This book is based in part on
presentations delivered at the 11^th World Congress of
Psychiatry (Hamburg, Germany,
1999). Consequently, the writing is
scholarly and most passages are saturated with technical terminology. Readers not accustomed to academic works will
find these essays challenging. The ten
chapters of this book discuss various answers to the question, Has the
description and classification of mental disorders or diseases, as found in the
American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders 
(DSM) and the World Health Organization’s ICD-10 Classification of Mental and Behavioural Disorders, Clinical
Descriptions and Diagnostic Guidelines, part of the International Classification of Diseases (ICD), been accurate, functional, and effective both in
clinical treatment and in teaching psychiatry and psychotherapy?

Topics considered include the
criteria on which classifications of mental disorders are and ought to be
based, the strengths and limitations inherent in an international
classification system, the effects of the recent rise of “comorbidity” (the diagnosing of several mental disorders
within one patient) on classification, the role of phenomenology in psychiatric
diagnosis, the efficacy of clinical assessment instruments in diagnosing, and
the difficulties encountered in the diagnosing and classification of mental
disorders across cultures and within developing countries. The authors courageously discuss various
problems inherent in any attempt to define mental disorders such as problems
with the way research into mental disorders is conducted and the way data is
then interpreted, difficulties encountered in classifying overlapping symptoms
and so-called “threshold cases” in which a patient doesn’t meet the criteria of
exhibiting severe symptoms, the problem of vagueness in the concept of harm to
self or others as a criteria for diagnosis, and the ubiquitous risk of
pathologizing the normal when classification is too broad and general, or
omitting disorders when classification is too narrow and specific.

Chapter 4, which deals with
comorbidity, is particularly interesting. 
In it the authors argue that the diagnosis of discrete mental diseases
according to various diagnostic manuals has always been difficult. They point out that “for mental disorders, comorbidity, defined
as the increased risk of multiple disorders occurring together, is the rule
rather than the exception.” They argue
that disorders are polygenic, multifactorial and developmentally complex, and
that it is an “inescapable fact of life for clinicians that most patients who
satisfy the criteria for one particular category of mental disorders usually
satisfy the criteria for others as well” 
(pp. 80-81). The question this
raises for the clinician is, Which diagnosed disorder should be treated? Or are the combination of disorders, in
other words the sum of the comorbidity, a new and discrete disorder requiring
yet another treatment not mentioned in the manuals? The authors say that in cases of comorbidity clinicians make
treatment choices based on a number of criteria: they limit assessment to only a few of the disorders due to time
constraints and resources limitations, they choose to treat only those disorders
about which the patient is complaining, they treat those with which they are
most familiar and feel most competent in treating, and they treat only those
disorders the patient’s insurance provider has agreed to cover. The analysis in this chapter reveals many
common clinical biases and a shocking economic pragmatism among mental health
providers that many patients may not be aware of.

This book can be read from two
perspectives. If it is read from a
psychotherapist’s point of view then the discussion is interesting, thought
provoking, and often enlightening. But
if the reader has the slightest doubts about the fundamental assumptions on
which psychotherapy is based then these discussions of diagnosis and
classification will seem like watching a tailor expend his energy on sewing the
perfect buttonhole before he has even begun to construct the suit. In effect the writers of these chapters are
attempting to justify the systematic methods they use for recognizing and
cataloging that which their critics say doesn’t exist, namely individual markers,
symptoms, or traits which clearly identify discrete mental illnesses.

For example, the editors are
careful to point out at the very beginning of the book, “That current
diagnostic categories really correspond to discrete natural disease entities is
appearing now more and more questionable. . . Thirty years of biological
research have not been able to identify a specific marker for any of the
current diagnostic categories” (p. ix). This will raise a number of questions in any
inquiring mind such as, Is it realistic
to expect that mental distress will ever be defined in terms of specific
biological “markers”? Isn’t it the case
that whenever a biological marker—a physical cause—is found for a so-called
mental disorder the classification of “mental disorder” is then dropped and it
becomes, by definition, a medical disease, as in the case of Alzheimer’s
disease? If the answer is “yes” then it
would mean that for any non-physical distress to remain classified as a “mental disorder” it must necessarily
continue to remain free of any biological cause that is verifiable by the
empirical means employed in medical science. 

And what about those other cases in
which a “condition” becomes “normalized,” such as when, in 1973, a board of
prominent American mental health professionals simply voted homosexuality off
their list of mental illnesses? These
type of questions challenge the very foundation on which diagnosis and
classification are based. They lead to
the conclusion that psychotherapy will continue to exist only so long as there
are enough “mental disorders” not attributable to biological causes and not
voted into normalcy. Is it any wonder
then that, in order to sustain the profession, new “mental disorders” are
“discovered” by mental health professionals on an almost daily basis? And is it any wonder that critics of the
mental health professions argue that it’s not enough to merely discuss how to
effectively diagnose and classify but that the very processes of diagnosing and
classifying itself should come under both moral and scientific scrutiny?

Interestingly, the editors hail
from universities in Italy, Germany, Spain, and Switzerland, while the
contributors are literally from all over the world. This may give the reader the comforting feeling that there is
universal consensus among professionals about psychiatric diagnoses and
classifications—a feeling that these essays reveal to be quite unfounded.  

An interesting read in strongly
technical language, this book gives penetrating insights into the kinds of
consequential issues with which contemporary mental health services providers
are currently struggling. It succeeds
in answering many questions about how non-physical distress is perceived by
professionals at the same time that it raises many more. I would recommend this book to anyone
practicing in the mental health field, and to consumers of mental health
services who are comfortable reading academic works.

© 2002 Peter B. Raabe

Peter B. Raabe
teaches philosophy and has a private practice in philosophical counseling in
North Vancouver, Canada. He is the author of the book Philosophical
Counseling: Theory and Practice (Praeger, 2001).

Categories: Philosophical, MentalHealth