Estados Gerais da Psicanálise

Publicada pela World Psychiatric Association

Section on Classification, Diagnostic Assessment and Nomenclature

Newsletter

August 5, 2003
Editorial

We are glad to announce that this issue represents the beginning of a new phase for the WPA Classification Section's Newsletter, as it is going to feature, from now on, a wide range of contributions by the Section members on key topics (either assigned to or suggested by them) for the development of the related fields of psychiatric diagnostic assessment and classification of mental disorders. The idea is to derive the greatest benefit from the expertise, clinical wisdom and variety of perspective of its membership, as well as to better reflect the growing involvement of our ranks with the Section's activities in this critical moment for the future of international diagnostic systems. Thus, we would like to encourage our colleagues to contact either the Chair or the Newsletter Editor to submit proposals for short papers. Reports and accounts of relevant activities, meetings and publications are equally welcomed. Furthermore, according to our plans to turn this Newsletter into a true forum and to better serve the field, we also intend to publish contributions by other key players, not formally linked to the Section.

Another important fact should be emphasized about the content of this issue. Through the following pages, the reader will certainly realize the emerging interest on diagnosis as a comprehensive formulation and as a process, aimed to describe and serve the person, with the participation of all protagonists. Additionally, the conclusions of this series of recent meetings seem to be not only congruent with each other, but also mutually supportive. Thus, we believe this confluence is to be taken seriously as a strong indicative of the kind of approach we are in need in our discipline and we do hope that this will fully inform the revision process of our current diagnostic systems.

Featured in this issue:

Diagnosis for the Person: Two Symposia at the WPA Vienna Thematic Conference, by Christian Haasen

The Trialog on Diagnosis with Users, Families and Mental Health Professionals: A report from the WPA Vienna Thematic Conference (June 2003), by Michaela Amering

"Trialogue": an exercise in communication between consumers, carers and professional mental health workers beyond role stereotypes, by Michaela Amering

Values and Psychiatric Diagnosis: A report from the London Research Methods Working Group (July 2003), by Claudio E.M. Banzato and Matthew Broome

Les Etats Generaux de la Psychiatrie, a Conference on French Psychiatry (Montpellier, June 2003), by Michel Botbol

A Commentary on Psychiatric Diagnosis and Classification: A Conceptual Asymmetry, by Claire Pouncey

Minutes of the Section's Business Meeting (San Francisco, May 2003)

Diagnosis for the Person: Two Symposia at the WPA Vienna Thematic Conference on Diagnosis in Psychiatry: Integrating the Sciences (June 19-22, 2003),
by Christian Haasen¹

From L to R: Said Abdel Azim, Allan Tasman, Somnath Chatterji,
Juan E. Mezzich, Michaela Amering, Levent Kuey, John Cox,
Claudio E.M. Banzato and Ricardo Testa

The conference was held at a time where the development of diagnostic systems has been consolidated around DSM and ICD, while other diagnostic systems, that may still play an important role on a national level, have lost importance on an international level. DSM and ICD have become the reference point for any major research project, so that it is not surprising that the majority of presentations at an international conference on diagnostic issues focused on discussing the validity of diagnostic criteria of mental disorders, new developments within the diagnostic systems and problems with diagnosing mental disorders that are not sufficiently covered by the two existing diagnostic systems.

Both the opening ceremony and the main lectures focused on the future perspective of diagnostic systems. Important progress has been made in diagnosing mental disorders by moving away from diagnostic systems based on schools of thought and towards descriptive diagnostic systems. Nonetheless the limitations of this development have become more and more apparent: the subjective experience of the individual is not accounted for sufficiently, the models still focus mainly on pathology and do not present any aspect of functioning or disability, despite the fact that functioning and disability may have a greater impact on outcome and quality of life.

One very exciting pair of symposia organized by the WPA Section on Classification, Diagnostic Assessment and Nomenclature dealt exactly with these aspects of diagnostic systems. In presenting both the current state of development of the International Guidelines for Diagnostic Assessment (IGDA), as well as the various perspectives of users of such a system, the pair of symposia brought forward important questions for the development of diagnostic systems in an invigorating and productive way.

The first symposium "Diagnosis for the Person: Exploring the Levels of the Model", chaired by Juan Mezzich and Petr Smolik, guided the audience through the different levels proposed by the IGDA. First, Claudio Banzato critically assessed the state of the art with respect to the standardized presentation of clinical disorders. Somnath Chatterji followed with a presentation of WHO efforts in formulating a classification of functioning, disability and health. Thereafter Marianne Kastrup presented the weaknesses and strengths of diagnostic systems in assessing factors related to the contextual universe. Heinz Katschnig summarized efforts in standardizing quality of life as a dimension to be included in future diagnostic systems. And lastly Juan Mezzich presented an innovative component of future diagnostic systems - an idiographic formulation, as proposed by the IGDA. This idiographic formulation would complement standardized multiaxial formulation through a narrative statement focused on what is unique and most meaningful clinically for the patient and family. The elements of the idiographic formulation follow contextualized clinical problems, patient's positive factors for clinical care, and expectations for health restoration and health promotion.

The second symposium "Diagnosis for the Person: Perspectives of Users of the Diagnostic Model", chaired by Juan Mezzich and Somnath Chatterji, gave the audience a comprehensive view of the perspectives of those professionals, that would be using future diagnostic systems. The aim of the symposium was to look at diagnostic systems not just from a clinical perspective, as has been the main focus in the development of previous diagnostic systems, but more from a health perspective in general. Levent Kuey presented the adult psychiatric clinician perspective, emphasizing the dual forces, which each psychiatrist face: "population-based universal objectivity" and "person-based unique subjectivity". Carlos Berganza's presentation discussed some of the critical issues in child psychiatry and concluded with a proposal concerning areas of improvement in the current nosological systems in child psychiatry. This was followed by Michaela Amering's presentation focusing on the perspective of the community and public health psychiatrist: the inclusion of the concepts of disability, context, health resources, and quality of life supports a diagnostic process that is relevant to life and work in the community, thereby playing a key role in overcoming prognostic skepticism and stigma. John Cox's presentation on the research perspective, taking the case of perinatal psychiatry as example, dealt with the issues related to the validation of psychometric instruments across cultures. Allan Tasman rounded up the symposium with the educator's perspective, emphasizing the risk of standardized diagnostic and treatment concepts and the potential of renewed introduction of biopsychosocial approaches.

All in all the conference included many other symposia of great interest, such as various symposia from the area of cultural psychiatry, that raised the question of validity of diagnostic systems in culturally different or diverse settings. Broad consensus seems to be emerging towards a truly integrated and comprehensive international diagnostic system. The World Psychiatric Association, its Classification Section and its Member Societies, in collaboration with WHO, may play a significant role in such a development.

The Trialog on Diagnosis with Users, Families and Mental Health Professionals:
A report from the WPA Vienna Thematic Conference (June 2003),
by Michaela Amering²

On Sunday afternoon, when the WPA Thematic Conference on "Diagnosis in Psychiatry - Integrating the Sciences" (19 - 22 June 2003) had been officially closed, a new crowd moved into the Vienna Hofburg, the old summer palace of the Austrian emperors. A "Trialog" meeting had been announced. The main organizers of the WPA conference, Professors Norman Sartorius, Wolfgang Fleischhacker and Heinz Katschnig had offered to present and discuss the results of the preceding three days of intensive scientific exchange to patients and their family members and mental health professionals from different backgrounds.

Professor Michaela Amering of the Vienna University had organized the event in the tradition of a so-called "Trialog" - a regular discussion event in Vienna for almost ten years, where professionals, patients and family members meet regularly to exchange their - sometimes mutually exclusive, sometimes shared - views about mental health, mental illness, treatment, psychiatric services and research and other topics of interest to all or some of them.

Well over one hundred persons attended this meeting and made the room (probably one of Kaiser Franz Josef's larger dormitories) look very crowded. They listened to what the experts had to say and discussed it formally and informally. Representatives of users and relatives' organizations shared the podium with the representatives of the congress and commented, complemented and challenged what the scientists had to say. Contributions from the floor comprised a large spectrum of constructive and critical statements and clearly showed that the topic of the conference is of great interest to people living with psychiatric diagnoses. A lot of real life expertise as well as conceptual consideration were presented. The tenor of many professional presentations during the three days of the conference with a call for including users and families in the discussion process around classification in psychiatry certainly gained momentum at this trialogic meeting.

At the end of the two-hour long session it became clear to everyone that diagnosis in psychiatry is useful for different purposes, but also that the traditional categorical way of classifying mental disorders will soon be outdated. It was appreciated that the multiaxial approach will gain more importance in the future and that this approach is both scientifically more sound than the traditional categorical one and at the same time more user friendly in the sense that diagnostic assessments can be better tailored to encompass individual needs of patients. The representative of the relatives' organization especially referred to the workshop on "Diagnosis for the person", chaired by Juan Mezzich and Somnath Chatterji, suggesting that a personalized narrative part of the diagnostic formulation not only respects the development towards empowerment and patient self-determination with new emphasize on subjective and individualized assessments and treatment approaches, but will also help in the establishment of a new form of collaboration between clinicians, consumers and families in a common natural language. Hope was expressed that - as a side effect of giving up blunt categorical diagnosis - reductionism, prognostic scepticism and stigma might be reduced for the individual as well as for the field.

"Trialogue": an exercise in communication between consumers, carers and professional mental health workers beyond role stereotypes,
by Michaela Amering³
"Trialogue" stands for the encounter of the three main groups of individuals who deal with psychiatric problems and disorders and with the mental health system - people with experiences of severe mental distress, family members/friends and mental health professionals. This encounter occurs under special conditions - outside the family, outside psychiatric institutions, outside a therapeutic setting. It is the aim of the Trialogue to facilitate communication about the personal experiences in dealing with psychiatric problems and disorders and their consequences. The participating groups strive towards giving up their isolation and lack of common language. Mutual understanding and necessary delimitation from the vast variety of the participants' different backgrounds concerning experience and knowledge are to be established. Trying to understand and share the complex and very heterogeneous subjective experiences may well lead towards establishing a common language, which implies building the basis of a culture of discussion seen to be necessary for working together effectively. It is widely argued from different areas of research that acknowledging the personal experiences of users in planning, organizing and doing practical work is necessary to improve both research and practice in dealing with psychiatric problems and disorders. Engaging in the Trialogue is the necessary training to further enhance this process.

The "First Vienna Trialogue" was established after the World Conference for Social Psychiatry in Hamburg in 1994 by a small group of people representing users, relatives and professionals. Since then, Trialogue meetings have been held twice a month - every other Thursday - with 15 to 40 people in attendance. In the beginning, the meetings were only publicized verbally, followed by newspaper ads and announcements within user- and professional organizations. Everyone interested in participating in the Trialogue was welcome. It was our experience that users formed the largest share of regular participants, followed by family members/friends and professionals (social workers, psychologists, nurses, patient's advocates, guardians, psychiatrists). As an open group, the number of attendants and the compositions of members from the three groups vary each time, and there is a mix of regulars and of those who drop by to see what the group is like. The venues of the meetings have changed a couple of times. The Trialogue strives towards finding a place outside psychiatric institutions, unaffiliated with a particular self-help organization and apart from therapeutic or family relations thus offering a "neutral ground" that does not offer an advantage or a privilege for any of the participating groups. The meetings are moderated by different members of the group in a rotating system.

The so-called "psychosis-seminar" in Hamburg served as the role model for the "First Vienna Trialogue", a model adopted at many different places in the German speaking countries. As a result of a meeting of psychosis seminars in 1996 in Bonn/Germany comprising 170 members, a team of people began to evaluate the results of the psychosis seminars and published a guideline in German (Bock Th, Buck D, Esterer I (1997). The accounts of a user, a relative, and a psychiatrist on their experiences with trialogue have been published in English in 2002 (Amering M, Hofer H, Rath I) demonstrating how new, different, extraordinary and unusual this type of encounter is. The publication does emphasize the great opportunities it engenders as well as the difficulties that are bound to arise once you seriously engage in a Trialogue.

References

1. Michaela Amering, Harald Hofer, Ingrid Rath (2002) The "First Vienna Trialogue" - experiences with a new form of communication between users, relatives and mental health professionals. In: Lefley, HP, Johnson DL (Eds) 2.Family interventions in mental illness: International perspectives. Westport, CT, London: Praeger

2. Bock Th, Buck D, Esterer I (1997) "Es ist normal, verschieden zu sein." Psychose-Seminare - Hilfen zum Dialog. Psychosoziale Arbeitshilfen 10. Psychiatrie Verlag, Bonn.

WPA Philosophy and Humanities Section
Values and Psychiatric Diagnosis: A report from the London Research Methods Working Group (July 2003), by Claudio E.M. Banzato and Matthew Broome⁴

The recently launched WPA Philosophy and Humanities Section, chaired by Bill Fulford (Oxford and Warwick, UK) and co-chaired by Giovanni Stanghellini (Florence, Italy), organized an important meeting to explore candidate methodologies for studying the way in which values come into the assessment and diagnosis of mental distress and disorder. This seminar, creatively designed to allow maximum time for discussion and exchange of ideas, was funded by the National Institute for Mental Health in England (NIMHE), as work on values in mental health has become a particular priority for NIMHE. The two-days working group, co-ordinated by Bill Fulford (Oxford and Warwick, UK) and John Sadler (UTSouthwestern Medical Center at Dallas), counted on the participation of many experts in methodology for dealing with values, as well as of different stakeholders, ranging from a diversity of mental health professionals to representatives of users and carers, including key policy makers. The WPA Classification Section was officially represented in this meeting by its secretary, and prominent members of this section, Ahmed Okasha (WPA President), Juan Mezzich (WPA President Elect) and Norman Sartorius, also attended the seminar and played an active role in the discussion. As a result of this signal meeting, a Diagnostic Values Research Network has been established. It is crucial to underline the fact that the conclusions of the working-group (embodied in its network statement of aims that will be publicized soon) are congruent with the overall conclusions of other recent meetings, for example, the symposium on Philosophical and Methodological Foundations of Psychiatric Diagnosis (New York, May 2003) and as such emphasize the methodological sophistication that can be generated from a partnership of humanities and sciences that is required to address the complexity of the experience of clinical psychiatry, both for physicians and for patients, and additionally recognition of the diversity of needs and perspectives of the stakeholders. This convergence certainly makes stronger the case for a change in the way the diagnostic assessment process is currently understood.

New Directions for Psychiatric Diagnostic and Classification: A Report from "Les Etats Generaux de la Psychiatrie", a Conference on French Psychiatry
(Montpellier, June 2003), by Michel Botbol⁵

From L to R: B. Martindale (WPA Zonal Representative for Western Europe), A. Besse (President of the French Association of Private Practice Psychiatrists), J.E. Mezzich (WPA President Elect), and M. Botbol (French Psychiatric Federation Classification for Child Psychiatry)

For the first time in France a joint meeting of all professional and scientific mental health organizations was recently held under the name of "Estates General of Psychiatry" in reference to the revolutionary assembly that launched the French revolution in the 18th century. This common meeting's aim was to defend the French model of Psychiatry exposed to heavy attacks for economic reasons.

To make a long story short, we could say that French psychiatry has been recently hit by the establishment in France of the managed care model and is now suffering the consequences of this system that our American colleagues have been already facing for quite some time.

In France these consequences are even more troubling due to several local circumstances, such as:

The weight of the public service in Psychiatry and the scarcity of private in-patients facilities.
The fact that most public social agencies rely on psychiatric public system to deal with the psychological part of their users' problems
The importance given in France to psychodynamic psychotherapy in treatment of most psychiatric disorders, as well as in the training of psychiatrists.

More than 2500 participants ensured the success of the meeting that was widely covered by the French media.

Psychiatric Diagnosis and Classification at the Top of the Agenda

In such a "political" context, it may be surprising to discover that Classifications were among the main topics that were discussed by the assembly. Moreover, one of the conclusions of the meeting was that one of the main commitments for French mental health professionals should be the necessity to build a new Classification fitting the needs of our psychiatric model.

For most of the participants, the current classificatory systems (DSM-IV and ICD-10) appear to be important part of the problem because they favor a reductionistic model of psychiatry leading to a denial of its specificity within the medical field. While advocating a sole biomedical model they ignore extensive fields of the discipline and good number of common clinical questions and practices. However, they determine the representations of what can be considered as an effective treatment with deep economic and academic consequences. In other words, most participants of this professional meeting see these Classifications as "managed care classifications" because they pay more attention to non-professional visibility than to clinical complexity.

Among their arguments were the following:

1. Despite of their claim to be "atheoretical" these two Classifications are based on a very specific conception of mental illness they see as an addition of descriptive symptoms with no overall appraisal of the psychic organization underlying the pathological manifestations. This conception is very close to a biomedical model of disease with the underlying idea that there is a bijection between symptoms or syndromes and treatments, with little consideration for the context. Even the limited complexity taken into account by the multiaxial DSM system does not seem to be really used for therapeutic purposes and appears to be only considered for epidemiological surveys or etiological research. Conversely, most French psychiatrists choose their therapeutic strategies considering the symptoms but also the underlying personality, interactions between symptoms and the environment, and the structural subjective organization of the patients' inner world. They then tend to treat complex situations rather than isolated disorders.

For most French psychiatrists, DSM and ICD current systems may be adapted for symptomatic drug prescription or specific therapeutic indications but conflicts with the opinion supporting many of their clinical practices, ranging from psychoanalytically informed Psychotherapy to Community Treatment. They find some support in studies (1) showing that personality configurations are much more predictive of the disorder's outcome than any symptomatic description, particularly in adolescent depressive or psychotic disorders; they distrust the Randomised Control Trial (RCT) studies' results showing manual based Cognitive Behavioral Therapy and pharmacological treatments to be the sole effective treatment in pathologies like Obsessive Compulsive Disorders or Eating Disorders; they see methodological bias in the diagnostic system on which this studies are based, and the reductionism of the therapeutic strategies they take into account. In other words, they consider that absence of evidence of effectiveness of their complex therapeutic strategies is not an evidence of absence of their effectiveness. In their opinion these RCT's results rather reflect the proximity of these studies' theoretical background with pharmacological or cognitive behavioral ones and to the fact that their methodology do not pay any attention to subjective criteria, which French psychiatrists consider essential for the long-term outcome (2).

For them, the drastic evolution of American psychiatry is a consequence of this system they see as a real threat for their practice, not a mark of progress in psychiatric services.

2. French psychiatrists' consideration to dynamic defence mechanisms and structural organization underlying the behavioral symptoms leads frequently to profound differences in diagnostic evaluation and therapeutic indications. From this point of view an Obsessive Compulsive Disorder patient for example, may be much closer to a Schizophrenic or a Narcissistic patient than to another OCD or Anxiety Disorders patient. Of course this patient will surely benefit from a pharmacological treatment and will have it prescribed by any French psychiatrist, as he would have it elsewhere, but the rest of the treatment strategy will have more to do with the underlying psychopathological organization than with the mere OCD symptoms. In some cases this may lead to a therapeutic program much closer to what would be proposed to a schizophrenic patient (3).

The same type of remark could be done for patients with depressions, antisocial behaviors, or addictions, and for all the clinical conditions that can hide different psychopathological organizations behind similar symptomatic manifestations.

Conversely, attention paid to underlying psychic organization can result in a common psychopathological categorization for very different behavioral manifestations. It is for example the case for Borderline Personality Disorders, a category that became a very strong marker in French Psychiatry and is central in the French Classification for Child and Adolescent Mental Disorders (4). Behind the symptomatic diversity this Classification finds common psychodynamic features. Some French epidemiological studies showed the relevance of this wide categorization.

This point of view led a French child psychiatrist (5) to describe more than twenty years ago a clinical condition he named "Psychotic Disharmony", disorder very similar to what Donald Cohen proposed at the end of the 90s under the name of Multiplex Developmental Disorders (6).

Even if, in many ways, they are not always very far from French Classification for Child and Adolescent Mental Disorders diagnostic conclusions for most of severe characteristic disorders, DSM and ICD current systems are thus very far from the diagnostic processes most French psychiatrist use in their everyday practice. It is then a problem due to theoretical factors even more than to cultural ones.

3. For the previous reasons many French Psychiatrists consider that these Classifications fail to label many clinical situations they see in ambulatory settings and even more those they encounter in non-clinical settings i.e. social agencies where they often have to intervene in adult or child psychiatry.

Epidemiological studies of homeless show for example that no more than 30 to 40% of this population can be labelled through DSM-IV or ICD-10 while clinical experience shows that many of the non labelled subjects are in deep psychic suffering and may benefit from adapted clinical attention (7). This gap is also noted with children of socially impaired families or with difficult adolescents.

Globally, these classifications do not then support the main aims of our public psychiatric system: 1) to outreach psychically suffering populations to prevent further psychiatric manifestations rather than to cure them when they are settled, and 2) to treat the patient in ambulatory setting rather than in in-patients programs. To rely on these classifications entails then a risk for these preventive "lighter" practices because it weakens the recognition of these pre-clinical patients' therapeutic needs.

4. Whatever the Classification of reference is, it is important for clinical purposes that patients do not be reduced to their nosographic labelling. It is therefore essential that a classification system give enough space for the patient personal history, the way he/she narrates it, the sense taken by the symptoms in the patient's history, and their intersubjective function. DSM and ICD current systems do not appear to respond to these needs because their main aim is precisely to avoid subjective diversity.

5. The priority given by these classifications' systems to unique objective categories' descriptions and categories' homogeneity, does not favor acknowledgement of cultural diversity that has to be specifically taken into account in psychiatric diagnostic.

Perspectives for the Future

Beyond this set of critics, French psychiatrists show a new interest for Classifications problems because they are aware that:

1. There is a need for a common worldwide reference for psychiatric diagnosis.

2. There is a move of WPA towards a classification's recognition of personal cultural and theoretical specificities. This new tendency received recently a public recognition through the publication of the IGDA diagnostic model (8) with its two components: one standardized multiaxial to facilitate communication across the world, and the other personalized idiographic to accommodate the theoretical and cultural perspectives of clinicians, patients and families.

3. They are aware that there is a strong open debate among our American colleagues on these topics. They recently discovered that this debate was sharing many of our concern about DSM negative consequences and the questions

4. Dealing with an improvement taking into account most of the critics we discussed in this paper among many others.

5. They are therefore aware that there is a real need for a deeper implication of French psychiatry in the current process of remodelling international classification's systems and ready to participate to this movement.

Invited by the meeting organising committee, Juan Mezzich WPA President Elect and former Chair of the WPA Classification Section gave an opportunity to enhance this new concern and to raise the hope for a progress in international classifications. The presence of Brian Martindale WPA Zonal Representative for Western Europe, confirms also that French psychiatry is now aware that its international commitment on these essential topics is the only way to deal with them, no matter how local the effects seem to be.

Bibliography
1. JEAMMET P. Les prémices de la schizophrénie. In: M De Clercq, J Peuskens (eds.) Les troubles schizophréniques; Bruxelles 2000
2. BOTBOL M.:" To prove or not to prove? Limitations of evidence based choice of treatment in eating disorders" in Mario Maj ed: "Evidence and Experience in Psychiatry : Eating Disorders", WPA edition , New York, March 2003
3. NECHMAD A, RATZONI G, POYUROVSKY M, MEGED S, AVIDAN G, FUCHS C, BLOCH Y, WEIZMAN R: "Obsessive compulsive disorder in adolescent schizophrenia patients" American Journal of Psychiatry, May 2003
4. MISES R; QUEMADA N; BOTBOL M; BURSTEIJN C; GARABE C; GOLSE B; JEAMMET Ph; PLANTADE A; PORTELLI C; THEVENOT J.P.: "French classification for Child and adolescent mental disorders" Psychopathology n° 2,3- Mars 2002
5. MISES R. : " Les pathologies limites de l'enfance ". Puf, Paris, 1990
6. S.TORDJMAN, P.FERRARI, B.GOLSE, C.BURSZTEJN, M.BOTBOL, S.LEBOVICI, D.COHEN "Dysharmonie psychotique et multiple developmental disorder : histoire d'une convergence"Psychiatrie de l'enfant, XL, 2, 1997
7. BOTBOL M "Santé mentale et grande exclusion"; Psychiatrie Française, vol XXIX, supplément 2/98
8. MEZZICH JE et al: "Essentials of the World Psychiatric Association's International Guidelines for Diagnostic Assessment (IGDA)"; British Journal of Psychiatry 2003; Supplement 43.

A Commentary on Psychiatric Diagnosis and Classification:
A Conceptual Asymmetry, by Claire Pouncey⁶

Most discussions of psychiatric nosology, including the WPA-WHO symposium reported in the last issue of this newsletter, speak of "diagnosis and classification" as two aspects of a single process. This is a habit we should break. 'Diagnosis' and 'classification' refer to very different medical and scientific practices. Conflating the two perpetuates conceptual unclarities that make the ongoing struggle to improve our nosologies more difficult than it need be.

It is important to remember that 'classification' and 'diagnosis' refer both to nouns (e.g., a classification of species, or the diagnosis of pneumonia) and to actions (e.g., the act of classifying animal species, or the act of diagnosing pneumonia). When we speak of "empirical classification" as a scientific activity, we describe a process of observing psychiatric symptoms in persons, grouping them in some statistically relevant manner, and finally positing the existence of disease entities based on these investigations. This process need not be straightforward. There are always competing hypotheses about which disorders to include in the resultant nosology and how to order them, just as there are rival views about how to identify and rank relevant symptoms, or about which statistical methods to apply. Classification-as-process, then, involves ongoing investigation and revision, so that the resultant classification-as-noun is always subject to revision. In other words, classification-as-noun refers to one iteration in the ongoing process of classification.

We can see the distinction between diagnosis and classification when we contrast the activity and results of the former with those of the latter. The activity of diagnosis involves applying the name of a disease entity to a single instance, as a summary means of describing what is wrong with him. Diagnosis-as-noun merely names such a summary of signs and symptoms. Diagnosis-as-process, like the process of classification, is fallible and subject to modification.

Discussions of the construction or modification of psychiatric nosologies refer to "diagnosis and classification" in the same breath because there is a relationship between the two processes, both of which contribute to the construction or revision of a nosology. We can best understand this relationship as a process that alternates between classification-as-process and diagnosis-as-process, resulting in a classification-as-noun. In gross terms, the process of classification involved observing individual persons who appear to be mentally ill in some way, identifying their symptoms, and grouping those symptoms as syndromes to posit individual disorders. The second step is to clarify the defining features of a posited disease entity by diagnosing that disorder in a fairly uniform research cohort, so that further studies may be conducted in order to refine further our understanding of that disorder. We continue to alternate between defining symptoms of mental disorders by investigating their manifestation in individual persons, and applying those diagnostic criteria to create more-or-less homogeneous research cohorts that allow us to identify other characteristic features of the disorder in question.

It is important to distinguish between the separate activities of classification and diagnosis of disease in individual persons. The first reason for distinguishing diagnosis and classification is to avoid confusion about what a psychiatric nosology classifies. Prominent authors on the subject of psychiatric nosology take two contradictory positions. On the one hand, some authors argue that a psychiatric nosology is meant to classify persons, such as Hempel's claim that "the objects of classification in psychiatric taxonomy are not the various kinds of mental disorder, but individual cases which are assigned to various classes according to the kinds of mental disorders they exemplify." We have seen that this application of disease names to individual persons is diagnosis, not classification. On the other hand, some authors argue that a psychiatric nosology is meant to classify disorders as abstract entities, such as the DSM-IV claim that "A common misconception is that a classification of mental disorders classifies people, when actually what are being classified are disorders that people have." If we understand a psychiatric nosology as a classification-as-noun that specifies disorders rather than persons, we avoid a host of arguments against psychiatric nosology as empty labeling. Psychiatric nosologies name mental disorders that are posited as hypothetical entities available for further investigation; psychiatric diagnosis is the activity that hypothesizes the presence of a mental disorder in an individual person.

Distinguishing the separate activities of classification and diagnosis also allows us to avoid confusion between philosophy and methodology. Much of the literature on psychiatric nosology mistakes the DSM and ICD emphasis on empirical classification, together with the rhetorical emphases on "atheoretical methods" and "operational definitions", as a commitment to a strictly empiricist epistemology, such as was popular in philosophy of science in the first third of the 20th century. Critics argue that a strong empiricist epistemology weakens psychiatric nosology by limiting the meanings of mental disorders to their observable features or symptoms. If this were the case, the meaning of a particular mental disorder would be coextensive with the diagnostic criteria used to diagnose it. However, psychiatric diagnostic and research practices demonstrate that diagnostic criteria named within both ICD and DSM are indicators for mental disorders, but do not completely define them. If we thought diagnostic criteria were "operational definitions" that fully defined mental disorders, there would be no point investigating family linkages, genetic bases, comorbidities, or sources of evidence for the existence of mental disorders. The fact that we do pursue such evidence suggests that diagnostic criteria do not serve as operational definitions in the strict empiricist sense that some critics understand them. Rhetorical mentions of "atheoretical methods" and "operational definitions", then, should not be confused with an empiricist epistemology.

As another example of the confusion of methodology and philosophy, consider the extensive debates over how to define 'mental disorder'. The debate suggests that psychiatric nosology presupposes a realist metaphysic based on the notion of natural categories or kinds. Debates about the proper definition of 'mental disorder' within the context of psychiatric nosology suggest that our individuation of mental disorders follows deductively from a broader definition of 'mental disorder', as if we began the nosologic process with a definition of 'mental disorder', deduced from this broad class the subclasses of mental disorders (e.g., anxiety, mood, psychotic, etc.), and then further distinguished the individual mental disorders within each subclass. The mistake is to infer from the fact that mental disorders are treated as discrete categories or kinds that they are defined by necessary and sufficient conditions, and thus that psychiatry endorses an essentialist or realist metaphysics. The relationship between individual mental disorders and a general definition of the concept 'mental disorder' must be argued rather than assumed.

As the WPA struggles with the conceptual clarifications that will advance future psychiatric nosologies, we should keep in mind that diagnosis and classification are separate but related activities. The activity of classification involves the scientific investigations that that together provide evidence for positing the existence of mental disorders. The act of diagnosis involves hypothesizing a specific disease entity as the cause of a single person's symptoms. We refine a psychiatric nosology by alternating between the inductive activity of classification and the deductive activity of diagnosis. Throughout this process, we should keep in mind that a nosology classifies disorders rather than persons, and that the method of constructing or modifying a nosology does not automatically identify the philosophy that grounds it.

Minutes of the Section's Business Meeting
San Francisco, USA, May 18 2003

From L to R: Levent Kuey, Juan E. Mezzich, Carlos E. Berganza
Claudio E. M. Banzato and Miguel R. Jorge

Venue: San Francisco Marriot - Salon 1 Lower B/2 Level
Time: 1:30pm-3:00pm
Participants: Carlos E. Berganza (Guatemala), Claudio E.M. Banzato (Brazil), Juan E. Mezzich (USA), Marianne Kastrup (Denmark), Levent Kuey (Turkey), Guido Mazzotti (Peru), Marco Antonio Brasil (Brazil), Miguel Jorge (Brazil), Norman Sartorius (Switzerland)

1. The minutes of the Section's Business Meeting in Yokohama were reviewed and approved.

2. The agenda for the present Business Meeting was approved.

3. It was decided that we should prepare a presentation of the Classification Section to be sent to all WPA member societies, together with a structured questionnaire asking them, among other questions, if they have a section on classification and if so, the name of the person in charge. In the case they do not have such a section, we should ask them to appoint a person to be contacted by us.

4. The Section Newsletter should be sent out regularly also to the WPA Zonal Representatives.

5. Juan Mezzich reported on the recent developments on International Classification and Diagnostic Systems, emphasizing the important role played by the WPA Section in this process, conducting surveys, organizing a series of symposia and collaborating closely with World Health Organization (WHO).

6. National and regional developments:

7. WPA International Guidelines for Diagnostic Assessment IGDA: The Essentials were finished and published as supplement in the British Journal of Psychiatry (May 2003), supported by Servier. Juan Mezzich will explore obtaining funds for additional copies for a wider distribution. The publishing copyright was mistakenly given to WHO. The editors of IGDA Essentials will prepare a letter to the Publisher of the British Journal of Psychiatry to correct the error. Another meeting specifically on IGDA to take place later today.

8. The Knowledge Base of the Sexual Health Educational Program: It is in the process of being finalized. The diagnostic component has been finished. It includes a comprehensive diagnostic formulation, focusing on the couple. It was an intersectorial enterprise involving both the Section on Human Sexuality and Psychiatry and the Section on Classification. The volume is to be submitted to publication soon.

9. Claudio Banzato reported on the Symposium on the Philosophical and Methodological Foundations of Psychiatric Diagnosis (New York, May 3-4, 2003). Many speakers wrote to us to say that it was a very stimulating meeting; they appreciated the diversity of the presentations that allowed an intense and productive debate. The symposium will be featured in a special issue of the Section Newsletter to be sent out later this week.

10.Upcoming Symposia:

11. The Section Newsletter: Claudio Banzato, the editor, reported on the previous issues (December 2002, March 2003, as well as on the upcoming one - May 2003). He will invite members to contribute specific reports. It was suggested that we could have a space for WPA Zonal Representatives to report on developments on diagnosis and classification in their respective areas.

12. Section's Official Journal (Psychopathology): Special double issue of the London Symposium published in 2002. Lilly has requested permission for translating it into Spanish and to publish 5000 copies. There are preliminary plans to publish the NY Symposium. The section leadership should communicate more directly with the Editors to enhance the partnership and to have a more significant role in editorial work.

13. General publications: Efforts should be made to translate the extant published material into other languages. The questionnaire mentioned in item 3 could include a specific question on the interest and availability to undertake the translations. The WPA Zonal Representatives should have an important role in identifying the key languages in their respective areas. Norman Sartorius suggested also to post translations (at least in abstract form) in the WPA website.

14. New members: It was agreed that the following people should be invited to become members of the Classification Section: Hagop Akiskal, Sam Tyano and Claire Pouncey. Another people contacted us manifesting their interest to join the Section. After we receive their CV, we will circulate them to the Section Committee for the due approval.

15. Other subjects:

Claudio E. M. Banzato, Secretary
Carlos E. Berganza, Chair

Bibliografia

1 - PD Dr. Christian Haasen (University of Hamburg, Germany).
2 - Prof. Michaela Amering (University of Vienna, Austria).
3 - Prof. Michaela Amering (University of Vienna, Austria).
4 - Dr. Matthew Broome (Institute of Psychiatry, London UK), Secretary, WPA Section on Philosophy and Humanities
5 - Psychiatrist, member of the French task force on the French Classification of Child and Adolescent Mental Disorders, Medical Director of "Clinique Dupré", BP 101, Sceaux 92333, France.
6 - Claire Pouncey, MD, PhD, is the newest member of the WPA Classification Section. She is author of "The Validity of Psychiatric Nosology", a Doctorate Dissertation in Philosophy.