Psychiatric Diagnosis and Classification - ResearchGate

INTERNATIONAL CLASSIFICATIONS 31
of cases that have significant distress and disabilityand with clinically
significant signs or symptoms who fail to fulfil the criteria for a disorder
in the present diagnostic classifications [23]. How one should define such
conditions has been left to arbitrarydecisions, mainlybased on relaxing the
diagnostic criteria. A good illustration is ``sub-threshold'' depression. Perhaps
the most common of psychiatric presentations in primary care, subjects
with this diagnosis do not meet the diagnostic criteria for anydepressive
disorder in the classification systems and yet are associated with sufficient
distress to lead to a consultation and have an impact on the person's
functioning [24]. In other words, the boundaries between ``sub-threshold''
and ``subclinical'' are not drawn at the same place. It is unclear if these
disorders are quantitativelyor qualitativelydifferent from the supra-threshold
categories within the diagnostic systems, such as adjustment disorders,
dysthymia and depressive episodes. Perhaps there is a need to focus on
these conditions in primarycare settings in order to understand what
distinguishes them from normal mood fluctuations given the life experience
of people, and to appreciate what theymean for the reorganization of the
current categories within the diagnostic system such as, for example, the
broadening of the notion of dysthymia to include both acute, sub-acute and
chronic states.
How ``clinical significance'' ought to be defined has been the subject of
recent debate [25, 26], mainlybased on tightening the diagnostic criteria. It
has been suggested that the notion of ``harmful dysfunction'' be used to
define psychiatric disorders. A dysfunction is construed as a failure of an
internal mechanism to perform one of the functions for which it is naturally
designed, i.e. a function the mechanism and form of which is understood in
evolutionarytheoryterms. Harm, on the other hand, is understood as a
value that is ascribed to that dysfunction depending on individual circumstances
transforming the dysfunction into a disorder. For example, though a
dysfunction of the brain may exist that interferes with reading ability, it
would not be a disorder in preliterate societies. The approach acknowledges
the combining of a factual scientific notion with a value component in the
creation of a ``disorder''. It must be noted though that this is not a problem
unique to mental disorders. A male with azoospermia maynot receive a
diagnosis of primaryinfertility) and maybe considered to be healthyuntil
he is required to procreate. Hence, while the concept of ``dysfunction'' is a
useful construct, the descriptor of ``harmful'' is not.
Separation of Diagnosis from Functioning and Distress
Diagnosis of a disease or disorder should be uncoupled from disability.
Disease process and disabilityor distress are distinct phenomena and their