Section on Classification, Diagnostic Assessment and Nomenclature
Newsletter
Section Committee Members Chair Carlos E. Berganza. Clínica de Psiquiatría Infantil Avenida La Reforma 13-70, Zona 9, Suite 11-B Guatemala, Guatemala C.A. Tel: (502) 2331-5806 Fax: (502) 2331-6773 E-mail:
[email protected] Co-Chair Yan-Fang Chen Beijing Huilongguan Hospital Department of Psychiatry Chang Ping Road Beijing 100096, China. Tel: +10-627-18744 Fax: +10-627-15354 E-mail:
[email protected] Secretary and Newsletter Editor Cláudio E. M. Banzato Department of Psychiatry, State University of Campinas (Unicamp) – PO Box 6111 Campinas, SP, Brazil, 13081-970. Tel: 55 19 3788-7206 E-mail:
[email protected] [email protected] Other Committee Members: Sergio J. Villaseñor (México) E-mail:
[email protected] Michel Botbol (France) E-mail:
[email protected] Michael First (USA) E-mail:
[email protected] Christian Haasen (Germany) E-Mail:
[email protected] WPA Secretariat Metropolitan Hospital Center 1901 First Avenue, Suite 4M-3 New York, New York 10029, USA Tel: +1 (212) 423-7001 Fax: +1 (212) 876-3793 E-mail:
[email protected] WPA Executive Committee President: Ahmed Okasha (Egypt) President Elect Juan E. Mezzich (USA) Secretary General: John Cox (United Kingdom) Secretary for Finance Samuel Tyano (Israel) Secretary for Education: Roger Montenegro (Argentina) Secretary for Sections: George Christodoulou (Greece) Secretary for Meetings Pedro Ruiz (USA) Secretary for Publications: Mario Maj (Italy)
August 2005 Editorial This is the last issue of our Newsletter under the current Section’s leadership and before the upcoming XIII World Congress of Psychiatry (WCP). In September, during the WCP in Cairo, new officers will be elected to lead the Section through a new and challenging triennium that will take us into the 2008 XIV WCP in Prague. For those of us who have enjoyed the privilege of leading the Section for these last three years, it may be the time to reflect on what has been accomplished, and what challenges remain for the next triennium and beyond, concerning our particular field. With the support of the current WPA leadership, and the active participation of its members, ours has become one of the most productive WPA Scientific Sections, as documented by the latest WPA General Survey. However, as WPA confronts its institutional responsibility of cooperating with the World Health Organization (WHO) in the development of the mental health component for the XI revision of the International Classification of Diseases (ICD-11), our Section is destined to play a critically important role in that effort. It is for that reason that the upcoming election during the business meeting of our Section in Cairo is so critical for all of us. We need to make sure that those elected to the leadership posts of the Section remain committed to the fundamental principles that inspire WPA as the foremost global organization representing our specialty, contributing thus to further develop psychiatric nosology and comprehensive psychiatric diagnosis. For us, it is time to say goodbye; to express our gratitude for your support and understanding; and to hope for the brightest future for our section, for WPA and for our profession.
Carlos E. Berganza Section’s Chair
Claudio E.M. Banzato Section’s Secretary
2
Featured in this issue: 1. Announcement of the upcoming WPA Classification Section business meeting during the XIII World Congress of Psychiatry (Cairo, September 2005) 2. Report from the Intersectional Symposium on The Construction of Future International Classification and Diagnostic Systems: The Role of the WPA Scientific Sections (Athens, March 2005) 3. Report from the Developmental Conference on ICD-11 Mental Disorders Chapter (Toulouse, April, 2005) by Juan E. Mezzich 4. Comorbidity: Clinical Complexity and the Need for Integrated Care. A Report from a WHO Workgroup by Ihsan M. Salloum & Juan E. Mezzich 5. Report from the Symposium on Defining Mental Disorder in DSM-V: Problems and Challenges (Atlanta, May, 2005) 6. The WPA-WHO Symposia on ICD-11 and on Diagnosis for the Person at the XIII World Congress of Psychiatry in Cairo (September 2005) 7. Review of John Sadler’s book Values and Psychiatric Diagnosis by Claire Pouncey 8. WPA Classification Section’s Triennial Report (2002-2005)
Announcement of the upcoming WPA Classification Section business meeting during the XIII World Congress of Psychiatry (Cairo, September 2005) The
WPA
Classification
Section
business
meeting
will
take
place
on
September 11 in the room Sakkara 3 (Stream 20) from 18:15 to 20:15. During the meeting new Section officers will be elected for the next triennium (2005-2008). The full agenda for the meeting will be released to the Section membership in due time.
3 Report from the Intersectional Symposium on The Construction of Future International Classification and Diagnostic Systems: The Role of the WPA Scientific Sections (Athens, March 2005)
Some of the participants in the intersectional symposium
Within the framework of the WPA Regional & Intersectional Congress “Advances in Psychiatry”, which took place in Athens (March 12-15, 2005), and in complete agreement with the main purpose of such meeting, fostering collaboration among scientific sections of World Psychiatric Association, the WPA Section on Classification, Diagnostic Assessment and Nomenclature organized a full day intersectional symposium on a very timely subject: “The Construction of Future International Classification and Diagnostic Systems”. The symposium was chaired by Juan E. Mezzich (WPA President Elect) and Carlos E. Berganza (Section’s chair) and counted on the participation of the following 13 WPA scientific sections: Philosophy and Humanities, Epidemiology & Public Health, Preventive Psychiatry, Psychoanalysis, Public Policy, Biological Psychiatry, Anxiety & Obsessive Compulsive Disorders, Women’s Mental Health, Schizophrenia, Personality Disorders, Addiction, Mental Retardation and Child & Adolescent Psychiatry. As expected, the symposium brought together a broad range of topics and perspectives relevant to the revision of the international diagnostic systems. A recurrent theme from several presentations was the perceived need for a person-centered diagnostic model. New
4 resources currently available were discussed such as the epidemiologic ones (latent class and trait approach), philosophical (values based practice -- philosophy as partner to empirical science) and from neurosciences (several candidates for psychobiological markers). Some areas were considered particularly problematic or deficient at this time, such as psychological functioning and experience of illness (whose several dimensions, phenomenological, structural, metaphoric or symbolic and etiologic, have not been receiving enough attention lately), personality disorders (in which there is growing support for dimensional approach as four higher-order domains have been recently identified), mental retardation (or intellectual disability) and child & adolescent psychiatry. By the same token, some general needs of the field were pointed out, such as strengthening the relationship between psychiatry and public health, development of measures of positive mental health and illness, a taxonomy of normal, basic mental functions, as account of the mutual influence (interaction) between mental and physical health (as it is well known that illnesses of all kinds cluster), and taking fully into account the value of diagnostic tools for non-psychiatrists. Finally, two topics were debated: the possibility of conciliating psychiatric diagnosis for the sake of clinical care and for the sake of research (the “one size fits all” approach was criticized) and the relationship between diagnostic systems and the identity of psychiatry, that is, the extent to which choices we make regarding the former define the latter.
Clarification Note In response to the “Report from the presentation of the Blueprint for ICD-11 MHC in the WHO Family of International Classification (FIC) Network Meeting in Reykjavik”, featured in the December 2004 issue of the WPA Classification Section newsletter, Dr. T. Bedirhan Üstün (WHO-CAT) wrote us to make the following clarification: according to the final executive summary (available at http://www.who.int/classifications/network/en/icelandexecutifsummary.pdf) “the development of the ICD Mental Health Chapter was recommended be assigned to WHO-CAT”
5 Report from the Developmental Conference on ICD-11 Mental Disorders Chapter (Toulouse, April, 2005) By Juan E. Mezzich
Some of the participants in the Developmental Conference on ICD-11 Mental Disorders Chapter: Back (From L to R): Carlos E. Berganza, Michael Linden, Levent Kuey, T. Bedirhan Üstün, Gavin Andrews, Ron Kessler, Yan Fang Chen, Kenneth Schaffner, Graham Mellsop, Robert Jakob, John J. McGrath. Front (From L to R): Claudio E. M. Banzato, Dan Stein, Michael First, Ayelet M. Ruscio, Juan E. Mezzich, Judith Jaeger, Bill Fulford, Assen Jablensky.
The Office of Classification Assessment, Surveys and Terminology of the World Health Organization (WHO-CAS), coordinated by Dr. T. Bedirhan Üstün, organized a Strategic Meeting to Plan for the Revision of the ICD-10 Chapter V, which was held on 15-17 April 2005 in Toulouse, France. Such conference aimed at establishing the overall design of the revision process, structure of workgroups, workplan, and timeline for the development of the ICD-10 Chapter V Revision. The meeting was attended by about 35 experts from all five continents, among them the full leadership and several other members of the WPA Classification Section. For three days several plenary sessions and break-out meetings took place. Prof. S. Hyman chaired the discussions. An
6 official executive summary of the meeting is expected to be released soon by WHO Classification Office. At the end of the Toulouse Conference many of the participants attended the Pinel Symposium on 18 April in nearby Soreze. Please see below the programs of the Toulouse Conference and the Pinel Symposium.
Conference on the Revision of Chapter V Toulouse, 15, 16, 17 April 2005 This Conference aimed at establishing the overall design of the revision process, structure of workgroups, workplan, and timeline towards the development of the ICD-11 Chapter V. DAY 1: Friday, 15 April 14:00 – 14:45
Opening and Introduction: ICD Revision Process T.B. Üstün, J.E. Mezzich, S. Saxena
14:45 – 15:30
The Overall Work Plan Overview: S. Hyman & T.B. Üstün Discussion - Q&A: G. Andrews
15:30 – 15:45
Coffee Break
15:45 – 16:30
Epidemiological Work Stream Overview: R. Kessler Discussion - Q&A: O. Gureje
16:30 – 17:15
Clinical Work Stream Overview: A. Jablensky, M. Linden Discussion - Q&A: J. Jaeger
17:15 – 18:00
Public Health Stream Overview: S. Saxena, & S. Chatterji Discussion - Q&A: C. Chute
18:00 - 18:30
Initial Introduction of Workgroups and Assignments
1. Specific Theme Groups a. Epidemiology
GROUP 1 (Day 2)
7
b. Phenotypes
GROUP 2 (Day 2)
c. Treatment Response
GROUP 3 (Day 2)
d. Children & Youth
Group A (Day 3)
e. Geriatric disorders f. Specified Brain Disorders g. Culture 2. Specific Mental Disorder Groups a. Substance Abuse Disorders
Group B (Day 3)
b. Schizophrenias & Psychosis
Group C (Day 3)
c. Mood & Anxiety
Group D (Day 3)
3. Public Health /Administrative Implications a. Public Health
GROUP 4 (Day 2)
b. Link to Terminology c. Casemix groupings d. ICD, DSM and other national classification coordination 19:30-22:00
MEETING DINNER
DAY 2:
Saturday, 16 April
GENERIC WORK GROUP TASKS 8:30 – 9:00
Knowledge Management and Sharing Platform Overview: T.B. Üstün, S. Berkowitz Discussion - Q&A: C. Banzato
9:00 – 9:30
Evidenced Based Reviews Overview: G. Andrews, R. Jenkins Discussion - Q&A: K. Ritchie
9:30 – 10:00
Field Trials and Global Practice Networks Overview: G. Reed Discussion - Q&A: C.E. Berganza
8
10.00 – 10.30
COFFEE BREAK
WORKGROUP SESSIONS: Day 2 - Theme Groups - Groups 1-4 10:30 – 11:00
Review of Charge to Workgroups
11:00 – 12:30
Parallel Break Out Meetings of Workgroups
12.30 – 14:00 WORKGROUPS)
WORKING LUNCH (together with your own
14:00 – 15:00
Parallel Break Out Meetings of Workgroups
15:00 – 16:00
Initial Feedback on Key Issues - Work groups reporting
16:00 – 19:30
Preliminary Coordinating Group Meeting
19:30 – 22:00
Meeting Dinner
DAY 3:
Sunday, 17 April
8:30 – 9:00
Review of Common Issues Overview: S. Hyman
9:00 – 12:00
Parallel Break Out Meetings of Disorder Workgroups A-D
12:00 – 13:30 13:30 – 14:15
LUNCH with WORKGROUPS Workgroups’ Reports & Compilation of Key Questions Common Issues around Coordination Between ICD Revision and the Revision of DSM and Other National/Regional
Classifications Overview: M. First C.E. Berganza 14.15 – 15.00
Developmental Workplan and Timeline Overview: J.E. Mezzich Discussion - Q&A: L. Colpe
15:00 – 15:45
Conference Conclusions & Next Steps S. Hyman, J.E. Mezzich, T.B. Üstün
9
Pinel Symposium on Psychiatric Classification and Diagnosis (Sorèze, Monday 18th April 2005) 9:30 am
Welcome J. P. CAUBÈRE, J.A. COSTA e SILVA, J.E. MEZZICH
9:45 am
Meanings and Models of Diagnosis in Psychiatry J.E. MEZZICH (New York) Historical and Conceptual Issues in the Classification of Mental Disorders Session chaired by C. BERGANZA (Guatemala) and Y. F. CHEN (Beijing)
10:15 am
The place of Philippe Pinel in the history of psychiatry and diagnosis P. PICHOT (Paris), C. PERDRIZET-CHEVALLIER (Bar-Le-Duc)
10:45 am
Phenomenological-anthropological approach to diagnosis and classification A. KRAUS (Heildelberg)
11:15 am
Philosophical perspectives on diagnostic systems K. SCHAFFNER (Washington)
11:45 am
WHO Plan for ICD Revision T.B. ÜSTÜN (Geneva)
12:15 pm
Contribution of Scientific Societies to the development of classification and diagnostic systems C. BANZATO (Campinas, Brazil) Classification and Diagnosis in Clinical Care and Public Health Session chaired by J.P. OLIE (Paris)
2:00 pm
The evolving place of values in diagnosis and health care K.W.M. FULFORD (Oxford/Warwick)
2:30 pm
Perspectives for the classification of mental disorders in children Ph. JEAMMET (Paris)
3:00 pm
The importance of classification and diagnosis for pharmacological treatments J.P. OLIE (Paris) Intervention by Pr. Philippe DOUSTE-BLAZY, French Minister of Solidarity, Health and Family
4:00 pm
The importance of classification and diagnosis for psychological management L. KÜEY (Istanbul)
4:30 pm
The importance of classification and diagnosis for the organization of clinical and social services G. MELLSOP (Auckland)
5:00 pm
Conclusions J.A. COSTA e SILVA (Rio de Janeiro), J.E. MEZZICH (New York)
10
Comorbidity: Clinical Complexity and the Need for Integrated Care A Report from a WHO Workgroup I.M. Salloum (Rapporteur, WHO Workgroup on Clinical Comorbidity) and J.E. Mezzich (Chair, WHO Workgroup on Clinical Comorbidity)
Clinical comorbidities are increasingly recognized as the defining realities of regular clinical care. The multiple and intertwined problems of comorbid clinical conditions represent a major challenge to traditional models of care focusing on single-disease entities. Comorbidity is becoming a global concern given the increased rate of chronic conditions and the growing prevalence of elderly populations worldwide. The challenge of clinical comorbidity is being addressed by the World Health Organization (WHO) through the establishment of a workgroup composed of invited experts from around the world and from WHO medical officers. The first meeting of this Comorbidity Workgroup took place in 2004. Diagnostic Issues Raised by Clinical Comorbidities The presence of clinical comorbidities poses significant challenges to current psychiatric diagnostic systems. Future development of modern classifications systems cannot afford to ignore the problem of comorbidity. Since the implementation of modern psychiatric diagnostic systems and the inclusion of the multiaxial diagnostic formats, the diagnosis of comorbidity became a focus of attention for two seemingly opposite reasons. The first reason originated from one of the stated goals of these diagnostic systems, which was to improve their clinical usefulness to enhance patients’ outcome by increasing the ability to recognize and therefore treat all presenting clinical problems. Thus, both the ICD-10 and the DSM (versions III and IV) included a multiaxial format that allows for comprehensive recording of patients presenting problems on multiple domains. This development has significantly enhanced the potential for improved clinical care, and also has highlighted the multiplicity of presenting conditions. The second reason stems from the lack of documented diagnostic validity for most mental disorders. This current lack of validity raises serious questions about the nature of many forms of mental disorders comorbidity. For example, the question of whether comorbid depression and anxiety disorders are truly independent conditions or whether the two disorders are an expression of one underlying condition has been frequently debated. On the other hand, research evidence has repeatedly demonstrated that comorbid conditions have negative prognostic implications regardless of their arguable diagnostic validity. The clinical significance of an additional anxiety disorder has been highlighted by the well documented increased risk of suicidal behavior for those with comorbid anxiety and mood disorders (1-4). Therefore, given the current state of knowledge of the nature of psychiatric
11 disorders, clinical validity rather than etiopathogenic validity (5, 6), may represent a key concept in considering comorbidity towards the future development of psychiatric classification systems. Enhancing the Usefulness of Current Diagnostic Systems Currently, the ICD-10 (7) and the DSM-IV (8) use the multiaxial system to list comorbid disorders, however, they do not explicitly indicate the potential relationship between the co-occurring disorders. Enhancing the current methods of recording comorbid conditions may further improve the clinical validity of future diagnostic systems. Several ways may be used to indicate the presence of multiple disorders. This may include a) a comprehensive listing of all identified disorders as primary, secondary, and tertiary disorders, etc; b) the use of a multiaxial system and listing disorders/ problems under the respective axis; c) indicate (through the use of asterisks and daggers) the potential relationship between the comorbid disorders; and d) the use of special axes (as in the Chinese Classification of Mental Disorders, Third edition) (9) to indicate the relationship between the co-occurring disorders. Expanding research on comorbidity should also be an important consideration for future classifications systems. This is rendered even more urgent and promising by the current advances in genetics and neuroimaging techniques as well as in methodological and epidemiological approaches.
WHO Clinical Comorbidity Workgroup, G e n e v a , S w i t z e r la n d , F e b r u a r y 2 0 0 4 . L t o R : M . V a r g h e s e , M . K o o p , A . M o h it , S . S a x e n a , J . M . B e r t o l o t e , J . E . M e z z ic h , B . S a r a c e n o , G . T ib a l d i, a n d I . M . S a l lo u m .
12
Clinical Comorbidities and the need for a comprehensive diagnostic model The presence of comorbidity, with its multiple facets and complexities, like no other condition, compel the adoption of a comprehensive diagnostic model as a cornerstone of patient care. In this model, all relevant information about the patient conditions is integrated with the goal of supporting health restoration and promotion of well-being. Thus future classification systems ought to allow for comprehensive assessments of the comorbid disorders at hands, along with resulting disabilities, contextual factors, quality of life, and factors affecting the individual’s healing, recovery, and optimization of health (10). References 1. 2. 3. 4.
5. 6. 7. 8. 9. 10.
Lecrubier Y: The influence of comorbidity on the prevalence of suicidal behaviour. European Psychiatry: the Journal of the Association of European Psychiatrists 2001; 16(7):395-9 Fawcett J: Suicide risk factors in depressive disorders and in panic disorder. Journal of Clinical Psychiatry. 1992; 53(Suppl):9-13 Angst J, Angst F, Stassen HH: Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry 1999; 60 Suppl 2:57-62; discussion 75-6, 113-6 Simon N, Otto M, Wisniewski S, Fossey M, Sagduyu K, Frank E, Sachs GS, Nierenberg AA, Thase ME, Pollack MH: Anxiety Disorder Comorbidity in Bipolar Disorder Patients: Data From the First 500 Participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). American Journal of Psychiatry. 2004; 161(12):2222-2229 Schaffner K: Philosophical Perspectives on Nosological and Diagnostic Validities, Paper presented at a WPA-WHO Symposium, WPA International Congress. Florence, Italy, 2004 Kendell RMD, Jablensky AMD: Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. American Journal of Psychiatry. 2003; 160(1):4-12 Mezzich J, E.: On developing a psychiatric multiaxial schema for ICD-10. British Journal of Psychiatry. 1988; 152(Suppl 1):38-43 American Psychiatric Association: DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 Chinese Society of Psychiatry: Chinese Classification of Mental Disorders, Third Edition (CCMD-3). Author, Jinan, 2002. Mezzich JE, Berganza CE: 9.2: International Psychiatric Diagnosis, in Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Edited by Sadock BJS, Virginia A. Philadelphia, PA USA, Lippincott Williams & Wilkins, 2005, pp 1034-1052
13 Report from the Symposium on Defining Mental Disorder in DSM-V: Problems and Challenges (Atlanta, May 2005)
From L to R: Claudio E. M. Banzato, Peter Zachar, Claire Pouncey, Robert Spitzer, John Sadler and Christian Perring
During the 2005 American Psychiatric Association Annual Meeting, which took place last month in Atlanta, there was an interesting symposium on Defining Mental Disorder in DSM-V: Problems and Challenges, which was organized and chaired by Claire Pouncey, member of the WPA Classification Section and of the Association for the Advancement of Philosophy and Psychiatry (AAPP). The session counted on the participation of John Sadler, Peter Zachar, Christian Perring, and Claudio Banzato, as speakers, and on the very special participation of Robert Spitzer, as a formal discussant. Sadler pointed out that recent literature has questioned the utility of DSM definition of mental disorder to guide inclusion or exclusion of categories and criteria and, in his presentation, addressed the following question “if not for guiding clinical judgments about disorder or no disorder, then for what purposes should we have a DSM definition?” building on his contributions on the role played by values in psychiatric diagnosis. Zachar discussed the implicit essentialism of many theories about the nature scientific categorization and put forward a modern kind of nominalism, called the practical kinds model, which “holds that the world is too complex to justify essentialist models of classification, but psychiatric disorders still have what philosophers call objective warrant and are real things”. Perring examined “the assumption of the DSM and theorists such as Wakefield and Gert that mental disorder must
14 be attributed to an individual rather than a group of people”, arguing that “it is not an a priori conceptual truth that mental disorders are individual”. In his view, decisions about a restrictive or expansive definition must take into account pragmatic considerations. Banzato (in a paper co-authored by Mario E.C. Pereira) addressed the question “what is the reach (and the limits) of a pragmatic definition of mental disorder?” They criticized what they called a “half-heartedly pragmatic attitude”, suggesting that the pragmatic solution implied by the current concept of mental disorder has been used by most psychiatrists simply as a rhetorical device that allows them a risk-free ontological leap. Finally, it should be noted that the symposium also benefited considerably from the comments by Michael First, from the audience.
WPA-WHO SYMPOSIA ON ICD-11 AND ON DIAGNOSIS FOR THE PERSON AT THE WORLD CONGRESS IN CAIRO
The XIII World Congress of Psychiatry in Cairo, September 10-15, 2005 has the richest scientific program in World Congress history (e.g., over 300 symposia and over 3,500 abstracts). This program contains a number of important sessions on classification and diagnosis. Particularly salient are two special WPA-WHO Symposia. One on ICD-11: Initial Development and Critical Review (September 11, 14:45-18:00 hours) and the other on Diagnosis for the Person: Science and Real People (September 13, 14:45-18:00 hours). Both will take place at Cheffren 1 Hall, Cairo International Convention Center. These two symposia have as background the WPA-WHO collaborative process on classification and diagnosis since 2001 and more recently the first ICD-11 Developmental Conference in Toulouse, April 15-17, 2005 and the Pinel Symposium on Psychiatric Classification and Diagnosis in Sorèze, April 18, 2005. WPA is committed to collaborating with WHO on the preparation of the ICD-11 Classification of Mental Disorders. WPA is also committed to undertake the development of a comprehensive and person-centered diagnostic model, engaging all its sections and components and the help of WHO in this effort. The latter project is also connected to an emerging WPA Institutional Program on Psychiatry for the Person: From Clinical Care to Public Health.
15 The programs and the abstracts of these WPA-WHO Symposia follow.
XIII WORLD CONGRESS OF PSYCHIATRY WPA–WHO Symposium on ICD-11: Initial Development and Critical Review 14:45 – 18:00 hours, September 11, 2005 Cheffren 1 Hall, Cairo International Convention Center Chairpersons:
Juan E. Mezzich (WPA) and T. Bedirhan Üstün (WHO)
First Half (14:45 – 16:15 hours):
Presenters
Key Presentations
Time (Min)
1. General ICD Mental Health Revision Plan
T.Bedirhan Üstün (WHO)
15
2. Work with Multiple Disciplines &
Juan E. Mezzich (New York)
15
3. WPA Scientific Sections Contributions 4. Field Trials and Global Practice Networks
Carlos E. Berganza (Guatemala) Geoffrey Reed (Int’l Psychological Society)
15 15
5. Epidemiological Perspectives
Ronald Kessler (Boston)
15
6. Public Health Perspectives
Benedetto Saraceno (WHO)
15
Second Half (16:30 – 18:00 hours):
Presenters
Discussion and Conclusions
Time (Min)
1. Formal Discussion: a. Clinician Comments
Michaela Amering (Vienna)
10
b. Educator Comments c. User/Family Comments
Levent Küey (Istanbul) Facilitated by Prof. S.A. Azim (Cairo)
10 10
2. General Discussion
Speakers & Audience
45
3. Conclusions
Juan E. Mezzich and T.Bedirhan Üstün
15
16 XIII WORLD CONGRESS OF PSYCHIATRY WPA–WHO Symposium on Diagnosis for the Person: Science and Real People 14:45 – 18:00 hours, September 13, 2005 Cheffren 1 Hall, Cairo International Convention Center Chair:
Juan E. Mezzich (Chair, WPA-WHO Workgroup on International Classification and Diagnostic Systems)
Co-chairs: Carlos E. Berganza (Chair, WPA Classification Section) and K.W.M. Fulford (Chair, WPA Philosophy & Psychiatry Section) Part I. Theoretical bases (14:45 – 16:15 hours) No.
Subject
1.
Conceptual Bases of Comprehensive Diagnosis
Juan E. Mezzich (New York)
Time (Min) 15
2.
A phenomenological-anthropological approach to psychiatric diagnosis
Alfred Kraus (Heidelberg)
15
3.
Values and diagnosis: the centrality of the person
KWM Fulford (Oxford/ Warwick)
15
4.
Comprehensive diagnosis and the science of wellbeing
Robert Cloninger (Saint Louis, USA)
15
Shekhar Saxena (WHO)
10
John Cox (Keele, UK)
10
Speakers & Audience
10
Formal Discussants General Discussion
Presenters
Part II. Clinical Illustrations (16:30 – 18:00 hours) No.
Subject
Presenters
1.
Multiaxial classification of patients with mental disorders
Michael Linden (Berlin)
Time (Min) 12
2.
Effectiveness of the CCMD-3 multiaxial diagnostic schema
Yan-Fang Chen (Beijing)
12
3.
Validation of the WPA IGDA diagnostic model
Claudio Banzato (Campinas, Brazil)
12
4.
Implementing the Latin American GLADP: Bringing the patient back
Carlos Berganza (Guatemala)
12
Formal Discussants
Anthony Sheehan (London)
10
General Discussion
Piers Allott (Wolverhampton, UK) All speakers and audience
10 22
17
SPECIAL WPA-WHO SYMPOSIA ABSTRACTS SWW01- SWW02 WPA-WHO Symposium on ICD-11: Initial Development and Critical Review Chairpersons: Juan E. Mezzich (WPA), T. Bedirhan Üstün (WHO) The objectives of this symposium are to present the broad plans for the development of ICD-11, in general and as a classification of mental disorders, as well as to obtain responses from a range of experts and stakeholders. It will be organized into two consecutive 90-minute slots. The first key report will present the general revision plan for the Mental Disorders Chapter of the International Classification of Diseases. The second will outline collaborative work with multiple disciplines and organizations. The third will review the prospective contributions of WPA Scientific Sections. The fourth will describe the plan for field trials and global practice networks. The fifth will present the epidemiological workplan. And the sixth will discuss public health perspectives. The responses to all the above conceptual and strategic plans for ICD-11 will start with formal discussions from clinicians, educators, and user/family representatives. These will be followed by a general discussion with the participation of the speakers and the audience. The symposium will end with a formulation of conclusions. Educational Objectives At the conclusion of this symposium the participants should be able to recognize the key features of the developmental plans for the ICD-11 mental health component as well as, in response, comments from clinicians, educators, and user/family representatives. Bibliographic References 1. Mezzich JE, Üstün TB (eds.)(2002): International Classification and Diagnosis: Critical Experience and Future Directions. Psychopathology 35, Special Volume 2-3. 2. Üstün TB (2004): ICD Revision Process: Towards ICD-11. Paper presented at the Reykjavik Meeting of the WHO Family of InternationalClassifications Network. SWW01.1 GENERAL ICD MENTAL HEALTH REVISION PLAN Tevfik Bedirhan Üstün WHO/Geneva. Switzerland The World Health Organization has recently prepared a plan for the revision of the International Classification of Diseases in general and of its Mental Health Chapter in particular. The basic elements of these plans discussed at the WHO Family of International Classifications Network Meeting in Reykjavik, October 2004 and in the First Developmental Conference for ICD-11 Mental Health Component in Toulouse, April 2005 will be presented.
18 SWW01.2 WORK WITH MULTIPLE DISCIPLINES & ORGANIZATIONS Juan E. Mezzich WPA. New York. USA The development of an instrument of global significance and utilization such as the International Classification of Diseases (ICD) must be accomplished through the engagement of a broad range of organizations and groups across the world. These include scientific, professional, advocacy and user/family bodies. Multidisciplinary and international collaboration are to be emphasized. SWW01.3 WPA SCIENTIFIC SECTIONS CONTRIBUTIONS Carlos E. Berganza San Carlos University School of Medicine. Guatemala The World Psychiatric Association (WPA) has presently 64 scientific sections with domains ranging from Addiction Psychiatry to Women's Mental Health. As part of the commitment formulated in February 2003 by the WPA Executive Committee for institutional collaboration with WHO for the development of ICD-11 and Related Diagnostic Systems, all Sections and other components of WPA are being engaged in this process. In line with this, the WPA Section on Classification and Diagnostic Assessment organized at the WPA Athens Congress, March 2005, a full-day Inter-Sectional Symposium on the Sections' Prospective Contributions to ICD-11 and Related Diagnostic Systems. The WPA Classification Section is also stimulating WPA Member Societies to organize and strengthen national classification sections to participate in the ICD-11 developmental process. SWW01.4 FIELD TRIALS AND GLOBAL PRACTICE NETWORKS Geoffrey Reed American Psychological Association. Washington, DC, USA A global network of practitioners will be a key component of the development of the Mental Disorders Chapter of ICD-11. Approximately 30,000 psychiatrists, psychologists, and other health professionals worldwide will participate in the network. The Global Practice Network (GPN) will make use of an internet-based platform to allow for rapid and precisely targeted dissemination of survey questions, rapid practitioner response, and automated collation of data in analyzable formats. Participation may be in any of the six official languages of the WHO, and the addition of other languages will be possible according to resources for translation. The GPN will make possible rapid validation and exploration in the field of constructs, symptom profiles and diagnostic markers, differential diagnoses, and other important issues as the ICD revision committees develop them. The GPN will make possible nearly simultaneous field-testing as the revision moves forward, ensuring that ICD-11 will reflect frontline practice experiences and therefore enhancing both its validity and its utility. Bibliographic References
19 Beutler, L.E., & Malik, M.M. (Eds.) (2002). Rethinking the DSM: A psychological perspective. Washington, DC: American Psychological Association. SWW01.5 EPIDEMIOLOGICAL PERSPECTIVES ON THE ICD REVISION PROCESS Ronald Kessler Harvard Medical School, Boston, MA, USA Epidemiological data has not been used as fully as possible in developing previous diagnostic systems due to a number of basic conceptual and methodological problems that are reviewed in this presentation. These problems can all be resolved, allowing epidemiological data to be used in four ways. First, community epidemiological studies can provide important basic descriptive information about patterns and correlates of mental disorders to help correct misconceptions based on treatmentseeking bias in clinical samples. Second, epidemiological data can be used to study patterns of association among symptoms to provide a principled basis for determining whether there is a true discrete disease entity that corresponds to the ICD or DSM diagnosis under investigation and, if so, to establish the thresholds on observed symptom measures that optimally define this latent taxon. Third, epidemiological data can be used to study associations between syndromes and external validators to help establish secondary thresholds. Fourth, clinical epidemiological data can be used to study the predictors of differential treatment response to support subtyping distinctions. The presentation closes with a brief discussion of a proposal for using epidemiological data in this way to support the ICD-11 revision process. Bibliographic References 1. Kessler, R.C. (2002). The categorical versus dimensional assessment controversy in the sociology of mental illness. Journal of Health & Social Behavior, 43(2), 171-188. 2. Kessler, R.C. (2002). Epidemiological perspectives for the development of future diagnostic systems. Psychopathology, 35(2-3), 158-161. SWW01.6 PUBLIC HEALTH PERSPECTIVES Benedetto Saraceno Director, Department Of Mental Health And Substance Dependence, WHO. Switzerland [Abstract taken from lecture KL06.2: PSYCHIATRY BETWEEN BROAD HOLISTIC THINKING AND NARROW BIO-MEDICAL PRACTICE] Objective: the schism between the ritualistic use of holistic notions and the practice of medicine, which is strongly oriented towards the biological paradigm, is particularly evident in psychiatry. The lecture will describe the gap between actual mental health care provision and complexity of people is needs. Implications of adopting a bio-psychosocial paradigm will be also discussed. Method: Data on mental health services organization worldwide will be provided. Results: Shifting from a biomedical approach to a bio psychosocial one would cause important changes in the formulation of mental health policies, financing mental health programs and in the daily practice of services. Such changes would imply the recognition of the importance of the role of service users
20 and families and of collaboration between the health sector, local communities and other sectors of society. Conclusions: Psychiatry seems to be conditioned by the biomedical model and this may reduce the effectiveness of its interventions. There are many cultural, social and economic reasons which may explain the resistance to the consequences that the bio psychosocial approach would cause in the practical organization of services. Bibliographic References World Health Organization. Atlas Country Profiles of Mental Health Resources. Geneva: World Health Organization; 2001
SWW03-SWW04 WPA-WHO Symposium on Diagnosis for the Person: Science and Real People Chairperson: Juan E. Mezzich, Mount Sinai School of Medicine, New York, NY, USA Co-chairpersons: Carlos E. Berganza, Chair, WPA Classification Section K.W.M. Fulford, Chair, WPA Philosophy Section Building on recent conceptual and methodological advances, the need is now emerging for improved and more valid international classification and diagnostic systems. In response to this need, the development of a comprehensive diagnostic model focused on the totality of the person, covering illness, context and positive health, using multiple levels of categorical, dimensional, and idiographic descriptions, and engaging interactively clinicians, the patient and the family, is being planned within the framework of the WHO ICD/ICF Family of International Classifications. Both etiopathogenic validity and, particularly, clinical validity will be emphasized in this work. This WPA-WHO Symposium will address the development of such a person-centered comprehensive diagnostic model through presentations on its theoretical bases, as well as on illustrations of its clinical feasibility and value. SWW03.1 CONCEPTUAL BASES OF COMPREHENSIVE DIAGNOSIS Juan E. Mezzich WPA. New York, USA The need for a comprehensive diagnostic model has been noted vis-à-vis recent developments in clinical care and public health policy at national and international levels. Comprehensive diagnostic schemas are aimed at assessing both pathological and positive aspects of health. They utilize categorical, dimensional and idiographic/narrative methods, and engage clinicians, the patient, and the family interactively. SWW03.2 A PHENOMENOLOGICAL-ANTHROPOLOGICAL APPROACH TO PSYCHIATRIC DIAGNOSIS Alfred Kraus Psychiatric University Clinic Heidelberg, Germany
21
A considerable amount of statements, commentaries, critiques, and proposals for the new development of diagnostics and classifications, as they are represented in the glossary of diagnostic manuals, stem from different phenomenological-anthropological oriented psychopathological approaches, i.e. eidetic and constitutive phenomenological as well as existential-hermeneutic approaches. These approaches try to go back to the altered original experiences of the patient in his relationship to himself, to the world, and to others, before these, under the framework of the medical model, are recoded into symptoms or criteria defining certain medical diagnoses. The term "phenomenon", differentiated from that of symptom, is here limited to that which reveals itself by itself without any theoretical presupposition. "Anthropological" in this context means that essential structures of man, such as self-relationship or self-awareness, intentionality, embodiment, temporality, intersubjectivity are made the basis for the description and understanding of the phenomena of a certain psychiatric disturbance. The diagnostic entities are here seen as typically altered modes of human being. Thus the patient as a person is in the center of a so-called "phenomenological-anthropological diagnostics", which shows its clinical value only in connection with a symptomatological or criteriological diagnostics, supplementing it. The particular advantages of a phenomenological-anthropological diagnostics will be shown. These are for instance: 1. By the orientation to the whole of a certain way of being of the patient the single phenomena are determined by that whole, allowing for a faithful differentiated description of the altered original experiences of the patient. 2. By the unifying structure of that whole the single phenomena can be connected to each other in an understandable way. 3. The gained phenomenological types of modes of being, which will be compared to the so-called prototypes, can support or put in question existing diagnostic entities or 4. Can even promote the development of new ones. 5. With the aid of socalled "anthropological proportions" polar relationships within or between certain classification entities can be established. 6. The closeness of phenomenological-anthropological descriptions to the life-world of the patient, seeing him not only as a victim of but in some way also as an agent in his illness, allows the guidelines and norms of rehabilitation and psychotherapy to result from the diagnostic process itself. On that basis a dialectic-polar concept of personality disorders and proposals for the diagnosis of major depression with melancholic features is presented. Bibliographic References How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry: In: Nature and narrative (Fulford B. et al.). Oxford University Press, Oxford New York 2003 SWW03.3 VALUES AND DIAGNOSIS: THE CENTRALITY OF THE PERSON KWM (Bill) Fulford1 1.1. Professor Of Philosophy And Mental Health, University Of Warwick, Coventry. UK Philosophers have traditionally distinguished between cognitive concepts of the person and what the 17th century British empiricist philosopher, John Locke, called 'forensic' concepts. Broadly, cognitive concepts rely on continuity of memory and other descriptive features of the person while forensic concepts emphasise the importance of emotion, motivation and other value-laden aspects. These two ways of conceptualising what it is to be a person correspond with debates in psychiatry and other areas of healthcare about whether diagnosis and disease classification should be solely descriptive or whether they should include values and other 'forensic' aspects of the person. This paper briefly outlines the correspondence between philosophical debates about the person and
22 debates in psychiatry and in medicine about classification. It argues that, if psychiatry and medicine are to be genuinely human disciplines, ie concerned with real people in real situations, rather than being understood as no more than applied biology, then we need to find ways of combining traditional descriptive approaches to diagnostic classification with evaluative and other idiographic approaches. SWW03.4
COMPREHENSIVE DIAGNOSIS & PRACTICAL PSYCHIATRY: A SCIENCE OF WELL-BEING PERSPECTIVE C. Robert Cloninger, MD Washington Univ. Medical School, St. Louis. USA In this lecture I will summarize a practical approach to clinical psychiatry that addresses the whole person as an individual shaped by unique somatic, mental, and spiritual influences. My approach begins with a description of aspects of the mental status examination that are adequate to describe the whole person. The foundation for this approach is described in my book Feeling Good: The Science of Well-Being as summarized in another lecture at this meeting. Here I will discuss practical aspects of diagnosis and treatment that is non-reductionistic and takes into account the value of traditional syndromal diagnoses without assuming that categories provide a complete account of the complex psychobiological nature of human information processing. Differential diagnosis and treatment are both greatly improved by beginning with an adequate biopsychosocial model of human personality rather than with the reified categories of DSM and ICD.
SWW04.1 MULTIAXIAL CLASSIFICATION OF PATIENTS WITH MENTAL DISORDERS Michael Linden Research Group Psychosomatic Rehabilitation At The Charité University Medicine And The Rehabilitation Center Seehof, Teltow/Berlin, Germany It is for long established and generally accepted that caseness, case conceptualizations and even more treatment is not only based on diagnosis but also on a variety of other parameters. The present handling of multiaxiality in ICD or DSM is insufficient. Improvements are needed in respect to the multidimensionality of illness characteristics, somatic comorbidity, psychosocial factors, and personality of patients. 1. Illness characteristics which go beyond diagnosis but have a high impact on case and treatment conceptualizations are [1.1.] type of present episode (e.g. psychotic features, somatic syndrome, agitated, retarded), [1.2.] severity of present episode (e.g. mild or severe), and [1.3.] course (e.g. first episode, recurrent, incremental recurrent, chronic, chronic exacerbating) ICD-11 should have a structure that makes the inherent mutidimensionality of axis I more explicit. 2. Somatic comorbidity plays an important role in the description, classification and especially the treatment of mental disorders. Interactions between mental and somatic disorders include [2.1] somatic disorders which cause psychological problems (e.g. panic disorders as a consequence of implantable cardioverters), [2.2.] deterioration of somatic illnesses because of mental disorders (e.g. heart infarction and depression), [2.3.] somatic disorders which are mainly behavioral problems (e.g. diabetes and eating behavior). Psychiatrists should maintain good medical training and should not only formulate psychiatric but also somatic diagnoses. Multiaxiality in this respect means multiple diagnoses. 3. There is a close relation between mental disorders and psychosocial factors.
23 Any mental disorder is either [3.1.] caused by psychosocial factors (e.g. PTSD), or [3.2.] causes psychosocial problems (e.g. schizophrenia and communication with others), or [3.3.] is interrelated with psychosocial problems in a feed-back loop (e.g. depression and marital problems), or [3.4.] patients attribute retrospectively their present state to past life events and hold respective subjective illness concepts, independent of the fact whether this is scientifically proven or not (e.g. I had do drink because my spouse left me). In any case, therapists will have to assess and take into account such peristatic factors. Because peristatic factors play a role in any mental disorder, the chapter on adjustment disorders should be revised and peristatic negative life events be integrated into a separate axis (e.g. major depression [axis I] with family problems [axis x]). 4. The "personality" of patients plays a major role in how persons cope with mental disorders. "Personality disorders" on axis II are distinctive mental disorders and do not allow to characterize patients independent of any axis I diagnosis. "Personality disorders" should be listed in axis I while axis II should list "personality accentuations" which can be used as an additional description for any patient independent of the axis I diagnosis (e.g. major depression with anancastic personality or hysteric personality). SWW04.2 EFFECTIVENESS OF THE CCMD-3 MULTIAXIAL DIAGNOSTIC SCHEME Yan-Fang Chen Beijing Huilong Guan Hospital. Beijing. China The conception of multiaxial system (five axes) of DSM- IV has already been demonstrated useful for treatment planning. ICD-10 has also published its handbook to guide clinicians how to use the multiaxial system. Following such experience from abroad, the task force of CCMD-3 designed a seven axes diagnostic system. From the results of the field trials of CCMD-3, the authors found that the seven axes diagnostic system was suitable for the diagnosis of mental disorders. And the system has its own characteristics. For examples, in axis V. (Global Functioning): the present social functioning, the best premorbid social functioning, and the worst social functioning during the current episode were rated; in Axis VI (Global Assessment of Present State): the global assessment of present state, clinical effect, change of psychiatric symptoms, insight, and present social functioning are considered altogether, and Axis VII (Relationships between Axes): There are difficulties to describe the relationships between various axes. Axis VII of CCMD-3 gives a better answer to this issue. The author of the manual of Rating Test for Health and Disease (RTHD), which is matched to CCMD-3, designed axis VII, in which a formula like "? ()?", could show the relationship between axes. Therefore, CCMD-3 and its matched diagnostic instrument-RTHD are useful tools for clinical practice in accordance with the bio-psychological-social model. SWW04.3 VALIDATION OF THE WPA IGDA DIAGNOSTIC MODEL Claudio Banzato Campinas. Brazil In 2003, the WPA Section on Classification published the Essentials of the International Guidelines for Diagnostic Assessment (IGDA). These guidelines have at its core a comprehensive diagnostic model composed of a standardized multiaxial diagnostic formulation and an idiographic personalized formulation. A pilot study in Brazil aimed at examining the usability and usefulness of IGDA will be presented and discussed.
24
SWW04.4 IMPLEMENTING THE LATIN AMERICAN GLADP: BRINGING THE PATIENT BACK Carlos Berganza San Carlos University School Of Medicine. Guatemala The Latin American Guide for Psychiatric Diagnosis constitutes a Latin American annotation of the ICD-10 mental health chapter. It includes a presentation of the Latin American context for illness and health, a comprehensive diagnostic formulation along the lines of WPA's IGDA, the presentation of ICD-10 mental disorder categories and diagnostic criteria along with Latin American comments to facilitate effective use in the region, and a set of culture-related syndromes and idioms of distress. The GLADP was published in 2004 in Guadalajara, Mexico by the Section on Diagnosis and Classification of the Latin American Psychiatric Association, and has been mounted for free access and downloading at the websites of the Mexican Psychiatric Association and the World Psychiatric Association. Since then, it has been the subject of symposia, courses and workshops at many national and regional congresses in Latin America. Educational materials to facilitate the implementation of GLADP have been developed. Programs of research are being initiated in the region to document the usefulness of GLADP.
Philosophical and Methodological Foundations of Psychiatric Diagnosis Guest Editors: Banzato, C.E.M. (Campinas); Mezzich, J.E. (New York, N.Y.); Berganza, C.E. (Guatemala City) We are particularly pleased to announce that the special monographic issue of Psychopathology (Volume 38, Number 4) with the concise proceedings of the symposium on Philosophical and Methodological Foundations of Psychiatric Diagnosis (New York, May 2003) will come out by the end of this month.
25
Values and Psychiatric Diagnosis (John Z.Sadler), Oxford University Press, 2004.
Book Review by Claire L. Pouncey
Philosophy of psychiatry has been developing as an interdisciplinary field of study for over a decade, thanks in large part to John Sadler.
Sadler co-founded the Association for the
Advancement of Philosophy in Psychiatry, and co-edits that organization’s journal, Philosophy, Psychiatry, and Psychology. He has written numerous articles about the role of values in shaping psychiatric classification.
Whereas the influence of values is often viewed as a source of
embarrassment to psychiatry, Sadler has argued consistently that psychiatry cannot disregard its nonempirical influences. Now, in his book Values and Psychiatric Diagnosis, Sadler develops his views further, making explicit the values that influence psychiatric knowledge and practice, calling attention to the many ways values shape psychiatric classification and diagnosis, and explaining how values enrich psychiatry rather than undermine it. Sadler’s focus is psychiatric classification, primarily the Diagnostic and Statistical Manual of Mental Disorders (DSM). His primary project is to identify the values in play in the DSM, and to provide a framework for understanding what those values are, how they interact, and how they have been prioritized in the DSM products and discussions about it. His secondary project is to suggest ways that those priorities can be recalculated to improve future nosologies. These projects require Sadler to traverse the intellectual territories of both psychiatry and philosophy. As he acknowledges, interdisciplinary footing can be tricky, but Sadler maneuvers both terrains adeptly.
Sadler brings to his discussion the analytic acumen of a clinician,
successfully diagnosing many of the ills that have plagued psychiatry in the last 50 years. His perspective, however, is that of a philosopher with an eye trained on the conceptual rather than the practical elements of psychiatry. The question he poses for himself is how to make sense of and address the confusions of a medical subspecialty that as yet has no laboratory test, biopsy, or imaging study to confirm its fundamental ontology. This inchoate focus generates a great deal of
26 controversy from a variety of academic disciplines, from psychology to gender studies, and Sadler respectfully, systematically, and authoritatively considers each of the major criticisms and assigns it a place in the values landscape. The first third of the book sets out the terms of Sadler’s debate.
He is deliberately
permissive in his definition of ‘value’, allowing that values are any action-directing concepts – goals, purposes, principles, guidelines, rules of thumb, etc. – that lend themselves to qualitative rather than quantitative measure. For Sadler, syntactically, values can be both objects (e.g., “the good”) and predicates (e.g., “good psychiatric care”). Semantically, evaluational statements can represent underlying commitments, logical entailments, or material consequences. Sadler presents a typology of the values that guide the metaphysics, epistemology, and methodology behind psychiatric classifications: aesthetic, epistemic, ethical, ontological, and pragmatic. He scrutinizes the concept of classification, questioning what characteristics make a ‘good’ scientific classification, and what values such standards reflect. The author goes on to identify and analyze the values reflected in the purported goals of the DSM. The second part of Sadler’s discussion addresses the many existing challenges to the DSM promulgated by various disciplines. Sadler interprets each as a conflict about values. Chapter 4 questions whether the DSM serves psychiatrists more than the patients they treat. It discusses the interests of patients, professions, and guilds, and identifies real and apparent conflicts among them. The chapter argues that the marketing of the DSM (rather than the classification itself) suggests that its publisher is more interested in labeling patients or turning a profit than in pursuing more clinically and scientifically noble ends. Chapter 5 addresses the ontological question of what it is to be a mental disorder. It argues that, in contrast to much of the existing literature, what is central to nosology is not the formal definition of ‘mental disorder’, but rather our deeply help convictions about the nature of mental disorders. The chapter identifies and explains six “ontological values” of the DSM: empiricism, hyponarrativity, individualism, naturalism, pragmatism, and traditionalism. It reviews challenges to these assumptions from several disparate schools of thought, reinterpreting each criticism as an objection to one of the DSM’s values assumptions. Chapter 6 tackles the thorny subject of the influence of values with regard to DSM judgments about sex, gender, and their allegedly disordered states. It interprets some of the most vituperative criticisms of the DSM as questions about the proper relationship between moral and nonmoral values. Arguing that “Moral evaluations in a category . . . are problematic only if the identity and validity of the concept is semantically and empirically dependent on them”, the chapter proposes two tests to determine whether a proposed mental disorder is merely a conflict between
27 individual and societal preferences.
It argues that the goal of psychiatric nosology is not to
medicalize immoral behaviors, but to articulate a shared vision of the social good against which moral failures are identified and measured. Chapter 7 addresses cultural relativism, or more specifically, how the various values that shape psychiatric nosology permit or prevent the application of a given diagnosis across culturally specific instances. It critically reviews some of the work in psychiatric anthropology, and uses that approach to identify ten value assumptions that are local to Western psychiatry. The chapter calls for increased awareness of the value-based nosological assumptions that do not generalize across cultures, and recommends ongoing efforts to develop standards for cross-cultural validation. Chapter 8 explores the tensions that arise when the traditional values that have shaped psychiatric nosology are challenged by the incompatible values introduced by psychiatric genetics. The chapter characterizes and explores a conflict not between psychiatry’s values and those of outside critics, but between two different approaches internal to psychiatry, a re-prioritization of ontological and epistemic values that are not in contention, but which are weighted differently by different psychiatric subcommunities. Chapter 9 takes yet another turn, using continental philosophy to introduce and contrast “poietic” and “technological” modes of being, ways of understanding how our basic commitments and viewpoints direct how we relate to and behave in the world. In viewing psychiatrist-patient relationships as ones between diagnosticians and instances of illness, we lose an important interpersonal, moral aspect of medical care. We restore this moral aspect by refusing to make diagnosis the ultimate clinical concern, and remembering that diagnosis is merely instrumental in serving the overall goal of helping ill persons. The chapter reminds us that a classification is not a textbook for good care, and that “Learning to diagnose mental disorders by reading about them in the DSM is similar to learning to dance by reading a book about Martha Graham.” Chapter 10 argues that politics, being value laden, are necessarily part of psychiatric classification, and indeed, science in general. In response to DSM critics who argue that the DSM is faulty or biased because of the politics that influence it, the chapter analyzes the notion of politics itself. It distinguishes laudable from corrupt aspects of politics, and identifies the aims of the American Psychiatric Association as a political organization. It argues that political values are intrinsic to psychiatric classification, but that the DSM process as it now exists fails to fully allow for the value of epistemic freedom. DSM’s shortcoming is this particular failure, and not the influence of politics per se. Chapter 11 constitutes the third part of Sadler’s project. Here, he makes two moves. First, Sadler changes his focus from classification to diagnosis, arguing that although a classification
28 names diagnostic concepts, the practice of diagnosis reaches far beyond what a nomenclature or taxonomy can possibly provide. He argues that in order to enrich the practice of psychiatric diagnosis, which is informed both by scientific knowledge and by established practice principles, we need to experiment with thoughtful alternatives to the existing psychiatric classifications. To this end, the chapter introduces a schema for understanding how the values discussed in the preceding chapters influence psychiatric nosology, and analyzes the priority those values are assigned and the prominence they are given. Sadler shows how alternative classifications might be developed by reassigning either the priority or the prominence of each of the values he considers in the body of the book. In the end, Sadler emphasizes that values engage with and are intrinsic to science, rather than standing in opposition to it. He argues eloquently that the more conspicuous we can make our values, the better position we will be in to develop psychiatry in ways that suit our myriad clinical, scientific, and social purposes. Sadler comprehensively discusses heated and technical topics in a voice that is conversational and easy to read. Still, he will have his critics. Despite the title, the book’s focus is classification rather than diagnosis, and Sadler does not specify in detail what the relationship between diagnosis and classification is. Further, Sadler’s main argument relies heavily on various notions of validity, which Sadler neither challenges nor explicates in terms of the values of psychiatry. Philosophers are likely to feel frustrated by the terse treatment given to value theory generally; psychiatrists and nosologists may find themselves looking for more explicit practical direction than Sadler provides. However, as Sadler states, his primary aim is to stimulate further discussion and development of ideas. He offers an invitation to debate rather than a final solution to the problem. This goal he accomplishes admirably.
Values and Psychiatric Diagnosis is an important
contribution to both psychiatry and the philosophy of psychiatry.
For psychiatry, Sadler
persuasively demonstrates that values appropriately and necessarily shape both psychiatric science and practice.
Rather than undermining our science, values deserve explicit and deliberative
attention. For philosophy, Sadler tackles value theory and epistemology at their intersection, generating a theory of social knowledge that addresses psychiatry’s extradisciplinary critics and contributes importantly to social epistemology. In sum, this book will provide stimulating reading for academicians and clinicians alike, and it cannot be ignored by the authors of future psychiatric classifications.
29 WPA SECTIONS TRIENNIAL REPORT (2002-2005) Name of Section: Section on Classification, Diagnostic Assessment and Nomenclature Number of Members: 84 Number of Countries represented: 37 Officers (name, address, telephone number, fax-number, e-mail) Chair:
Dr. Carlos E. Berganza Clínica de Psiquiatría Infantil Avenida la Reforma 13-70, Zona 9 Condominio Real Reforma, Suite 11-B Guatemala, Guatemala, C. A. Tel.: (502) 2331-5806 Fax: (502) 23316773 E-mail:
[email protected]
Co-chair:
Dr. Yang-Fan Chen Beijing Huilongguan Hospital Department of Psychiatry Chang Ping Road Beijing 100096 China. Tel: 10-627-18744 (O) Tel: 10-627-18744 (H) Fax: 10-627-15354 E-mail:
[email protected]
Secretary:
Dr. Cláudio E. M. Banzato R. Egberto F. A. Camargo, 1200 – 52 C Campinas, SP, Brazil – 13092-621 Tel: 55 19 3258-4608 Fax: 55 19 3289-4819 E-mail:
[email protected] and
[email protected]
Activities since August 2002 Number 1.
Section Symposia:
12 Yokohama: 1
Other Meetings: 11
Section Symposia within WPA Meetings: 8 Section Symposia in other (non-WPA) Meetings: 2 Section Symposia organized independently: 2 Philosophical and Methodological Foundations of Psychiatric Diagnosis May 3-4, 2003 – New York City, USA International Symposium on Psychiatric Diagnosis and Neuropsychopharmacology August 13-15, 2003 – Cordoba, Argentina
30
Number 2.
Consensus statements
0
Position statements
0
Educational programs
2
WPA’s International Guidelines for Diagnostic Assessment Sexual Health Educational Program in collaboration with WPA Section on Psychiatry and Human Sexuality ………………………………………………………………………………… 3.
Section’s Publications
YES X
NO
Bulletin or Newsletter: The following 8 issues of the Section Newsletter were published online since August 2002: December 2002 March 2003 May 2003 August 2003 December 2003 May 2004 December 2004 August 2005 [They all can be found within WPA Online at: http://www.wpanet.org/home.html] Journal: Psychopathology (WPA Classification Section’s official journal) Books/Monographs: (please mention details) International Classification and Diagnosis: Critical Experience and Future Directions (edited by Juan E. Mezzich, New York, and T. Bedirhan Üstün, Geneva). Special double issue of Psychopathology 2002; 35: 59-201. Essentials of the World Psychiatric Association´s International Guidelines for Diagnostic Assessment (IGDA). The British Journal of Psychiatry, 182 (suppl. 45), 37-66, 2003. Philosophical and Methodological Foundations of Psychiatric Diagnosis (edited by Claudio E.M. Banzato, Juan E. Mezzich and Carlos E. Berganza). Psychopathology 2005: 38(4). ………………………………………………………………………………... 4.
Inter-sectional collaboration
Number
Symposia with other sections
6
It should be mentioned the Inter-Sectional Symposium on The Construction of Future International Classification and Diagnostic Systems: The Role of the WPA Scientific Sections (Athens, March 2005)
31 Publications with other sections:
Section on Psychiatry and Human Sexuality and Section on Classification: The Knowledge Base of the Sexual Health Educational Program (SHEP)
Intersectional Consensus or Position statements (please mention details) ………………………………………………………………………………… 5.
Research
Number
Sectional research projects:
Inter-sectional research:
WPA-WHO Workgroup on Conceptual and Methodological Bases for new International Classification and Diagnostic Systems (ICDS) Sexual Health Educational Program: the diagnostic component. It was an intersectional enterprise involving both the Section on Human Sexuality and Psychiatry and the Section on Classification.
Collaborative research with other components (please mention details)
…………….
………………………………………………………………………………… 6.
Does the section plan to participate in the WPA Inter-sectional Congress, Athens 12-15 March 2005 and contribute to the Volume “Advances in Psychiatry”?
YES X
NO
7.
Has the Section delivered its updated Membership list to the Secretary for Sections?
YES X
NO
8.
How do you rate the overall performance of your section?
Excellent X
Fair
Good 9. 10. 11.
Does your section have at least 20 members? With how many of your members do you correspond regularly?
YES X
Poor NO
> 20
Future perspectives of the Section The section has been very active recently organizing meetings, publishing monographic volumes and engaging in collaborative work that we hope will help to foster the development, in a international and integrated fashion, of the next generation of diagnostic and classificatory systems. We expect the Section to play a key role in the upcoming process of revision of ICD-10/FIC.
Carlos E. Berganza, Chair Cláudio E. M. Banzato, Secretary August, 2005
