically informed hierarchy of disorders” would consist in.
The most interesting chapters of the book focus on cultural issues. Srinivasa Murthy and Narenda Wig discuss psychiatric diagnosis and classification in developing countries. They briefly explain traditional medical systems in India and South East Asia, China, Arabic or Islamic cultures, and in Africa, and then they discuss the incidence of acute psychosis, depressive disorders and other psychiatric conditions. The authors emphasize that acute transient psychosis occurs far more frequently in developing countries and that these do not fit into the traditional subdivision of psychoses into schizophrenia and manic-depressive illness. They end by setting out the shortcomings of current classificatory systems and the future needs of developing countries with respect to classification. The chapter provides an extremely helpful overview of these issues, giving a wealth of data and citations to the relevant literature.
Horacio Fabrega engages in more theoretical questions in his examination of evolutionary theory and culture. Fabrega focuses on Wakefield’s widely discussed “harmful dysfunction” (HD) account of the nature of mental disorder and the peer discussion of this account in a recent special issue of a journal.  The dysfunction part of Wakefield’s definition refers to the failure of internal psychological mechanisms, and it is evolutionary psychology that should tell us the purpose of these mechanisms and when they are functioning as nature designed. Fabrega discusses the feasibility of an explanation from evolutionary psychology of the ways that people in different cultures exhibit depression, social phobia and psychopathy. He surveys the ways that evolutionary psychology tries to explain the phenomena associated with these disorders, and he does not find that the cultural variation in the symptoms poses a great challenge to the harmful dysfunction analysis of mental disorder. Nevertheless, Fabrega argues that the HD approach “cannot be expected to neatly serve the needs of diagnostic systems, at least in the foreseeable future” (p. 124), and in particular argues that it is hard to explain psychopathy simply as the failure of an evolved psychological mechanism for altruism. More generally, he argues that evolutionary psychology is not useful in explaining culturally specific forms of psychopathology, and furthermore, it is very hard to untangle cultural elements from universal approaches in the explanation of the functioning of the “psyche” and its disturbances. While expressing these reservations about the role of evolutionary psychology in classification schemes, Fabrega argues that the theory could play a part in the classification of mental disorder, possibly through separate axes or numerical coding schemes in a system of diagnosis. He concludes by arguing that culture will continue to be play an important role in how psychiatrists assess psychopathology. While Fabrega’s chapter has many virtues, it could have benefited with better editing, so that the form of the argument was clearer, and his view about the relation between psychiatry, culture and the harmful dysfunction account of mental disorder was in sharper focus.
In sum, Psychiatric Diagnosis and Classification provides some useful background to the contemporary debate on the nosology of psychopathology. None of the papers develops detailed and powerful arguments for well-defined conclusions, but they do address a wide range of relevant considerations.
 Clark, L.A. (ed.) (1999). Special section on the concept of disorder. Journal of Abnormal Psychology. 108: 371-472.
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© Christian Perring.
Christian Perring teaches in the Philosophy Department at Dowling College, Long Island, New York. Dr. Perring's main research interest is in philosophy of psychiatry and psychology, and he also works on medical ethics, moral psychology and personal identity.
Perring, C. (2002). Review of Psychiatric Diagnosis and Classification edited by Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor and Norman Sartorius. Human Nature Review. 2: 413-415.