Academic journal article East Asian Archives of Psychiatry

The Gradation of Psychopathology: For Better or for Worse

Academic journal article East Asian Archives of Psychiatry

The Gradation of Psychopathology: For Better or for Worse

Article excerpt


Lately, there has been a growing interest in the dimensional concept of psychiatric diagnosis, along with a tendency to replace the categorical concept by the dimensional one. Before favouring either of these concepts, more light should be shed on the specifics of the categorical and dimensional approach to diagnosing mental disorders. A comparison of the main features of the categorical and dimensional concepts of psychiatric diagnosis has been made. The strengths of the categorical concept are weaknesses of the dimensional one, and vice versa. The clinical utility of the categorical concept over-rates the dimensional model, whereas the dimensional concept provides more information about the respective individual. Usefulness of the categorical concept is the major reason why it is going to stay as a cornerstone of psychiatric diagnostics.

Key words: Classification; Diagnosis; Psychopathology


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A categorical system assigns mental syndromes to categories. On the other hand, a dimensional system classifies clinical presentations based on quantification of attributes rather than assignment to categories.1

The notion of psychopathological phenomena as phenomena that are given on a continuum - from healthy states to slight deviations from the 'normal' and from moderate to severe pathological disturbances - has been around for 100 years.2 Yet mental disorders have been presented as discrete and distinct entities, meaning as categories, in the DSM-III and DSM-IV of the American Psychiatric Association.3,4 The DSM constitutes the first time that psychiatric syndromes were operationally defined in an attempt to enhance reliability and validity of psychiatric diagnoses.

Several circumstances paved the way for the construction of the DSM-III and DSM-IV. The psychiatric community was taken by surprise when Kendell et al5 published the results of the examination of psychiatric diagnostic practice on both sides of the Atlantic in 1971. After interviewing the same patients, psychiatrists in New York City diagnosed the patients' mental problems as indicative of schizophrenic disorder twice as frequently as their colleagues in London, who said that the patients diagnosed as having schizophrenic disorder by the American psychiatrists actually had depressive disorder, personality disorder, and neurotic disorder. These findings rang an alarm. The question was raised: can we trust psychiatrists? What is psychiatric diagnosis all about? Thus, the task of making psychiatric diagnosis more reliable, preferably as reliable as is the diagnosis in somatic medicine, emerged as a matter of priority. The more so as the courts and health insurance companies also exercised pressure on psychiatrists to do their best to increase the reliability of the diagnosis of mental disorders. The categorical presentation of psychiatric disorders was regarded as the right way to achieve this goal.6 Moreover, antipsychiatrists in the 1970s argued that psychiatrists had labelled social dissenters as mentally ill to discredit them. Hence, a diagnosis of generic mental disorder that would impede labelling of political dissidents as mentally disordered, and thereby help psychiatry to reaffirm or regain the status of a medical discipline, was badly needed. The DSM-III and DSM-IV operational definition of generic mental disorder was an answer to this need.

However, the disease entity assumption that conceptually makes the foundation of the DSM-III and DSM-IV has been increasingly questioned.7-10 At the same time, the idea of the dimensionality of psychopathological phenomena has been promoted by an ever greater number of psychiatrists and psychologists.11-14 Thus, in preparation for the DSM-V that is due to be published in 2013, the consideration of "the advantages and disadvantages of basing part or all of DSM-V on dimensions rather than categories" was highly recommended. …

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