Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Classification and Clinical Psychopharmacology

DSM-III

In contradistinction to the ICD-9, and more in keeping with the goals of ICD-10, the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) of the American Psychiatric Association is oriented to fulfill the needs created by and necessary for psychopharmacologic progress. It is a multi-axial system of evaluation (Axis I - Clinical Syndromes, Axis II - Personality Disorders, Axis III - Physical Disorders, Axis IV - Psychosocial Stressors and Axis V - Highest Level of Adaptive Functioning) which is based on operationally defined criteria (see Appendix IV, Tables I, II, III and IV).

Preparation of the DSM-III by a Task Force on Nomenclature and Statistics of the American Psychiatric Association (APA) began in 1976. It was completed and approved at the 1979 Annual Meeting of the APA and was published in 1980.

In DSM-III each mental disorder is characterized by a clinically significant behavioral or psychological syndrome which is associated with either a painful symptom or impairment in one or more important areas of functioning. DSM-III diagnoses imply behavioral, psychological, and/or biological dysfunction. DSM-III is not a classification of patients but a classification of disorders. It deals with illnesses and not with disturbances in the relationship between the person and society.

The origin of the DSM-III can be traced to DSM-I, published in 1952. DSM-I, the first edition of the Manual, was firmly rooted in Adolf Meyer's (1915, 1934) psychobiological view that mental disorders represent reactions of the personality to psychological, social, and biological factors. By the time the second edition, DSM-II, went into effect in 1968, the classification was brought in line with the 8th edition of the International Classification of Diseases of the WHO. The term "reaction," was not used any longer and the terms used by and large did not imply a particular theoretical framework for understanding nonorganic mental disorders. Subsequently, however, there was a divergence between the ICD and the DSM. Thus, for example, the traditional separation between psychosis and neurosis present in ICD-9 was eliminated, and both terms were replaced by the single term "disorder" in the DSM-III. In the DSM-III disorders traditionally subsumed under functional psychoses are grouped under four major headings: schizophrenic disorders, paranoid disorders, psychotic disorders not elsewhere classified and affective disorders. Five types of schizophrenic disorders are differentiated, i.e., disorganized, catatonic, paranoid, undifferentiated and residual; within paranoid disorders, four diagnoses, i.e., paranoia, shared paranoid disorder, acute paranoid disorder and atypical paranoid disorder; within psychotic disorders not elsewhere classified, brief reactive psychosis, schizoaffective disorder and atypical psychosis; and within affective disorders, bipolar disorders, major depression, cyclothymic disorder and atypical depression. Furthermore, in the DSM-III, consideration is given to the course of schizophrenic disorder, and each of the different types are identified as subchronic, chronic, subchronic with acute exacerbation, chronic with acute exacerbation and in remission; and to the "subclassification" of major depressive episode, in terms of "in remission," "with psychotic (mood-congruent or mood-incongruent) features," "with melancholia" and "without melancholia" (see Appendix IV, Table I).

There is little doubt that the DSM-III represents a major step toward reintegrating psychiatry with other medical disciplines. Canadian critics of this conceptual approach to diagnosis, however, contend that the quest for reliability, operational rigor, and completeness has overshadowed concern for validity, clinical flavor, and psychodynamic understanding. The same critics argue that dismissal of psychodynamic formulations, and neglect of humanistic approaches to complex and ambiguous realities reflect an arid view of psychiatric diagnosis. According to one of these critics "DSM-III is like a bikini--it shows you everything but the essentials." DSM-III is "a gigantic defense against diagnostic problems in psychiatry.” The same Canadian critics disagree with the elimination of terms, such as “psychotic,” “neurotic” and “psychopathic” and the abandonment of the exogenous/endogenous and neurotic/psychotic polarities. They argue that despite the problematic nature of these dichotomies, the distinctions are important and are not adequately represented in DMS-III.

The diagnoses of paranoid disorders and schizophreiform disorders of DSM-III were faulted for their almost total neglect of the European literature and consequently for relying heavily on the duration criterion in differential diagnosis (Engels, Ghadirian and Dongier, 1985). In spite of the critical comments, however, the Canadian survey revealed that over 90 percent of the 99 respondents (university based psychiatrists) used Axis I diagnosis in their undergraduate (94%) and postgraduate (99%) teaching and research (98%). Thus, the results of the survey corroborate the main findings of a former Canadian survey (with members of the Canadian Psychiatric Association), carried out by Junek (1983) who reported that the majority of his respondents ranked DSM-III as the future diagnostic system of choice.

June 13, 2024