Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications

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Abstract

Conforming to a medical disease model rooted in phenomenology and natural science, psychiatry classifies mental disorders according to signs and symptoms considered to be stable and homogeneous across individuals. Scientific studies addressing the validity of this classification are scarce. Following a seminal paper by Robins and Guze in 1970, validity of categories has been sought in specific criteria referring to symptoms and prognosis, aggregation in families, and “markers”, preferentially laboratory tests. There is, however, a growing misfit between the model and empirical findings from studies putting it to the test. Diagnostic categories have not been shown to represent natural groups delineated from the normal variation or from each other. Aetiological factors (genetic and/or environmental), laboratory aberrations, and treatment effects do not respect categorical boundaries. A more adequate description of mental problems may be achieved by: 1) a clear definition of the epistemological frame in which psychiatry operates, 2) a basic rating of the severity of intra- and interpersonal dysfunctions, and 3) empirical comparisons to complementary rather than exclusive dimensions of inter-individual differences in context-specific mental functions, treatment effects, and laboratory findings. Such a pluralistic understanding of mental health problems would fit empirical models in the neurosciences and postmodern notions of subjectivity alike. It would also clarify the assessment of dysfunction and background factors in relation to the requisites for penal law exemptions or insurance policies and make them empirically testable rather than dependent on expert opinion on issues such as whether a specific dysfunction is “psychiatric”, “medical”, or ascribable to “personality”.

Introduction

As a branch of modern medicine, psychiatry has applied models of disease (usually referred to as “disorders”) and pathogenesis to problems of the mind. Categorical diagnoses of disorders are based on structured evaluations of “operational” criteria thought to reflect various aspects of mental problems, such as painful “inner” experiences, reduced cognitive abilities, or maladaptive patterns of behaviours (American Psychiatric Association, 2000). The diagnostic categories are constructed as syndromes with criteria referring to various situations and time frames and ordered in hierarchies to avoid overlaps. Diagnoses are assigned by counting and comparing signs and symptoms to notions of diagnostic “cut offs” or “thresholds” and are understood to entail specific properties, such as aetiology, treatability, and prognosis. This system has drawn on phenomenological work, particularly that of Jaspers, its foremost theorist, who provided a philosophical rationale for focusing on abstract entities considered to be essential across individuals rather than on other aspects, such as subjective experiences, personhood, social relatedness, or culture, that were emphasized by other 20th century strands of thinking.

Categories have also supplied culturally well-defined roles for mental health experts, their patients, and any others confronted with persons who have mental health problems. This, essentially medical, “grand theory” of disease in psychiatry has brought progress indeed. Functional inter-rater diagnostic reliability for mental disorders has been greatly improved, and treatment strategies developed over the last 60 or so years, pharmacologic and psychotherapeutic alike, have reduced suffering and improved the quality of life for countless persons. Epidemiological and longitudinal knowledge about mental health problems is now easily accessible, not least on the internet. Criticism of diagnostic practices has become rare within psychiatry, while external critique tends to be discarded as “unscientific” or even “anti-psychiatric”.

But are we really confident that this medical model does not itself contain fundamental scientific weaknesses, even errors? Widely recognized problems are that large proportions of psychiatric patients meet more than one diagnostic definition, that many have incomplete remission of symptoms and remain severely disadvantaged, and that longitudinal and cross-cultural inconsistencies are common. In this paper, the validity of the current diagnostic categories that have come to structure both psychiatric practice and science will be assessed against the specific criteria developed since first proposed by Robins and Guze (1970). The effects of accepting the medical model as the grand narrative of mental health problems will be exemplified, and new strategies for the definition of such problems will be proposed.

Section snippets

Methods

In psychiatry, validity has mostly been an issue when determining how “validly” a diagnostic instrument may identify a diagnostic category. Comparatively less attention has been focused on the validity of the diagnostic constructs. A few leading psychiatrists have developed criteria for the validity of disorders (Andreasen, 1995, Kendell & Jablensky, 2003, Kendler, 1980, Robins & Guze, 1970). Robins and Guze argued that psychiatric diagnoses should be based on systematic studies instead of “a

Clinical validity (Robins and Guze criteria 1 and 3)

Considering what we now know about the epidemiology of mental health problems, it is obvious that what Andreasen expected in 1995 has not come about. First, no mental disorder (besides mental symptoms induced by medical diseases, such as Huntington's chorea) has yet been statistically distinguished from the normal variation by a “zone of rarity” or shown to constitute a “taxon” among other problem types in the population variance (Cloninger, 1999). Instead, the notions of “broader phenotypes”

Discussion

Despite the obvious lack of empirical support for today's diagnostic models, it is not without a sense of heresy one has to conclude that most, if not all, of the mental disorders known today, i.e. the categories that have structured both the psychiatric praxis and the research into their prevalences, patterns of distributions, “comorbidities”, and aetiologies, simply do not exist as such. The artefactual boundaries between syndromal categories—and between “disorders” and normality—may indeed

Acknowledgements

My co-workers in the Forensic Psychiatric research group in Malmö and Gothenburg and all the colleagues who have attended to my many questions over the last year are gratefully acknowledged for their valuable advice and practical help during the work on this paper, which has been proposed at a number of professional meetings since the first raw sketch presented at the “Sjögren Day” at the University of Lund in December 2005. Several anonymous referees and the editor of this journal are also

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