Deflating Psychiatric Classification

Claudio E. M. Banzato

Philosophy, Psychiatry, & Psychology, Volume 16, Number 1, March 2009,

pp. 23-27 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/ppp.0.0213

For additional information about this article

https://muse.jhu.edu/article/316643

Access provided by UFF-Universidade Fed Fluminense (16 Jun 2018 21:29 GMT)
 Deflating
Psychiatric
Classification
Keywords: nosography, comorbidity, utility, prag-
matism
S
ystems of classification bring order into
the world. They are a key part of the infor-
mational working infrastructure of the world
we inhabit (Bowker and Star 1999). Thus, much of
the human interaction hinges on these ordering—
pattern identifying and creating—systems. Formal
or informal, standardized or ad hoc, visible or
invisible, enforced or optional, there are a myriad
of classifications we necessarily live by.
Typically, classifications convey representations
of states of affairs to make interventions on them
feasible and, to some extent, predictable. In other
words, classificatory systems and schemes try to
confer intelligibility to the world. By succeeding
in such task, they may provide rational grounds
to human operation on reality (toward the most
diverse ends). This account fully applies to medical
classifications, which struggle to sort out all kinds
of diseases, ailments, complaints, and sufferings
that can possibly be targeted by medical interven-
tions. This means classifications are instrumental
to the ends pursued by medicine, quintessential
modificatory activity. In sum, classifications are
cognitive tools devised to build up knowledge by
making relevant distinctions, which may prove
helpful to guide human action.
© 2009 by The Johns Hopkins University Press
Claudio E. M. Banzato
By working well, classifications eventually tend
to become invisible. They end up looking just
natural, as if they were carved by nature itself. But
indeed purpose is the touchstone here. Even if a
given class of objects fully qualifies as a ‘natural
kind’ and necessary and sufficient criteria for class
membership can be definitely established, it does
not entail that it constitutes the best way to clas-
sify these objects irrespective of the context. Peter
Zachar (2002) offers a compelling example from
natural sciences, the utmost practical importance
of distinguishing between hydrogen and its iso-
topes (hydrogen, deuterium, and tritium). In this
case, the classificatory thrust stretches beyond the
shared atomic number. In his words, “A crucial
factor in recognizing them as distinct is that they
are used in distinct activities and practices. We
get a better neutron bounce with heavy water or
D2O. Deciding what aspects of internal structure
are important therefore cannot be isolated from
external factors.” (p. 220)
In contemporary psychiatry, diagnostic classi-
fication has been center stage for several reasons.
But before addressing them, however, a brief his-
torical detour is necessary. Back in the nineteenth
century, putting forward a new classification of
mental diseases was taken somewhat as a token
of psychiatric proficiency according to the witty
remark by the French physician and publicist
Philippe Buchez: “Upon believing that they have
24  ■  PPP / Vol. 16, No. 1 / March 2009
completed their studies, rhetoricians will compose
a tragedy and alienists a classification” (Ber-
rios 1999, 152). By the middle of the twentieth
century, many psychiatric classifications (based
on diverse principles and underlying theoretical
orientations) were still used across the world.
The British psychiatrist Erwin Stengel (1959), in
his influential report on classification of mental
disorders, pointed out that the issue of difficulty
of communication was then the order of the day
for psychiatry, because it was widely perceived as
one of the most serious obstacles to the progress
in the field.
The broad, worldwide survey carried out by
Stengel made it clear that classifications of all
shapes were used in different contexts, but they
were seldom appealing outside the boundaries of
the respective centers that generated them. Such di-
versity of classifications reflected not only different
functions or purposes they were meant to serve,
but also the role played by the history of a given
problem within a particular medical tradition and
cultural background. Thus, Stengel’s aims for an
acceptable statistical international classification
were relatively modest: it should simply ground
epidemiological work.
Stengel’s stance on classification was frankly
pragmatic and utilitarian. He understood well the
difficulties posed by the ‘disease entity’ assump-
tion in psychiatry and asked the straight question:
“Firstly, what do we classify in this field? Are we
classifying diseases or people?”, to which he of-
fered a compromised answer: “It may be said that
the material the psychiatrist has to classify consists
neither of diseases nor of people but of a variety
of disorders or reactions, a material which does
not readily lend itself to classification” (Stengel
1959, 612). For him, the pursued agreement on
the interpretation of psychiatric concepts for the
sake of diagnosis and classification should basi-
cally serve the purpose of communication.
A key aspect of Stengel’s recommendation,
surprising as it may sound nowadays in this age
of global psychiatry, is that an international clas-
sification should not impose itself and replace all
the others in use: “It should not be the purpose of
an international psychiatric classification to oust
and to take the place of regional or local classifica-
tions, many of which have a valuable function in
research and administration. Such classifications
may stimulate the study of new relationships and
thus advance knowledge. The only proviso to be
made for such classifications would be that they
should be readily convertible into the international
system” (Stengel 1959, 618–619). His caution-
ary motto about any international classification
thus read: “It must be a servant of international
communication rather than its master” (Stengel
1959, 618).
The realm of psychiatric classification changed
considerably within the last few decades. In some
key respects, Stengel did foresee several develop-
ments that eventually took place and brought
us here, such as the move toward a descriptive
(minimally inferential) and symptom-based classi-
fication, first materialized in American Psychiatric
Association (APA)’s Diagnostic and Statistical
Manual of Mental Disorders (DSM)-III (1980),
a rule-based classification with explicit inclusion
and exclusion criteria for class membership. This
approach had a massive, worldwide impact and
proved to be decisive for the internationalization
of psychiatry. The DSM-III and its successors not
only enjoyed a great acceptance (in the United
States as well as in many other countries), but
also ended up influencing the very development
of Chapter V (concerning mental and behavioral
disorders) of the official international classifica-
tion, the World Health Organization (WHO)’s
International Classification of Diseases (ICD)-10
(1992). Although the implementation of the ICD-
10 is still rather incomplete and little is known
about its everyday use by psychiatrists and other
mental health workers—and its actual impact on
the quality of clinical care delivered across the
world—it seems reasonable to acknowledge that
psychiatry has achieved its long-awaited ‘com-
mon language,’ even if with two quite distinctive
accents—the APA’s and the WHO’s.
It is likely that the current prominence of diag-
nostic classifications would surprise Stengel. In a
way, his best expectations in the late 1950s were
surpassed, but such a complete reversal of trends
raised problems of its own. Indeed, it was not all
about gains. So one should ask how did we get
here and at what costs? Addressing these issues
 Banzato / Deflating Psychiatric Classification   ■  25
should help to clarify the centrality of psychiatric
classifications nowadays.
In the 1960s and 1970s, the problem of lack
of reliability of the diagnostic concepts continued
to vex psychiatrists. Clearly, this also contributed
to fuel the antipsychiatric criticism (from varied
extraction and degrees of sophistication) both of
social and medical legitimacy of such specialty.
In response to this long-standing controversy, the
DSMs operated an empiricist turn, making a move
toward grounding classifications on scientific
empirical evidence, so diagnostic categories could
function as working testable hypotheses. There
was an explicit bet that ensuring reliability would
pave the way for validating diagnostic concepts.
Thus, the underlying hope was that provisory
conventional criterial definitions would eventu-
ally give way to independent invariants, taken
as ‘core’ or ‘essential property’ of the nosologic
unities, such as some sort of ‘causal bedrock’
(etiology or pathophysiological pathways), by
means of which a sufficiently robust explanation
of a given class of objects could then be provided.
Within this framework, diagnostic categories were
expected to end up mirroring natural and discrete
morbid entities. Therefore, a scientific classifica-
tion of mental disorders was bound to become a
naturalistic nosologic map.
Because the DSM-III proved to be very influ-
ential and created great expectations about the
prospective empirical validation of diagnostic
categories, it seems fair to take the DSMs (since
the 1980s) as a sort of disciplinary matrix of
psychiatry, which means they embodied a set of
underlying assumptions, beliefs, and values even-
tually shared by most psychiatrists (for an in-depth
analysis of DSM value commitments, see Sadler
[2005]). The fact is that DSM-informed practice
became mainstream psychiatry for the purpose
of research and clinical care. Thus, perhaps one
may treat, like Aragona actually does in this issue
of PPP, the DSM as a ‘paradigm’ in the Kuhnian
sense. Aragona even takes a step further and
suggests that this ‘DSM paradigm’ has entered a
period of scientific crisis, for reasons he addresses
in his article, namely the comorbidity issue vis-à-
vis the conflicting philosophical commitments of
DSM authors.
However, several objections may be construed
against his account. First, the controversy around
nosography of mental disorders has never ap-
peased; despite the huge success of such enterprise,
the DSM has had to face its many foes along
the way. Thus, it may be argued that the DSM
represented just a compromised pragmatic agree-
ment about the next steps among psychiatrists
who otherwise had little in common; so at best
it should count as a surrogate for a disciplinary
matrix. Second, it is doubtful whether there was
a period of ‘normal’ science within DSM frame-
work in the last three decades. For instance, has
psychiatry since the 1980s actually undergone
a period of scientific stability? Third, although
the adoption of rule-based classifications and the
agreement on explicit diagnostic criteria led to a
definite research program, the DSM’s utter rejec-
tion of theory makes it a bit far fetching to use
‘paradigm’ in the Kuhnian technical sense of the
term. After all, which was the prevailing theory
that worked well in the recent past but now is
failing? Fourth, comorbidity is widely recognized
as a byproduct of the DSM’s predominantly split-
ting taxonomic strategy. And it may well be an
undesirable feature for many reasons, especially
when the rates of comorbidity empirically found
are considered too high. But, again, that does not
mean it is a truly Kuhnian ‘anomaly,’ because it
is actually an anticipated side effect of the initial
setup, not some unexpected discovery that might
challenge an otherwise successful account of the
behavior of objects. In sum, the comorbidity is-
sue may indeed be irresolvable given the DSM
premises and commitments (according to the case
made by Aragona), but it is hardly an ‘anomaly’ in
the sense of a violation of the paradigm-induced
expectation. It strikes me as inconsistent and odd
to treat comorbidity at the same time as artifactual
byproduct and as anomaly.
Nevertheless, irrespective the word chosen to
qualify it, Aragona aptly frames the comorbidity
issue by outlining its several intertwined concep-
tual underpinnings and by convincingly showing
that such problem cannot be solved merely by
means of the usual empirical research. The very
‘disease entity’ assumption is deeply implicated in
the discussion of ‘intraparadigmatic’ and ‘revolu-
26  ■  PPP / Vol. 16, No. 1 / March 2009
tionary’ solution strategies proposed by Aragona.
Also, aesthetic and practical considerations seem
to play a role in such choice: the underlying ideal
of parsimony and neatness held by psychiatrists
must be taken into account.
It would be simply naïve to believe that a
DSM-like undertaking would suffice to provide
psychiatry with sound conceptual grounds. From
the fact that psychiatric classificatory systems
reflect key conceptual issues, it does not follow
that any given classification should qualify as
a replacement for psychopathological theory.
Bottom line, classifications perform a practical
demarcatory role in psychiatry: the limits of pro-
fessional responsibility and the accountability for
suffering depend to a large extent on the diagnostic
options available, as well as on the way diagnostic
constructs are conceptualized and classified. Thus,
their paramount pragmatic importance, echoing
William James (1907) pragmatist formula: “There
can be no difference anywhere that doesn’t make
a difference elsewhere—no difference in abstract
truth that doesn’t express itself in a difference in
concrete fact and in conduct consequent upon that
fact, imposed on somebody, somehow, somewhere,
and somewhen” (p. 144).
The purpose of any classification: there is where
the rub lies. So far, within the DSM framework,
a single classification should serve many masters
and purposes (clinical care, research, and teaching,
to mention just those explicitly acknowledged in
the manual). But one may ask whether or not such
ambition is attainable? If any given classification
is built out of the necessity of accommodating
very diverse end purposes, it would come to no
surprise if the several assumptions and commit-
ments held in good faith by their authors could
not be fully conciliated. Perhaps one might even
adapt (by replacing ‘truths’ by ‘purposes’) the
piercing Jamesian adage to read ‘the greatest en-
emy of any one of our purposes may be the rest
of our purposes.’
Another key distinction concerns the intrinsic
reach and limitations of a classification and the
way it is actually used in practice. It is crucial
to separate failures or dissatisfactions with a
given diagnostic system that are due to the faulty
instrument itself from those that are caused by
an improper use of it. For instance, psychiatrists
quite often fail to apprehend the implications of a
criterial definition, which is conventional but not
arbitrary. Furthermore, the caveat that diagnostic
categories are just practical tools is frequently
ignored in daily practice, to the dismay of the
nosologists who build these tools. Some examples
and consequences of such inept handling of clas-
sificatory systems follow.
First, it is way too common that psychiatrists
(often to their own professional benefit) speak
about diagnostic categories as clearcut diseases
that have been fully elucidated, grossly overesti-
mating the existing knowledge about them. Sec-
ond, in clinical routine, disorders are improperly
taken as causes of symptoms (‘these symptoms
are due to that disorder’ [Scadding 1990]), which
betrays deeply rooted ontological assumptions
about the nature of mental disorders. Third, the
reification of diagnostic categories may hinder
research because alternative models are seldom
empirically tested; even though diagnostic catego-
ries can be legitimately thought of as hypothetical
constructs, they are ordinarily taken for granted
in most empirical studies, which means that they
count as part of the necessary background to test
other kind of hypotheses, but are rarely tested
themselves against alternative options. Fourth,
clinical encounter may be significantly constrained
when diagnosis is reduced to just subsuming pa-
tient’s symptoms to the general types included in
the manual. After all, a classification should serve
the diagnostic process, not the other way around.
So the achievement of a psychiatric classification
must be measured by the benefits actually brought
to its diverse stakeholders: clinicians, researchers,
administrators, policy makers and, especially,
patients and their families.
Thus, regarding the discussion of the ‘third
intraparadigmatic solution’ (the complete liber-
alization of comorbidity), an important issued
is raised by Aragona: the diverse impact it might
have on researchers and clinicians. In this scenario,
he foresees an eventual divorce of clinical practice
from the DSM classification rules (an occurrence
one may infer he disapproves of). What Aragona
does not consider in his article, however, is the
very possibility of having separate classifications
 Banzato / Deflating Psychiatric Classification   ■  27
to serve different stakeholders and purposes.
So a key question, and not just for the sake of
handling comorbidity, is this: should we build
one single classification or several? A potentially
serious drawback of a ‘one-size-fits-all’ approach
is that the interests and needs of the different
stakeholders of classificatory systems may not fully
coincide. Actually, in that regard, WHO (ICD:
family of classifications) and APA (DSM: single
classification) have not adopted the same strategy.
Again, pragmatic considerations play a key role.
Arguably, part of the appeal of the DSM is that
everything comes in a single volume. This certainly
enhances the chance of having its content known
and mastered. As a matter of fact, the several
versions of Chapter V of the ICD-10 family of
classifications (for research, for primary care, the
multiaxial presentation for adults, the multiaxial
presentation for children and adolescents, etc.)
launched successively after the inaugural volume
(clinical description and diagnostic guidelines),
by different publishing houses, have not as yet
enjoyed widespread popularity.
I suspect that issues such as ‘conciliating the
many purposes of a classification,’ ‘having one
classification or several,’ and ‘addressing diverse
needs of different stakeholders’ seldom receive
due attention in the literature because current
diagnostic classifications have crystallized as the
cornerstone of psychiatric practice. This situation
is understandable given the difficulties of commu-
nication faced in the past and the recurrent attacks
on the medical identity of psychiatry. After all, it
is nice to have a neat document to display as a
proof of the scientific maturity achieved by the
discipline. But a classification is supposed to be a
tool, not a straitjacket. There are plenty of fasci-
nating and challenging problems in psychiatry—
both theoretical and clinical—that, despite being
germane to the classification of mental disorders,
cannot be reduced to such aspect nor dealt with
in a merely nosographic fashion. Hence, the claim
that psychiatry would be better off if we started
doing what is suggested in the title of this com-
mentary.
By deflating psychiatric classification it is meant
that the conceptual framework of the discipline
should become less dependable on nosographic
issues. Of course, alternative nosologic approaches
such as, for instance, those mentioned by Aragona
in the concluding remarks of his article (spectrum,
dimensional diagnosis, and etiopathogenic classifi-
cations) can and should be empirically tested, and
not just for the sake of overcoming the problem
of comorbidity. But perhaps instead of taking
the competition between them as a ‘battle of
paradigms,’ it would be more accurate to describe
this simply as an attempt to do better justice to
the highly complex task of conceptualizing psy-
chopathology for a myriad of purposes, which in
itself does require methodological and explanatory
pluralism; so combinations of models are to be ex-
pected. Theoretical openness is a condition for us
to build on the gains brought by current systems.
Besides, I think full consideration of the diversity
of their several stakeholders’ real-life needs should
inform the development of the next generation of
psychiatric classifications.
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