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