History of Psychiatric Diagnosis: a Guidebook for Nonclinicians
| Publication year | 1994 |
| Pages | 39 |
1994, January, Pg. 39. History of Psychiatric Diagnosis: A Guidebook for Nonclinicians
The latest edition of the American Psychiatric Association's listing of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition ("DSM-IV"), is scheduled to be published soon after this article appears. DSM-IV was developed to provide mental health professionals with a classification system for diagnoses which reflects the latest clinical and research data, and to serve as the basis for reliable and valid future research into mental disorders. However, the manual has become important to nonclinicians as well.
Third-party compensation for psychiatric treatment requires that patients suffer from mental disorders which justify the treatment provided. Reimbursement is therefore dependent on DSM diagnoses. Additionally, DSM diagnoses figure frequently in both civil and criminal litigation. Plaintiffs claiming psychological injury must demonstrate the presence of significant mental disorders. When the state seeks to commit someone in a civil action, it must prove that the person suffers from a serious mental disorder. Criminal and civil defendants seek to diminish their responsibility by arguing that their mental disorders prevented them from realizing what they were doing.
While no statute or court rule is tied specifically to the current edition of the DSM, the manual has become an accepted standard in court, where it serves to ensure that expert witness opinions are based on current scientific knowledge and not merely on idiosyncratic views of individual clinicians. It is therefore important that legal professionals who must examine and cross-examine such witnesses have an understanding of the process by which the DSM series was developed and on what an expert's claim to represent current scientific thinking in the field is based. This article is intended to serve as an introduction to that process.
Medicine, like science as a whole, began with a descriptive phase, in which phenomena of interest were categorized and classified on the basis of common observed elements. Without this taxonomic data base, further research would have been impossible because such research requires comparable populations of subjects so that findings can be reproduced by different investigators. By this process, more objective characteristics can be discovered and validated.
Psychiatry, unlike the rest of medicine, continues to deal predominantly with behavior and deviations from social norms which are not uniform across cultures. Its diagnostic nomenclature reflects this stage in development. Psychiatric diagnoses originated with German practitioners noted for their meticulous observations and descriptions of disordered behavior, more than their interest in the causes of that behavior.(fn1) However, the next major stage in taxonomy shifted the focus significantly.
Sigmund Freud began as a neurologist, trained in the scientific medicine of his day and hoping to discover anatomical and physiological causes of mental disorder. He recognized that the current technology was incapable of discovering physical causes of psychiatric symptoms, but never abandoned hope that some day such an approach would be possible. In the meantime, he proceeded to create a psychological typography of the mind, in hopes of establishing a conceptual system which could then be tested as new physical methods became available.(fn2)
Freud never conceptualized his theory of psychoanalysis as the basis for a whole system of treatment for mental disorders. He maintained throughout his career that his techniques were primarily research tools to collect psychological data to use in refining his theories, rather than practical methods for treating persons
Psychoses were those disorders which cause distortions in reality testing, including hallucinations (false sensory perceptions), delusions (false beliefs about circumstances which cannot be challenged with factual information) and ideas that the individual's thoughts are being controlled by external forces.
Neuroses were thought to be learned behaviors, based on unresolved fears from childhood which have been repressed and of which patients are not consciously aware. The fears cause symptoms such as phobias, anxiety, depression and compulsive behavior. Patients are aware that something is wrong with them but do not know exactly what.
Patients suffering from the third category, character disorders (now called personality disorders), were also conceptualized as having learned their behaviors, but (unlike neurotic patients) were believed to be unaware of any emotional problems in themselves. Their behaviors (antisocial, hysterical, passive-aggressive) typically bother others, but do not cause the patients any direct psychological problems.
Although his theories attempted to explain all types of mental...
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