Psychiatric Diagnosis and Classification - part 2 docx

Impact of Neuroscience and Genetic Research on Psychiatric Classification It has been suggested that clinical neuroscience will eventually replacepsychopathology in the diagnosis of ment

ratings Moreover, a series of such changesÐfrom DSM-III to DSM-III-R

to DSM-IV to DSM-V, for exampleÐrisks discrediting the whole process

of psychiatric classification Many difficult decisions about the balance ofadvantage and disadvantage will therefore be required Because the dis-advantages of minor changes will generally be as substantial as those ofmajor changes, there ought, in our view, to be a prejudice against minorchanges, even if this results among other things in perpetuating irritatingdifferences between the ICD and DSM definitions of some individual dis-orders [48]

Perhaps the greatest weakness of DSM-IV and ICD-10 is their tion of personality disorders Both provide a heterogeneous set of categories

classifica-of disorder and in both cases individual patients commonly meet the criteriafor two or three of these categories simultaneously As there is much evi-dence that human personality is continuously variable, and all contempor-ary classifications of the variation in normal personality are dimensional,there is a strong case for a dimensional classification of personality dis-orders and it is possible that this will be provided by DSM-V

Evolution of Concepts and the Language of Psychiatry

It is important to maintain awareness of the fact that most of psychiatry'sdisease concepts are merely working hypotheses and their diagnostic cri-teria are provisional The present evolutionary classification in biologywould never have been developed if the concept of species had beendefined in rigid operational terms, with strict inclusion and exclusion cri-teria The same may be true of complex psychobiological entities like psy-chiatric disorders Perhaps both extremesÐa totally unstructured approach

to diagnosis and a rigid operationalizationÐshould be avoided Defining amiddle range of operational specificity, which would be optimal for stimu-lating critical thinking in clinical research, but also rigorous enough toenable comparisons between the results of different studies in differentcountries, is probably a better solution

Impact of Neuroscience and Genetic Research on Psychiatric Classification

It has been suggested that clinical neuroscience will eventually replacepsychopathology in the diagnosis of mental disorders, and that phenom-enological study of the subjective experience of people with psychiatricillnesses will lose its importance Such a transformation of clinical psy-chiatry would replicate developments in other medical disciplines where

molecular, imaging and computational tools have largely replaced itional clinical skills in making a diagnosis In time, such developmentsmight result in a completely redesigned classification of mental disorders,based on genetic aetiology [49] The categories of such a classification andtheir hierarchical ordering may disaggregate and recombine our presentclinical categories in quite unexpected ways, and eventually approximate

trad-to a ``natural'' classification of psychiatric disorders

This, indeed, is already happening in general medicine where molecularbiology and genetics are transforming medical classifications New organiz-ing principles are producing new classes of disorders, and major chapters ofneurology are being rewritten to reflect novel taxonomic groupings such asdiseases due to nucleotide triplet repeat expansion or mitochondrial diseases[50] The potential of molecular genetic diagnosis in various medical dis-orders is increasing steadily and is unlikely to bypass psychiatric disorders.Although the majority of psychiatric disorders appear to be far more com-plex from a genetic point of view than was assumed until recently, moleculargenetics and neuroscience will play an increasing role in the understanding

of their aetiology and pathogenesis However, the extent of their impact onthe diagnostic process and the classification of psychiatric disorders is diffi-cult to predict The eventual outcome is less likely to depend on the know-ledge base of psychiatry per se, than on the social, cultural and economicforces that shape the public perception of mental illness and determine theclinical practice of psychiatry A possible but unlikely scenario is the advent

of an eliminativist ``mindless'' psychiatry which will be driven by biologicalmodels and jettison psychopathology It is much more likely in our view thatclinical psychiatry will retain psychopathology (i.e the systematic analysisand description of subjective experience and behavior) at its core It is alsolikely that classification will evolve towards a system with at least two majoraxes: one aetiological, using neurobiological and genetic organizing con-cepts, and another syndromal or behavioral±dimensional The mapping oftwo such axes onto one another would provide a stimulating researchagenda for psychiatry for the foreseeable future

3 World Health Organization (1992) The ICD-10 Classification of Mental and ioural Disorders Clinical Descriptions and Diagnostic Guidelines World HealthOrganization, Geneva

Behav-4 American Psychiatric Association (1994) Diagnostic and Statistical Manual ofMental Disorders, 4th edn (DSM-IV) American Psychiatric Association, Wash-ington.

5 World Bank (1993) World Development Report 1993: Investing in Health OxfordUniversity Press, New York

6 Sokal R.R (1974) Classification: purposes, principles, progress, prospects ence, 185: 115±123

Sci-7 Kant I (1970) The Essential Kant (Ed A Zweig) Mentor Books, New York

8 Nelson K (1973) Some evidence for the cognitive primacy of categorizationand its functional basis Merril-Palmer Quarterly of Behavior and Development, 19:21±39

9 Rosch G., Mervis C.B., Gray W., Johnson D., Boyes-Braem P (1976) Basic objects

in natural categories Cogn Psychol., 8: 382±439

10 Millon T (1991) Classification in psychopathology: rationale, alternatives, andstandards J Abnorm Psychol., 100: 245±261

11 Scadding G (1993) Nosology, taxonomy and the classification conundrum ofthe functional psychoses Br J Psychiatry, 162: 237±238

12 Horowitz L.M., Post D.L., French R de S., Wallis K.D., Siegelman E.Y (1981)The prototype as a construct in abnormal psychology: 2 Clarifying disagree-ment in psychiatric judgments J Abnorm Psychol., 90: 575±585

13 Cantor N., Smith E.E., French R., Mezzich J (1980) Psychiatric diagnosis asprototype categorization J Abnorm Psychol., 89: 181±193

14 Feinstein A.R (1972) Clinical biostatistics XIII: On homogeneity, taxonomy andnosography Clin Pharmacol Ther., 13: 114±129

15 Shepherd M., Brooke E.M., Cooper J.E., Lin T.Y (1968) An experimentalapproach to psychiatric diagnosis Acta Psychiatr Scand Suppl 201

16 Rosch E (1975) Cognitive reference points Cogn Psychol., 7: 532±547

17 Sullivan P.F., Kendler K.S (1998) Typology of common psychiatric syndromes

Inter-25 Kendler K.S (1996) Major depression and generalised anxiety disorder:same genes, (partly) different environmentsÐrevisited Br J Psychiatry, 168(Suppl 30): 68±75

26 Brown G.W., Harris T.O., Eales M.J (1996) Social factors and comorbidity ofdepressive and anxiety disorders Br J Psychiatry, 168 (Suppl 30): 50±57

27 Widiger T.A., Clark L.A (2000) Toward DSM-V and the classification of chopathology Psychol Bull., 126: 946±963

psy-28 Cloninger C.R (1999) A new conceptual paradigm from genetics and biology for the science of mental health Aust N Zeal J Psychiatry, 33: 174±186.

psycho-29 Cloninger C.R., Martin R.L., Guze S.B., Clayton P.J (1985) Diagnosis and nosis in schizophrenia Arch Gen Psychiatry, 42: 15±25

prog-30 Sigvardsson S., Bohman M., von Knorring A.L., Cloninger C.R (1986) Symptompatterns and causes of somatization in men: I Differentiation of two discretedisorders Genet Epidemiol., 3: 153±169

31 Woodbury M.A., Clive J., Garson A (1978) Mathematical typology: a grade ofmembership technique for obtaining disease definition Computers and Biomed-ical Research, 11: 277±298

32 Manton K.G., Korten A., Woodbury M.A., Anker M., Jablensky A (1994) tom profiles of psychiatric disorders based on graded disease classes: an illus-tration using data from the WHO International Pilot Study of Schizophrenia.Psychol Med., 24: 133±144

Symp-33 Faraone S.V., Tsuang M.T (1994) Measuring diagnostic accuracy in the absence

of a ``gold standard'' Am J Psychiatry, 151: 650±657

34 Kendell R.E (1989) Clinical validity Psychol Med., 19: 45±55

35 Stengel E (1959) Classification of mental disorders WHO Bull., 21: 601±663

36 Bridgman P.W (1927) The Logic of Modern Physics Macmillan, New York

37 Bleuler E (1950) Dementia Praecox, or the Group of Schizophrenias InternationalUniversities Press, New York

38 Schneider K (1959) Clinical Psychopathology Grune & Stratton, New York

39 Rice J.P., Rochberg N., Endicott J., Lavori P.W., Miller C (1992) Stability ofpsychiatric diagnoses: an application to the affective disorders Arch Gen.Psychiatry 49: 824±830

40 Hempel C.G (1961) Introduction to problems of taxonomy In Field Studies in theMental Disorders (Ed J Zubin), pp 3±22 Grune & Stratton, New York

41 Grayson D.A (1987) Can categorical and dimensional views of psychiatricillness be distinguished? Br J Psychiatry, 26: 57±63

42 Skinner H.A (1986) Construct validation approach to psychiatric classification

In Contemporary Directions in Psychopathology (Eds T Millon, G.L Klerman),

pp 307±330 Guilford Press, New York

43 Fabrega H (1992) Diagnosis interminable: toward a culturally sensitive

DSM-IV J Nerv Ment Dis., 180: 5±7

44 Hyman S.E (1999) Introduction to the complex genetics of mental disorders.Biol Psychiatry, 45: 518±521

45 Ginsburg B.E., Werick T.M., Escobar J.I., Kugelmass S., Treanor J.J., Wendtland

L (1996) Molecular genetics of psychopathologies: a search for simple answers

to complex problems Behav Genet., 26: 325±333

46 Eisenberg L (2000) Is psychiatry more mindful or brainier than it was a decadeago? Br J Psychiatry, 176: 1±5

47 Jablensky A (1999) The nature of psychiatric classification: issues beyond

ICD-10 and DSM-IV Aust N Zeal J Psychiatry, 33: 137±144

48 Andrews G., Slade T., Peters L (1999) Classification in psychiatry: ICD-10versus DSM-IV Br J Psychiatry, 174: 3±5

49 Kendell R.E (2000) The next 25 years Br J Psychiatry, 176: 6±9

50 Grodin M.A., Laurie G.T (2000) Susceptibility genes and neurological orders Arch Neurol., 57: 1569±1574

2

International Classifications and the

Diagnosis of Mental Disorders: Strengths, Limitations and Future

The classification of mental disorders improved greatlyin the last decade

of the twentieth centuryand now provides a reliable and operational tool

A common way of defining, describing, identifying, naming, and ing mental disorders was made possible bythe International Classification

classify-of Diseases (ICD), Mental Disorders chapter [1, 2] and the Diagnostic andStatistical Manual of Mental Disorders (DSM) [3] General acceptance of theICD and DSM rests on the merits of their descriptive and ``operational''approach towards diagnosis [4] These classifications have greatlyfacili-tated practice, teaching and research byproviding better delineation ofthe syndromes The absence of aetiological information linked to brain phy-siology, however, has limited understanding of mental illness and has been

a stumbling block to the development of better classifications This chapterreviews the strengths and limitations of the ICD system as a commonclassification for different cultures and explores the issues around futurerevisions given the expectations of scientific advances in the fields of genet-ics, neurobiology, and cultural studies

Psychiatric Diagnosis and Classification Edited byMario Maj, Wolfgang Gaebel, Juan Jose LoÂpez-Ibor and Norman Sartorius # 2002 John Wiley& Sons, Ltd.

Limits of Our Knowledge about Mental Disorders

Classification of mental disorders creates great interest because it offers asynthesis of our current knowledge of those disorders A classificationreflects both the nature of mental disorders (i.e ontology) and our approach

to know them (i.e epistemology) Like the periodic table of elements whichdisplays properties of atoms in meaningful categories, the classification ofmental disorders mayyield some knowledge about the ``essence'' of under-lying mechanisms of mental disorders At the same time, organization of theclassification mayreflect the conceptual path of how we know and groupvarious mental disorders Having all this knowledge organized in a classifi-cation presents a challenge for consistencyand coherence It also helps us toidentifyshortcomings of our knowledge and leads to further research onunresolved issues

Classification of mental disorders has traditionallystarted from a tical effort to collect statistical information and make comparisons amongpatient groups Todayits greatest use is for administrative and reimburse-ment purposes However, it has also gained importance as a ``guide'' inteaching and clinical practice, because of its special nature of bringingmental disorders into mainstream medicine Since earlier practice of psych-iatryand behavioral medicine was mainlybased on clinical judgementand speculative theories about aetiology, the introduction of operationaldiagnostics allowed for demystification of non-scientific aspects of variouspractices

prac-Current classification systems mainly remain ``descriptive'' They aim todefine the pathologyin terms of clinical signs or symptoms and formulatethem as operational diagnostic criteria These criteria are a logicallycoher-ent set of quantifiable descriptors that aim to identifythe presence of apsychopathology Our knowledge today, with a few exceptions, does notallow us to elucidate the underlying mechanism as to what actually consti-tutes the disorder or produces the symptom The path from appearances toessence depends on the progress of scientific knowledge

As scientific knowledge advances, we become aware that the current

``descriptive'' system of classifications, however, does not fully map onthe neurobiologyin terms of its pathophysiological groupings For example,obsessive-compulsive disorder, which has been shown to have a totallydifferent neural circuit, has been grouped together with anxietydisorders[5±7] Similarly, despite the hair-splitting categorizations of anxiety anddepressive disorders with complex exclusion rules, clinical and epidemi-ological studies indicate high rates of comorbidityand similar psychophar-macological agents prove efficacious in their treatment [8±11] Despite thebelief of distinct genetic mechanisms between schizophrenia and bipolardisorders, familystudies have shown the concurrent heritability[12] Such

examples will inevitablyaccumulate to identifyparadoxes between theappearance and the essence (i.e the underlying mechanisms).

The classification of mental disorders is built on observation of logical human behaviors It identifies patterns of signs or symptoms that arestable over time and across different cultural settings, and can be informedbynew knowledge of the waythe mind and brain work Such a classifica-tion is a reflection of (a) natural observable ``phenomena'', (b) cultural ways

patho-of understanding these, and (c) the social context in which these experiencesoccur Since one of the major purposes of a diagnostic classification is tohelp clinicians communicate with each other byidentifying patterns linked

to disability, interventions and outcomes, these classifications have oftenevolved based on the ``sorting techniques'' that clinicians use All psychi-atric classifications are therefore human tools intended for use within asocial system Therefore, in thinking about the classification of mental dis-orders, multiple factors need to be taken into account, simplybecause ourunderstanding of genetics, physiology, individual development, behavioralpatterns, interpersonal relations, familystructures, social changes, and cul-tural factors all affect how we think about a classification The twentiethcenturyhas been marked byseveral distinct phases in the waymentalphenomena and disorders have been understood The determinism of psy-choanalysis and early behaviorism has been superseded by the logicalempiricism of biological psychiatry that is searching for the underpinnings

of human behavior in the brain in particular, and in human biologyingeneral Our current knowledge of mental disorders remains limited be-cause of the lack of disease-specific markers, and is largelybased on obser-vation of concurrent behavioral and psychological phenomena, on response

to pharmacological and other treatments and on some data on familialaggregation of these elements The task of creating an international classifi-cation of mental disorders is, therefore, a verychallenging multiprofessionaland multicultural one that seeks to integrate a varietyof findings within aunifying conceptual framework

STRENGTHS OF ICD-10: A RELIABLE INTERNATIONAL OPERATIONAL SYSTEM

The ICD is the result of an effort to create a universal diagnostic system thatbegan at an international statistical congress in 1891 with an agreement toprepare a list of the causes of death for common international use Subse-quently, periodic revisions took place and in 1948, when the World HealthOrganization was formed, the sixth revision of the ICD was produced.Member states since then have decided to use the ICD in their nationalhealth statistics The sixth revision of the ICD for the first time contained a

separate section on mental disorders Since then extensive efforts have beenundertaken to better define the mental disorders There has been a syn-chronybetween ICD-6 and DSM-I, ICD-8 and DSM-II, ICD-9 and DSM-IIIand ICD-10 and DSM-IV with increasing harmonyand consistencythanks

to the international collaboration

In the most recent tenth revision of the ICD (ICD-10), the mental disorderschapter has been considerablyexpanded and several different descriptionsare available for the diagnostic categories: the ``clinical description anddiagnostic guidelines'' (CDDG) [1], a set of ``diagnostic criteria for research''(DCR) [2], ``diagnostic and management guidelines for mental disorders inprimarycare'' (PC) [13], ``a pocket guide'' [14], a multiaxial version [15] and

a lexicon [16] These interrelated components all share a common tion of ICD grouping and definitions, yet differentiate to serve the needs ofdifferent users

founda-In the ICD-10, explicit diagnostic criteria and rule-based classification havereplaced the art of diagnosis with a reliable and replicable system that hasconsiderable predictive validityin terms of effective interventions Its devel-opment has relied on international consultation and has been linked to thedevelopment of assessment instruments The mental disorders chapter of theICD-10 has undergone extensive testing in two phases to evaluate the CDDG

as well as the DCR The field trials of the CDDG [17] were carried out in 35countries where joint assessments were made of 2460 different patients Foreach patient, clinicians who were familiarized with the CDDG were asked torecord one main diagnosis and up to two subsidiarydiagnoses Inter-rateragreements, as measured bythe kappa statistic, for most categories in the

``two-character groups'' (e.g F2, schizophrenic disorders) were over 0.74,indicating excellent agreement It was lowest at 0.51 for the F6 category,which includes personalitydisorders, disorders of sexual preference, dis-orders of gender identityand habit and impulse disorders At a moredetailed level of diagnosis, agreement on individual personalitydisorders(except dyssocial personality disorder), mixed anxiety and depression states,somatization disorder and organic depressive disorder were below accept-able limits As a result, the descriptions for these categories were improvedand clarified Some categories were omitted altogether from the ICD-10 due

to poor reliability(e.g the categoryof hazardous use of alcohol)

Based on the experience gathered from the field trials of the CDDG, theICD-10 DCR were developed with the assistance of experts from across theworld Operational criteria with inclusion and exclusion rules were specifiedfor each diagnostic category For the DCR field trials [18], 3493 patients wereassessed in a clinical interview bytwo or more clinicians across 32 countries.Once again, for the F6 categorythe kappa value of 0.65 (though improvedfrom the CDDG field trials) was lower than for the other 9 two charactercategories, which all had kappas over 0.75 For the more detailed diagnoses,

poor kappa values of <0.4 were obtained mainlyfor those categories thatwere either polymorphic syndromes (e.g acute psychotic disorders) or were

at the milder end of the spectrum (e.g hypomania, mild depressive episode)

LIMITATIONS OF CLASSIFICATION OF MENTAL

DISORDERS IN THE ICD

The new classification systems have generally greatly facilitated teaching,clinical practice, scientific research, and communication What then are theproblems?

Classification by Syndromal Similarity

The ICD categories are grouped bytheir syndromal similarity, i.e thecommon clustering of a set of symptoms and signs in clinical practice with

no other organizing principle deemed to be necessary This approach may,however, not always be valid, since a higher order rule may overrideapparent similarities or differences For example, given external character-istics, one mayintuitivelyclassifysharks and dolphins as fish, based on thesimilarities in appearance and the nature of the habitat Yet, this wouldobviouslybe false as a higher order rule dictates that dolphins are mammalsand sharks are not Categories in the ICD (and DSM) having passed the test

of expert consensus (and therefore providing the face validitythat theyareindeed commonlyidentifiable patterns in clinical patients) do not alwaysmake scientific sense and mayhave created boundaries where none exists.For example, it appears arbitrary(and therefore unacceptable) to classifythesevere end of the psychosis spectrum as a ``disorder'' while classifying themilder version within the personalitydisorder group In fact the currentcriteria for schizophrenia in both DSM and ICD have been viewed as havingserious limitations as they rely heavily on psychotic symptoms that may bethe final common pathwayfor a varietyof disorders Features occurringbefore the advent of psychosis that are clinical, biological, and/or neuro-psychological in nature may provide more information about the genetic,pathophysiological, and developmental origins of schizophrenia [19].The separation of the diagnostic criteria from aetiological theories was anexplicit approach undertaken to avoid being speculative, since these theor-ies about causation had not been empiricallytested However, this ``atheore-tical'' approach has also been severelycriticized because, if one takes atotallyatheoretical and solelyoperational approach, it maybe possible toclassifynormal but statisticallyuncommon phenomena as psychiatric dis-orders [20] Diagnostic categories have been proposed and accepted merely

because of recognizable patterns of co-occurring symptoms rather than cause of a true understanding of their distinctive nature that would makethem discrete categories within a classification.

be-What Defines a Mental Disorder?

While ICD is a classification of diseases (or ``disorders'' in the context ofmental illness), there is no explicit agreement on the definition of a mentaldisorder Despite the call for a definition [21], no agreement has beenforthcoming and this ambiguitycreates a fuzzyboundarybetween disorderand wellness At the lowest level, a mental disorder is an identifiable anddistinct set of signs and symptoms that commonly produce disability, andthat the healers in the societyclaim to be able to ameliorate through variousinterventions While practical, such a definition can lead to error, e.g homo-sexualitywas once defined as a disorder

The answer to the question ``What is a disorder?'' needs to be evaluatedagainst rigorous scientific standards rather than just from societal or per-sonal points of view A disorder maybe defined bya set of general prin-ciples that characterize a specific entity, such as common aetiology, signsand symptoms, course, prognosis and outcome It may then have othercorrelates, such as familial aggregation (due to genetic or contextual factors),

a pattern of distress or disability, and a predictable range of outcomesfollowing a varietyof specific interventions Robins and Guze [22], in theirclassic paper, proposed five phases for establishing the validityof psychi-atric diagnosis: clinical description, laboratorystudies, delimitation fromother disorders, follow-up studyto show diagnostic homogeneityover time,and familystudyto demonstrate the familial aggregation of the syndrome.Experience gathered since then shows that some of these criteria lead tocontradictoryconclusions For example, if one wants to define schizophre-nia byits diagnostic stabilityover time, the best approach is to define theillness at the veryoutset bya duration criterion of six months of continuousillness, which tends to select for subjects with a poor outcome In contrast,the familial aggregation of schizophrenia is best demonstrated when thenotion of the disorder is broadened to include the notion of ``schizotaxia''Ð

a broad spectrum notion that views the predisposition to schizophrenia to

be characterized by negative symptoms, neuropsychological impairmentand neurobiological abnormalities and schizophrenia to be a psychoticneurotoxic end-point in the process The latter approach suggests thatnarrowing the definition of schizophrenia using the former strategymay

in fact hinder progress in identifying the genetic causes of the disorder [19].The lack of a definition of what is a disorder also creates an ambiguityabout so-called ``sub-threshold'' disorders Manyhave shown the presence

of cases that have significant distress and disabilityand with clinicallysignificant signs or symptoms who fail to fulfil the criteria for a disorder

in the present diagnostic classifications [23] How one should define suchconditions has been left to arbitrarydecisions, mainlybased on relaxing thediagnostic criteria A good illustration is ``sub-threshold'' depression Per-haps the most common of psychiatric presentations in primary care, subjectswith this diagnosis do not meet the diagnostic criteria for anydepressivedisorder in the classification systems and yet are associated with sufficientdistress to lead to a consultation and have an impact on the person'sfunctioning [24] In other words, the boundaries between ``sub-threshold''and ``subclinical'' are not drawn at the same place It is unclear if thesedisorders are quantitativelyor qualitativelydifferent from the supra-thresh-old categories within the diagnostic systems, such as adjustment disorders,dysthymia and depressive episodes Perhaps there is a need to focus onthese conditions in primarycare settings in order to understand whatdistinguishes them from normal mood fluctuations given the life experience

of people, and to appreciate what theymean for the reorganization of thecurrent categories within the diagnostic system such as, for example, thebroadening of the notion of dysthymia to include both acute, sub-acute andchronic states

How ``clinical significance'' ought to be defined has been the subject ofrecent debate [25, 26], mainlybased on tightening the diagnostic criteria Ithas been suggested that the notion of ``harmful dysfunction'' be used todefine psychiatric disorders A dysfunction is construed as a failure of aninternal mechanism to perform one of the functions for which it is naturallydesigned, i.e a function the mechanism and form of which is understood inevolutionarytheoryterms Harm, on the other hand, is understood as avalue that is ascribed to that dysfunction depending on individual circum-stances transforming the dysfunction into a disorder For example, though adysfunction of the brain may exist that interferes with reading ability, itwould not be a disorder in preliterate societies The approach acknowledgesthe combining of a factual scientific notion with a value component in thecreation of a ``disorder'' It must be noted though that this is not a problemunique to mental disorders A male with azoospermia maynot receive adiagnosis (of primaryinfertility) and maybe considered to be healthyuntil

he is required to procreate Hence, while the concept of ``dysfunction'' is auseful construct, the descriptor of ``harmful'' is not

Separation of Diagnosis from Functioning and Distress

Diagnosis of a disease or disorder should be uncoupled from disability.Disease process and disabilityor distress are distinct phenomena and their

presence for a diagnosis is neither necessarynor sufficient Each one of theICD and DSM diagnostic entities is defined bythree rubrics: (a) specificphenomenology, (b) signs and symptoms and (c) rules that exclude thediagnosis being made in certain circumstances The DSM definition, inaddition, calls for ``clinicallysignificant impairment or distress'', meaningthat disruption in social, occupational, or other areas of functioning mustaccompanythe set of observable phenomena While the intent of this criter-ion was to distinguish mental disorders from dailyexperiences of distressand broaden the clinical focus beyond symptoms, this criterion blurs theconstruct of functioning with the definition of mental disorder For so-called

``physical disorders'' (e.g diabetes or tuberculosis), clinical significance isnot required for diagnosis Putting ``distress'' or ``impairment in function-ing'' as a necessaryprerequisite for diagnosis of a mental disorder is of littleuse if these are not operationalized or independentlyassessed [27] Besides,this approach has major implications for receiving treatment or services.The lack of ``distress or impairment'' would preclude a diagnosis, andwould disallow earlyprovision of care that could prevent the disorderworsening It would impair research and subjects without impairmentwould be excluded from studies to identifythe cause or treatment of thedisorder

Manypatients in primarycare settings fall into sub-threshold diagnosticcategories, particularlythose with depression as noted above In decidingwhen to initiate treatment, functional change maybe even more importantthan discrete symptom profiles Recognizing and treating depression as acomorbid condition in patients with other medical illnesses represents anadditional challenge for the primarycare physician In anxietydisorders, itremains questionable whether the current ICD-10 diagnosis of generalizedanxietydisorder, defined bya six month minimum duration and fourassociated symptoms, is the most appropriate option Using this definition

a substantial proportion of disabled subjects with lesser levels of anxiety,tension and worrying remain outside the diagnostic criteria, and hence may

go untreated

The uncoupling of disabilityfrom diagnosis would allow the examination

of the unique prognostic significance of disabilityand the interactive tionship and direction of change in symptomatology and functioningfollowing interventions It would allow the development of more rationalforms of intervention, including rehabilitation strategies, which are specif-icallytargeted to improving functioning byaltering individual capacityormodifying the environment in which the person lives in order to improvereal life performance It would also underscore efforts to make changes atthe level of health policyand the need to deal with larger social issues such

rela-as stigma in order to improve access to care and social participation ofpsychiatric patients

The development of the International Classification of Functioning, abilityand Health (ICF) [28] is an important landmark in this regard.Disabilityrelated research suggested the need for a revision of the ICFframework that would focus on an ``aetiologyneutral'' and ``universal''model that would also then allow the development of a common metric tocompare ``physical'' with ``mental'' and alcohol or other drug use disordersand allow for arguments for parityof these conditions In recognition of theneed to define disabilityin a manner consistent with a clear conceptualframework, the current revision of the ICF has focused on providing oper-ational definitions of all dimensions and for all terms The ICF classifiesfunctioning at the level of bodyor bodypart, the whole person, and thewhole person in a social context Disabilitythus involves dysfunctioning atone or more of these same levels: impairments, activitylimitations andparticipation restrictions Activityand participation can be described fur-ther in terms of capacity(what a person can do given a uniform environ-ment, i.e the environment adjusted abilityof the person) and performance(what happens in the person's real life environment, i.e what the persondoes in actual life) Having access to both performance and capacitydataenables the ICF user to determine the ``gap'' between capacityand perform-ance If capacityis less than performance, then the person's current environ-ment has enabled him or her to perform better than the data about capacitywould predict: the environment has facilitated performance On the otherhand, if capacityis greater than performance, then some aspect of theenvironment is a barrier to performance.

Dis-The distinction between environmental ``barriers'' and ``facilitators'', aswell as the extent to which an environmental factor acts in one wayoranother, is also captured bythe qualifier for coding environmental factors

in the ICF

In summary, the assessment and classification of disability in a differentsystem is a strong theoretical and practical requirement to refine the defin-ition of mental disorders The separate classification of disease and disabil-ityphenomenon in ICD and ICF is likelyto lead to better understanding ofthe underlying body function impairments for mental disorders and associ-ated disability In this way we would be able to describe and delineate moreclearlythe features of mental illness

Mind, Brain or Context?

Recent progress in the cognitive sciences, developmental neurobiologyandreal time in vivo imaging of the intact human brain has provided us withnew insights into the basic correlates of emotions and cognitions that shouldinform a new psychopathology A better understanding of the neural

circuitryinvolved in complex emotional and cognitive functions will erate the development of testable hypotheses about the exact pathophysio-logical bases of mental disorders.

accel-Genetic sciences emphasize the interaction between the genome and theenvironment and hopefullywill lead to a better understanding of theplasticityof the human brain and how it malfunctions in mental disorders.This approach is different from seeking a molecular pathologyfor everymental sign, and the progress of gene expression through central nervoussystem function to emotional and cognitive constructs will always describemultilinear processes

Progress in the neural sciences is alreadyblurring the boundaries of thebrain and mind, yet such a mind±body dualism as expressed in the organic

vs non-organic distinction in the ICD (but not in DSM) does have a utility Itdirects the clinician to payspecial attention to an underlying ``physical''state as the cause of the ``mental'' disturbance However, the term ``organic''implies an outmoded functional vs structural and mind vs bodydualism.Similarly, at the other end of the spectrum, cultural relativism can under-mine efforts towards the meaningful diagnosis of mental disorders Theview that stigma and labelling can wronglydefine a person as ill impliesthat mental illnesses are ``myths'' created by society This has resulted in adevaluation of insights that are inherent in a cultural perspective A similardanger of further dismissing the role of cultural factors in the causation,maintenance and outcome of mental disorders exists when culture is seen asantithetical to neurobiology

International Use: Need for Universalism and Diversity

As an international classification of diseases, the ICD must contain a allyneutral list of all possible disease entities The frequencies with whichthese conditions occur in different settings cannot be a principle used toinclude or exclude conditions The need to find a ``common language'' ofmental disorders must be balanced with the need to keep local sensitivities

cultur-in mcultur-ind, and to allow users of the classification to fcultur-ind the appropriateconceptual equivalents and to identifyvariations in their culture

Culture

Although some cultural elements have been included in the ICD and DSM,much remains to be done There is a need to move beyond ``culture-boundsyndromes'', the inclusion of which perhaps does little more than pay lipservice to the recognition of the role that culture plays in the manifestation

of mental disorders These conditions reflect an extreme, and provide little ifanyunderstanding of the complex interaction between culture and mentalphenomena There is a need for a better cultural formulation of diagnosisand for informed research to address the impact of culture on the explana-tory, pathoplastic and therapeutic processes Unless typologies are formu-lated on the basis of careful research, sound theory, and clinical relevance,theyare likelyto be relegated to the status of historical artefacts.

``Etic'' versus ``Emic'' Approaches

There is a fundamental dilemma with all international cross-cultural parisons: the need to provide an international common language while notlosing sight of the unique experiences that occur as a feature of living indifferent social and cultural contexts There is need to look for global,universal features of mental conditionsÐan approach that is driven byanalysis and emphasizes similarities rather than differences The ``etic''approach relies on multi-group comparisons and is often carried out from

com-a viewpoint thcom-at is loccom-ated outside of the system Equcom-ally, it is importcom-ant tounderstand the diverse nature of human experience that needs to be dis-covered within a culture-specific system, and to emphasize the differencesfrom one culture to another (the ``emic'' approach) A balance between thetwo approaches is in the interest of an international classification

For example, a Dutch psychiatrist, with three of his Dutch colleagues,classified 40 Ethiopian visitors to a psychiatric outpatient clinic in AddisAbaba In spite of the culture-specific wayin which Ethiopians present theircomplaints, the diagnostic criteria of DSM appeared to be useful and theinter-rater reliabilitywas comparable with that from America The resultswere congruent for the categories that are well defined, like psychotic andaffective disorders This agreement did not applyto the somatoform andfactitious disorders [29]

Conversely, the Explanatory Model Interview Catalogue (EMIC) wasused to elicit indigenous explanations of illness and patterns of prior helpseeking, and generated the popular humoral theories of mental disorder.Even though most laypersons are unfamiliar with the content of the classicaltreatises of Ayurveda, the humoral traditions which they represent stillinfluence current perceptions While case vignettes written in this traditioncan clarifythe nature of the relationship between cultural, familial andpersonal factors that influence the experience of illness, and can provideunique insights for care [30], the underlying aetiological explanation is notinformative

Unique national classificatorysystems, such as the Chinese tion of Mental Disorders, third edition (CCMD-3), often attempt to strike a