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Tuesday, 28.03.2017

Bertalan Pethö, Thomas A. Ban: DCR Budapest-Nashville

Bertalan Pethö, Thomas A. Ban in collaboration with Andras Kelemen, Gabor Ungvari, Istvan Karczag, Istvan Bitter, Judith Tolna (Semmelweis Medical University, Budapest), Marek Jarema, Francois Ferrero, Eugenio Aguglia, Giovanni Luca Zuria, Olaf K. Fjetland (Vanderbilt University, Nashville): DCR Budapest-Nashville in the Diagnosis and Classification of Functional Psychoses. Karger, Basel, 1988; Psychopathology 1988; 21 (4-5): 152-240. 

Based on Pethö B, Ban TA, Kelemen A, Ungvari G, Karczag I, Bitter I, Tolna J: Kutatasi Diagnosztikai Kriteriumok functionalis psychosisok korismeresehez. Ideggyogyaszati Szemle 1984; 37: 102-31. (In Hungarian).

INFORMATION ON CONTENT: Recognition of the inadequacy of diagnostic categories in Kraepelin’s classification for psychiatric research led to the development of the KDK Budapest and its English adaptation, the DCR (Diagnostic Criteria for Research) Budapest-Nashville. The DCR is based on a linear disease model; a socio-medical concept of psychosis; and psychopathology-based diagnoses. In the DCR, an attempt was made to synthesize the experience of different psychiatric schools (German, Scandinavian, French, American, English), and for the identification of pathognomonic and holistic characteristics of psychiatric illness. Karl Leonhard’s classification of endogenous psychoses, based on clinical syndromes described by Carl Wernicke and Karl Kleist, was chosen as the framework, because it is a more detailed and subtle classification than Kraepelin’s or Bleuler’s. However, the DCR is not a replica of Leonhard’s classification even with regard to endogenous psychoses. It differs from Leonhard’s system by its emphasis on the characteristics of the form (Gestalt) and overall clinical picture, and by its shift of emphasis from the end state to the first or index psychosis. The central component of the DCR is its Diagnostic Assessment Scale (DAS), a diagnostic decision tree that consists 524 variables, organized into 179 diagnostic decision clusters yielding to 213 (including tentative, provisional, working, final, atypical and undifferentiated) diagnoses. It separates “minor psychiatric disorders”, from the “psychoses”, and “symptomatic-organic psychoses” and “mental retardation with psychoses” from the “functional psychoses,” before entering into differentiation within the “functional psychoses”. Thus, in the DCR “functional psychoses” are divided into “reactive” (“psychogenic”) and “endogenous” with ”delusional development” in between; “endogenous psychoses” into “affective” (“phasic”) and “schizophrenic” with “cycloid psychoses” in between; “affective psychoses” into “bipolar” and “unipolar”, and “schizophrenic psychoses” into “nonsystematic” and “systematic.” The DCR includes a glossary of all DAS items in which definitions are primarily based on John (Jan) Hoenig and Marion Hamilton’s translation from German into English, the 7th edition of Karl Jaspers’ General Psychopathology, and on William Guy and Thomas A. Ban’s translation from German into English, the 3rd edition of the AMDP (Association for Methodology and Documentation in Psychiatry) System Manual.. It also includes definition of DCR diagnoses, a display of DCR’s diagnostic process and a list of 72 original references. 


POSTING CO-AUTHOR’S STATEMENT: The KDK Budapest was developed by a team of Hungarian psychiatrists in the Department of Psychiatry, Semmelweis University involved in research in “endogenous psychoses” under the leadership of Bertalan Pethö. Instrumental to its development was Pethö’s adoption of Jasper’s contention that in nosology one is guided by the “idea of disease” in order to isolate “relative disease entities” that would provide “useful orientation points” for research; his definition of “psychosis” as a nonspecific syndrome characterized by lack of insight and sufficient severity to disrupt everyday functioning with collapse of customary social life that may call for psychiatric hospitalization; and his findings in a six-year follow-up study that supplementation of psychopathological and personality variables with social adjustment variables lowered predictive validity of diagnoses made at the time of the index psychoses. The DCR Budapest-Nashville, the English adaptation of the Hungarian KDK with some minor modifications, was developed in collaboration between Pethö’s team in Budapest, Hungary, and Ban’s team at Vanderbilt University, in Nashville, Tennessee, USA. Ban’s research was focused on resolving the pharmacological heterogeneity of “consensus-based diagnoses”. He considered identification of treatment responsive subpopulations within consensus-based diagnoses, a “prerequisite,” for breaking the impasse in neuropsychopharmacology research, and in the pharmacotherapy of psychiatric illness with psychotropic drugs. His observations and findings with Leonhard’s classification and the German-AMDP System indicated that pursuing research in psychiatric nosology and psychopathology might yield to pharmacologically sufficiently homogeneous populations to meet clinical and research needs. At the time of its publication in the late 1980s, it appeared that DCR diagnoses provide pharmacologically more homogeneous populations than consensus-based diagnoses. Today, almost three decades later the concept of “functional psychoses” is no longer in the vocabulary of psychiatry, but DCR diagnoses still seem to provide pharmacologically more homogeneous populations than consensus-based diagnoses.

From the 12 co-authors of the DCR, four were to become professors and chairs of university departments in psychiatry: Eugenio Agulia in Trieste, Italy; Istvan Bitter in Budapest, Hungary; Francois Ferrero in Geneva, Switzerland; and Marek Jarema in Warsaw, Poland.

Thomas A. Ban
January 9, 2014