Diagnostic Classification in Psychiatry:

what is left out

Segunda Jornada Internacional de Clasificación y

Diagnóstico Psiquiátricos

Lima, 23-25 September 2010

Claudio E. M. Banzato, M.D., Ph.D.

University of Campinas (Unicamp), Brazil
“If men define situations as real, they
are real in their consequences.”
Thomas and Thomas, 1928
 CLASSIFICATIONS WE LIVE BY

Systems of classification bring order into the world.

They are a key part of the informational
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.

Banzato, 2009
CONSEQUENCES OF
CLASSIFICATIONS AND STANDARDS

The key question of the taken-for-grantedness

of objects

“Each standard and category valorizes some point of

view and silences another . This is not inherently a bad
thing – indeed it is inescapable. But it is an ethical choice,
and as such it is dangerous – not bad, but dangerous.”

Bowker and Star, 1999

CLASSIFICATIONS IN SCIENCE

Heuristic device:

Ordering or arrangement of objects into groups
or sets on the basis of their relationships

Main purposes:

Economy of memory

Ease of manipulation

Retrieval of information

Generation of hypotheses

Robert S. Sokal, 1971

DEFINITION OF STANDARD

Any set of agreed-upon rules for the

production of (textual or material) objects

In several respects, classifications and

standards are two sides of the same coin

Bowker and Star, 1999

 THE CASE OF THE “METRE”

International prototype bar stored at the Pavillon

de Breteuil near Paris (standard from 1889 to 1960)

Current defintion: the distance covered by light in a vacuum

over a duration of 1/299 792 458 of a second

“This new definition signals a major epistemological break in

the field of metrology: the standard is no longer a mere level of
reference to which the object to be measured can be compared, the
standard is an integral part of a theory.”
Bruno Falissard, 2008
DIAGNOSIS AND CLASSIFICATION SHOULD NOT
BE INADVERTENTLY CONFLATED

 Diagnosis: decisive activity and process, of

utmost importance in medicine. Etymologically:
to distinguish, to discern [the word has two
components: through, thoroughly, asunder + to
learn to know, to perceive] (OED)

 Classificatory tools should serve diagnosis,

not the other way around
 THE MUSIC OF TIMES

 The 1950s: general dissatisfation with

classifications, a serious obstacle to
progress in psychiatry was difficulty of
communication (Stengel, 1959)

 The
2000s: ICD-10 and DSM-IV are the
common language of psychiatry, the
masters of international communication
 POSSIBLE GAINS BROUGHT BY
CURRENT DIAGNOSTIC SYSTEMS

 Strengthening of the medical identity of

psychiatry

 Demystification of psychiatric diagnosis

 Reduction in the stigma associated with

mental disorders

 Fostered the development of psychiatric

epidemiology
 UNTOWARD EFFECTS OF
CURRENT DIAGNOSTIC SYSTEMS

 Intrinsic
problems
 Problems secondary to misuse

 Problems related to the classificatory

scheme (taxonomy)
 Problems related to the diagnostic
guidance provided (diagnostic model at
their core)
Banzato, 2008
CHANGES IN CONTEMPORARY
PSYCHIATRY

To which extent recent classifications (that is,

after DSM-III) helped to shape the changes in
contemporary psychiatry?

Conversely, we may ask to which extent the

recent classifications (that is, after DSM-III) are
just the surface expression of deeper ideological
changes in the field ?
WHAT IS WRONG WITH CURRENT
PSYCHIATRY?

Disregard or neglect of psychopathology, body of

knowledge and skills specialized and not easily accessible

Instead, the profession has been feeding on false promises

of imminent breakthroughs in neurobiology or genetics,
which are periodically renewed

Classifications are inadvertently taken as surrogate for

clinical acumen

Symptom and sign ascertainment have become

increasingly questionable, so even the supposed gains on
reliability are not warranted
Jablensky, 2010
Peter Zachar e Ian Hacking
accounts on Kinds

Harvard University
Press, 1999

Princeton University
Press, 1995
Natural kinds

o Regular entities, internally consistent

from one instance to another

o Well delimited in nature

o Defined by necessary and sufficient

properties or attributes that are
inherent to them, as well distinctive
The strong tendency to essentialism

 Equating the defining internal property or

attribute to the essence of the entities or
objects

 Equating the discrimination of the essence

of entities or objects to carving nature at its
joints

 Whatever does not satisfy criteria for a

natural kind is thus artificial or arbitrary
THE PRACTICAL KINDS MODEL

o Pluralist and anti-essentialist, and yet realist

o It does not deny that things have internal structures, but

only that those are sufficient to determine the pertinence to a
given category, irrespective purpose

o Inevitable role of external (relational) criteria, which must

include purpose

o Therefore, in this model, utility is a component of validity

Full epistemological compatibility with scientific thinking

Pragmatism does not imply at all any relativism of the type
“anything goes”
Zachar, 2000 and 2002
EXTERNAL (RELATIONAL) CRITERIA

A compelling example from natural sciences, the extremely

practical importance of distinguishing between hydrogen and its
isotopes (hydrogen, deuterium and tritium). The matter goes
beyond just sharing the 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 D20. Deciding what aspects of
internal structure are important therefore cannot be
isolated from external factors.”

Zachar, 2000 and 2002

 INDIFFERENT VERSUS INTERACTIVE
KINDS
(LOOPING
EFFECT)
o People react to the way they are classified, not necessarily in
a predictable way (as it was supposed in the labeling theory).
Psychiatric categories (and nomenclature) may affect the way
people frame their own experience, describe their sufferings,
ailments, etc.

o Classificatory looping: effect mediated by the awareness of

being classified.

o These very changes somewhat caused by classificatory

systems themselves may eventually modify to a certain extent
the subject of their classification. Thus, it is like a truly
evolving and interactive process. Describing and classifying
clinical disorders would not have a natural term.

Ian Hacking, 1999

Interactive kind: human beings,
who care a lot about the way they
are classified. For instance, some girls
worry about not being classified as
“popular” at school.

Indifferent kind: the former

planet Pluto, now a dwarf planet,
whose orbit remained the same
after its reclassification in 2006
 Why Classifications Matter

Classificatory tools

are built out of deeply ingrained – and

often implicit – convictions about the nature
of mental disorders

and, therefore, may – either purposefully or
inadvertently – constrain diagnostic practice to
a great extent

“A psychiatric nosology, then, is not simply a systematic ordering

of categories found in nature (what philosophers term ‘natural
kinds’) but constitutes a map and charter of a social world.”
Kirmayer, 2005
 INFLUENCE OF
CLASSIFICATIONS ON
DIAGNOSTIC PROCESSES
 A neglected aspect in the nosographic
literature is the constraints that diagnostic
categories and classificatory schemes may
impose (either intentionally or inadvertently)
on the clinical encounter

 Diagnostic labels are presently being used by

the patients to name their complaints. On the
side of the clinicians, reification has also
hardly been resisted. So, what kind of
psychiatric clinics can actually take place
within such a context?
SO, WHAT IS MISSING IN THE
PICTURE?
Person: key concept for psychiatry

“The smallest unit of meaning is

the life of the whole person.”
Thornton, 2006

o Embodied being
o Body-subject
o Self-reflexive embodied agent
What are our working (and hidden) concepts
of ‘man’ and ‘fulfilled life’ (eudaimonia)?

“Psychiatrists work toward helping people with all

manner of maladies, from problems-in-living to chronic,
debilitating diseases; but what the profession, and
its practitioners, believe about the best way to
live is their bestkept secret.”
Sadler, 2005
Shifting perspectives and multiple levels of analysis

o Psychiatry, as any other branch of medicine, is quintessentially a

modificatory activity, so diagnosis is supposed to be linked to
some sort of rationale for interventions that target certain kinds of
human suffering (pathos)

o But in psychiatry, a medical specialty not strictly defined in

terms of biological substrata, it should be much clearer that the
person is the unity of analysis par excellence

o However, there is a need to constantly shift perspectives in

clinical care, focusing alternately on different levels of organization
(zooming in and zooming out, from within the body to beyond the
individual)
 The centrality of the
clinic

Pathos & Logos

Logically and chronologically, the Pathos comes first,

conditioning the Logos, calling it forth

Hence, when it comes to the pathological, the last

word belongs to the clinic

Georges Canguilhem, 1943

So, if

“The pathological is the direct concrete

feeling of suffering and impotence, the
feeling of life gone wrong.”
Georges Canguilhem, 1943

One has to ask

In which way a particular life is being

affected by the pathology, what actually
has been denied to a given subject
WHAT IS LEFT OUT OF
CLASSIFICATIONS IS MEANING

The subject’s morbid experience has been seen just as

a particular instance of how things tend to happen

But lawlike explanations never tell the whole story

So, it is crucial to acknowledge the space of reasons

Subjective experience has to be captured

through a narrative account of the subject’s
thoughts and actions
Thornton, 2006
 Diagnosis beyond classifications

In the clinical encounter, the process of diagnosis,

which involves…

…getting to know who the person (body-subject) is

…finding out what her concrete feelings are
…learning what her driving-forces and goals in life are

…has necessarily a narrative component at its

very core
 What’s in a label?

“Seemingly purely technical issues like how to name

things and how to store data in fact constitute much of
human interaction and much of what we come to
know as natural. We have argued that a key for the
future is to produce flexible classifications whose users
are aware of their political and organizational
dimensions and which explicitly retain traces of their
construction. [...] The only good classification is a
living classification.”

Bowker & Star, 1999

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