Psychiatric Diagnosis PDF
Preview Psychiatric Diagnosis
PSYCHIATRIC DIAGNOSIS Psychiatric Diagnosis Edited by Vivian M. Rakoff, M.A., M.B.B.S., F.R.C.P.(C) Professor of Psychiatric Education Department of Psychiatry University of Toronto Harvey C. Stancer, Ph.D., M.D., F.R.C.P.(C) Professor of Psychiatric Research Department of Psychiatry University of Toronto and Henry B. Kedward, M.A., M.D., F.R.C.P.(C) Professor, Department of Psychiatry University of Toronto © Brunner/Mazel, Inc., 1977 Softcover reprint of the hardcover 1st edition 1977 978-0-333-23716-8 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission First published in the United States of America 1977 by Brunner/Mazel, Inc., New York Published in Great Britain 1978 by THE MACMILLAN PRESS LTD London and Basingstoke Associated companies in Delhi Dublin Hong Kong Johannesburg Lagos Melbourne New York Singapore and Tokyo British Library Cataloguing in Publication Data Psychiatric diagnosis. 1. Mental illness -Diagnosis I. Rakoff, Vivian M II. Stancer, Harvey C III. Kedward, Henry B 616.89'075 RC469 ISBN 978-1-349-03755-1 ISBN 978-1-349-03753-7 (eBook) DOI 10.1007/978-1-349-03753-7 Contents Contributors vii Introduction ix I. DSM-III: GUIDING PRINCIPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 By Robert L. Spitzer, M.D., Michael Sheehy, M.D. and jean Endicott, Ph.D. 2. PsYCHOANALYTIC DIAGNOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 By Robert]. Stoller, M.D. 3. NEUROPSYCHOLOGICAL CoNCEPTS AND PSYCHIATRIC DIAGNOSIS 42 By Ralph M. Reitan, Ph.D. 4. THE INADEQUACIES oF CoNTEMPORARY PsYCHIATRIC DIAGNOSIS. . . 69 By Roy R. Grinker, Sr., M.D. 5. THE LIMITS OF STANDARDISATION 84 By john K. Wing, M.D., Ph.D. 6. THE SCOPE AND VALIDITY OF THE SCHIZOPHRENIC SPECTRUM CoNCEPT ................................. 109 By Paul H. Wender, M.D. 7. GENETIC PATTERNS AS THEY AFFECT PsYCHIATRIC DIAGNOSIS .... 128 By George Winokur, M.D. v vi Contents 8. THE VULNERABLE BRAIN: BIOLOGICAL FACTORS IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION . . . . . . . . . . . . . . . . . . . . . . • 153 By H. M. van Praag, M.D. 9. A CRITICAL OvERVIEW OF DIAGNOSIS IN PsYCHIATRY ........... 189 By Alvan R. Feinstein, M.D. 10. PANEL DISCUSSION ......................................... 207 Index ................................................... 229 Contributors JEAN ENDICOTT, PH.D. Assistant Professor of Clinical Psychology, Department of Psychiatry, College of Physicians and Surgeons, Columbia University; Member, Task Force on Nomenclature and Statistics of the American Psychi atric Association ALVAN R. FEINSTEIN, M.D. Professor of Medicine and Epidemiology, Yale University School of Medicine ROY R. GRINKER, SR., M.D. Chairman of the Department of Psychiatry of Michael Reese Hospital H. M. VAN PRAAG, M.D. Professor of Psychiatry, Biological Psychiatry, State University, Gron ingen, Holland RALPH M. REITAN, PH.D. Professor of Psychology and Neurological Surgery, University of Washington MICHAEL SHEEHY, M.D. Director of Outpatient Services and Research, Columbia Presby terian-New York State Psychiatric Institute; Member, Task Force on Nomenclature and Statistics of the American Psychiatric Association vii viii Contributors ROBERT L. SPITZER, M.D. Professor of Clinical Psychiatry, Columbia University; Chairman, Task Force on Nomenclature and Statistics of the American Psychi atric Association ROBERT J. STOLLER, M.D. Professor, Department of Psychiatry, University of California School of Medicine, Los Angeles PAUL H. WENDER, M.D. Professor of Psychiatry, University of Utah, College of Medicine, Salt Lake City, Utah JOHN K. WING, M.D., PH.D. Professor of Social Psychiatry, The Institute of Psychiatry, University of London, England GEORGE WINOKUR, M.D. Professor and Head, Department of Psychiatry, University of Iowa College of Medicine Introduction In common with the terms used in medicine and surgery, psychiatric diagnostic labels are derived from a ragbag of conceptual models: Diag noses may be the names of symptoms, syndromes, signs or biochemical entities or historical relics-a received shorthand for complex states. But psychiatry has suffered more than its companion healing arts from a lack of generally accepted theoretical approaches or even commonly accepted empirical practice which could have provided the basis of a professional lingua franca. And even widely used terms may be applied very differ ently in different places, as the well-known U.S./U.K. study demonstrated. In some instances the problem is something like the situation encoun tered with languages such as Arabic, in which there is a language of usage so different from the formal language of literature that the ordinary man in-the-street can barely follow the meaning of the literary language. In psychiatry this takes the form of the gap between elaborate diagnostic codes used for research purposes by epidemiologists and others and the limited repertoire of diagnoses used by the work-a-day clinician which rarely go beyond schizophrenia, depression, anxiety state, addiction, or ganic state, personality disorder, or neurosis. At any particular moment in history diagnostic labeling can only be as good as the prevailing technology or, failing that, the prevailing accepted philosophy. Yet, allowing for all the uncertainty and confusion, psychi atric diagnosis in general is not as good as it could be, in the sense that it has not, at this time, incorporated recent advances in the associated sciences and disciplines-so that usage trails behind available knowledge. ix X Psychiatric Diagnosis There is in psychiatry very little well-based knowledge of patho genesis; this is a situation that is fairly common in the history of the healing professions. However, in medicine and surgery there have fre quently been effective therapies for maladies that have been poorly understood in terms of their causes and pathology. There is little of this pragmatic comfort for the psychiatrist since part of the problem is also the paucity of objectively defined therapeutic modalities of predictable effectiveness. The great majority of patients who traditionally present their suffering to psychiatrists fall into the framework of life problems or the loosely defined neuroses. The therapies for such conditions are usually psychotherapies of one kind or the other. For more severe psychiatric conditions, therapeutic practice begins with (or is based upon) prescrip tion of phenothiazines, anti-depressants, anxiolytics, and lithium. The small range of materia medica more accurately reflects the pragmatic diagnostic labels referred to above rather than the elaborate grids and cross references encountered in classifications, such as the schedules of the World Health Organisation's diagnostic codes or the carefully re searched versions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. The organisers of the symposium from which this book is derived planned to deal with the issue of psychiatric diagnosis from a range of points of view informing current practice. The intention was to examine each approach in terms of its advantages and shortcomings. We were particularly concerned to avoid diagnostic schemata based upon purely theoretical or speculative positions unsupported by empirical evidence. However, we were aware, as :pr. Wing writes, that all diagnostic cate gories, no matter how utilitarian or empirically derived, contain hypo theses which may or may not be explicit, or which may or may not have been subject to investigation. We also attempted to structure the symposium to reflect not only conceptual variety but in a crude sense a hierarchy of diagnostic con cerns and possibilities. We planned to have contributions ranging from the most palpably objective techniques of diagnosis through the applica tion of the basic clinical and epidemiological sciences to the consideration of the patient's subjective motivational states. And having done that, we hoped to consider the "summa" of present knowledge as it is reflected in diagnostic schedules covering the entire range of adult psychiatric disorder. The reader will find two descriptions of complete psychiatric diag nostic schedules: Dr. Spitzer and his colleagues have presented the
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