Heterogeneity in psychiatric diagnostic classification (original) (raw)
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Hyponarrativity and Context Specific Limitations of the DSM-5
2015
This article develops a set of recommendations for the psychiatric and medical community in the treatment of mental disorders in response to the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, i.e., DSM-5. We focus primarily on the limitations of the DSM-5 in its individuation of complicated grief, which can be diagnosed as Major Depression under its new criteria, and Post-Traumatic Stress Disorder (PTSD). We argue that the hyponarrativity of the descriptions of these disorders in the DSM-5, defined as the abstraction of the illness categories from the particular life contingencies and personal identity of the patient (e.g., age, race, gender, socio-economic status), constrains the DSM-5’s usefulness in the development of psychotherapeutic approaches in the treatment of mental disorders. While the DSM-5 is useful in some scientific and administrative contexts, the DSM’s hyponarrativity is problematic, we argue, given that the DSMs are designed to be useful guides for not only scientific research, but also for the education of medical practitioners and for treatment development. Our goal therefore is to offer suggestions for mental health practitioners in using the DSM-5, so that they can avoid/eliminate the problems that may stem from the limitations of hyponarrativity. When such problems are eliminated we believe that effective psychotherapeutic strategies can be developed, which would be successful in repairing the very relationships that are strained in mental disorder: the patient’s relationship to herself, her physical environment, and her social environment.
Background. Research on comorbidity of psychiatric disorders identifies broad superordinate dimensions as underlying structure of psychopathology. While a syndrome-level approach informs diagnostic systems, a symptom-level approach is more likely to represent the dimensional components within existing diagnostic categories. It may capture general emotional, cognitive or physiological processes as underlying liabilities of different disorders and thus further develop dimensional-spectrum models of psychopathology. Methods. Exploratory and confirmatory factor analyses were used to examine the structure of psychopathological symptoms assessed with the Brief Symptom Inventory in two outpatient samples (n = 3171), including several correlated-factors and bifactor models. The preferred models were correlated with DSM-diagnoses. Results. A model containing eight correlated factors for depressed mood, phobic fear, aggression, suicidal ideation, nervous tension, somatic symptoms, information processing deficits, and interpersonal insecurity, as well a bifactor model fit the data best. Distinct patterns of correlations with DSM-diagnoses identified a) distress-related disorders, i.e., mood disorders, PTSD, and personality disorders, which were associated with all correlated factors as well as the underlying general distress factor; b) anxiety disorders with more specific patterns of correlations; and c) disorders defined by behavioural or somatic dysfunctions, which were characterised by non-significant or negative correlations with most factors. Conclusions. This study identified emotional, somatic, cognitive, and interpersonal components of psychopathology as transdiagnostic psychopathological liabilities. These components can contribute to a more accurate description and taxonomy of psychopathology, may serve as phenotypic constructs for further aetiological research, and can inform the development of tailored general and specific interventions to treat mental disorders.
Libr. Trends, 1998
PSYCHIATRIC activity that CLASSIFICATION IS A PROFOUNDLY IMPORTANT directs subsequent treatment decisions, assumptions about etiology, and prognostic considerations. While the ideal classification scheme would be clear, concise, comprehensively inclusive of, and hospitable to, the entities under consideration, in practice, all classification systems reflect tradeoffs and embody flawed structures. Accordingly, it is essential to be fully cognizant of the shortcomings, biases, and tacit assumptions of extant systems so that classifications can be improved and so that misrepresentations will not be blindly repeated or reproduced. Modern psychiatric classification and diagnosis are almost exclusively defined within the context of the nomenclature and diagnostic categories of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). This article adapts Giddens’s (1984) theory of “structuration” to explain how at least some of the consequences of ...
Conceptual validity of a phenomenological classification of psychiatric patients
Journal of Psychiatric Research, 1975
No SOONER were computers able to handle the data than did psychologists and psychiatrists interested in establishing a more objective and reliable classification of psychiatric patients begin to apply empirical classification methods to psychiatric phenomena. Methods of factor analysis, cluster analysis, Q-sorts and a variety of other techniques have been used. The objective has been to identify the distinct patterns that occur repeatedly in nature in highly similar form. From a simple classification point of view, such distinct homogeneous types should provide the basis for most reliable segregation of patients. Some investigators have reasoned further that syndromes, which are recognized by the coexistence of particular unique patterns, are often found to be associated with distinct disease processes. Others have been more pragmatic, being concerned only with objective, reliable, and useful descriptive classification. WITTENBORN et al., ' were perhaps first to report extensive multivariate analyses of the phenomena of psychopathology in 1953. BECKY followed the next year with an application of Q-sort methodology that resulted in description of six distinct types of schizophrenia, and GRINKER et al.,3 followed shortly with the description of four sub-types of depression (which bear considerable similarity to those identified in our own work). LORR et al.,4 undertook extensive cluster analyses of symptom and behavior rating profiles for large samples of patients from the general inpatient psychiatric population and identified six major phenomenological types. It is not possible, in this brief introduction, to analyze in detail the similarities and differences in classification concepts that might be derived from these and other empirical investigations.
… , and Humanities in …, 2012
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM -whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.
World Psychiatry, 2018
We report on a global survey of diagnosing mental health professionals, primarily psychiatrists, conducted as a part of the development of the ICD-11 mental and behavioural disorders classification. The survey assessed these professionals' use of various components of the ICD-10 and the DSM, their attitudes concerning the utility of these systems, and usage of "residual" (i.e., "other" or "unspecified") categories. In previous surveys, most mental health professionals reported they often use a formal classification system in everyday clinical work, but very little is known about precisely how they are using those systems. For example, it has been suggested that most clinicians employ only the diagnostic labels or codes from the ICD-10 in order to meet administrative requirements. The present survey was conducted with clinicians who were members of the Global Clinical Practice Network (GCPN), established by the World Health Organization as a tool for global participation in ICD-11 field studies. A total of 1,764 GCPN members from 92 countries completed the survey, with 1,335 answering the questions with reference to the ICD-10 and 429 to the DSM (DSM-IV, DSM-IV-TR or DSM-5). The most frequent reported use of the classification systems was for administrative or billing purposes, with 68.1% reporting often or routinely using them for that purpose. A bit more than half (57.4%) of respondents reported often or routinely going through diagnostic guidelines or criteria systematically to determine whether they apply to individual patients. Although ICD-10 users were more likely than DSM-5 users to utilize the classification for administrative purposes, other differences were either slight or not significant. Both classifications were rated to be most useful for assigning a diagnosis, communicating with other health care professionals and teaching, and least useful for treatment selection and determining prognosis. ICD-10 was rated more useful than DSM-5 for administrative purposes. A majority of clinicians reported using "residual" categories at least sometimes, with around 12% of ICD-10 users and 19% of DSM users employing them often or routinely, most commonly for clinical presentations that do not conform to a specific diagnostic category or when there is insufficient information to make a more specific diagnosis. These results provide the most comprehensive available information about the use of diagnostic classifications of mental disorders in ordinary clinical practice.
Classification in psychiatry: Inevitable but not insurmountable
The debate about psychiatric nosology was reignited last year when the fifth edition of the Diagnostic and Statistical Manual (DSM) was published to widespread criticism. Critics cite a number of problems with ‘psychiatric diagnosis’, though it is sometimes unclear which classificatory practices are included under this broad heading. Although it may be possible to avoid the problems inherent in the DSM system, other difficulties associated with classification (labelling, stigma) may prove harder to escape. The first part of this article argues that some form of psychiatric classification is made inevitable by the communicative, epistemic and ethical pressures on psychiatry. In the second half it is suggested that there are ways to think differently about our relationship to psychiatric classification, and that these could play a role in mitigating the harms outlined by diagnosis’ critics.