Article

Commentaire du texte de Spitzer et Endicott 1978 : « Troubles médicaux et mentaux : proposition d’une définition et de critères », un article clé du débat sur la nosographie psychiatrique

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Résumé L’article de Spitzer et Endicott de 1978 fait partie des travaux préparatoires de la troisième édition du Manuel diagnostique et statistique de l’American Psychiatric Association (DSM-III). Cet article souligne la nécessité de définir le concept général de trouble mental pour mieux identifier les principes directeurs permettant de déterminer quels états devaient être inclus dans la classification, quels états devaient être exclus, et comment ces états devraient être délimités. L’article décrit une proposition de définition et les critères généraux pour délimiter un trouble médical. La première originalité de cet article est de proposer un retournement : le trouble mental sera délimité à partir d’une définition générale des troubles en médecine. La deuxième originalité est de proposer une position hybride : le trouble médical est défini à l’intersection d’une perspective physiologique (fondée sur les faits) et d’une perspective sociale reliée à la notion de handicap (notamment fondée sur les valeurs). Malgré les originalités des positions de Spitzer et Endicott et leurs intérêts persistant pour clarifier le débat actuel autour de la psychiatrie, la problématique majeure des critères proposés semble l’absence de tentative de relier ensemble le niveau du dysfonctionnement physiologique supposé dans l’organisme avec celui du niveau du handicap. Cette absence pourrait être liée au fait que les auteurs ne proposent pas une théorie de référence du fonctionnement cérébral ou mental. Nous analyserons donc comment le projet récent des Research Domain Criteria (RDoC) (pour « Critères pour des domaines de recherche ») peut répondre à la limite du projet initial de Spitzer et Endicott. Il sera souligné cependant que les modèles d’explication en médecine ne sont pas entièrement guidés par le savoir physiologique mais restent fondamentalement un choix pragmatique, et ainsi il sera proposé un niveau intermédiaire d’explication physiologique entre le niveau d’explication du fonctionnement cérébral tel que les neurosciences le constituent, et le niveau de pratique de l’action médicale psychiatrique.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Le trouble mental se manifeste par des changements qui affectent la pensée, l'humeur ou le comportement d'une personne, et qui lui causent de la détresse ou de la souffrance (2). Les troubles mentaux sont pour l'heure difficilement caractérisables comme une entité clinique parfaitement définie par son étiologie et sa physiopathologie (2), ce qui dénote un grand intérêt de la communauté scientifique en santé mentale de pouvoir identifier les facteurs de risques ou de vulnérabilité associés à l'émergence de ces troubles. ...
... Le trouble mental se manifeste par des changements qui affectent la pensée, l'humeur ou le comportement d'une personne, et qui lui causent de la détresse ou de la souffrance (2). Les troubles mentaux sont pour l'heure difficilement caractérisables comme une entité clinique parfaitement définie par son étiologie et sa physiopathologie (2), ce qui dénote un grand intérêt de la communauté scientifique en santé mentale de pouvoir identifier les facteurs de risques ou de vulnérabilité associés à l'émergence de ces troubles. Ainsi, des variables telles que: le faible niveau socio-économique, la consommation des drogues et l'exposition à des facteurs de stress sont étudiés (1). ...
Article
Full-text available
Introduction: Mental health is a state of equilibrium and well-being, any alteration of which leads to the appearance of a state of distress and/or mental disorder. Objective: The objective of this work was to study familial and environmental factors associated with mental disorders. Materials and methods: A cross-sectional study was conducted in the Psychiatry Department of the Point G University Hospital Center from April 1, 2016 to March 31, 2017 among outpatients with a psychiatric disorder in whom factors associated with psychiatric disorders were studied. Results: We included 288 patients. The median age was 33.0 years. The sex ratio was 1.88 in favor of males. Married patients accounted for 45.5%. First born uterine siblings accounted for 26.7%. Patients born of an inbreeding alliance accounted for 25.7%. Cases with a family history of a psychiatric disorder represented 59.0% and those who spent their childhood with their parents accounted for 64.2%. Cases of psychoactive substance use prior to the onset of the mental disorder accounted for 42.7%. The main psychosocial stress factors that preceded the onset of the mental disorder were grief (46.2%) and family conflict (22.6%). Psychotic disorders accounted for 77.8%. Conclusion: Our results show an association of mental disorders with family history of psychiatric disorder among patients followed in psychiatry. Further studies, such as genetic association may prove useful.
... Un symptô me est une manifestation clinique que le sujet é prouve et remarque, un signe est une manifestation dont le sujet peut faire l'expé rience, mais qui est é galement observable de l'exté rieur par d'autres [21]. Les discussions sur l'é laboration du DSM-III ont porté sur l'opé rationnalisation des critè res afin d'amé liorer la fiabilité de l'é valuation des symptô mes et signes psychiatriques et donc du diagnostic [25,29]. La liste des critè res du DSM est cependant devenue la ré fé rence pour les termes sé miologiques en psychiatrie, ré duisant ainsi et simplifiant le corpus des signes et des symptô mes é tudié s [4,26,27]. ...
... Malgré ces limitations et enjeux, le DSM reste pour autant un projet de recherche clinique avec une forte utilité pour harmoniser les pratiques diagnostiques en psychiatrie dont la pertinence ne doit pas être sous-estimé e puisqu'ayant permis de positionner le champ psychiatrique de plein droit dans le domaine mé dical [25]. ...
Article
Résumé Ce premier article, d’une série de deux, portant sur l’approche physiologique de la sémiologie psychiatrique, propose d’explorer la place de la physiologie et de la sémiologie clinique dans trois systèmes de classifications psychiatriques proposés actuellement en recherche : le Manuel diagnostique et statistique des troubles mentaux (DSM), le projet Research Domain Criteria (RDoC), et le projet Hierarchical Taxonomy of Psychopathology (HiTOP). Pour chacun de ces systèmes sera présenté le principe général, le lien avec la physiologie et la sémiologie, et les limitations principales. La physiologie et la clinique occupent une place et un rôle variables dans ces trois systèmes de classifications psychiatriques. Le DSM propose une liste de critères sémiologiques pertinents au regard de l’histoire clinique de la psychiatrie, mais le choix de ces critères et leur organisation restent guidés par des enjeux purement pratiques et nosographiques avec une place très restreinte de la physiologie. Le projet RDoC ne propose pas de liste de critères sémiologiques. Sa pertinence clinique et pratique est donc clairement questionnable, mais ce projet a le mérite de souligner l’importance de la physiologie dans l’approche médicale des troubles mentaux. Le projet HiTOP ne propose pas en soi de liste de critères sémiologiques, mais un cadre organisationnel hiérarchisé de la nosographie permettant d’associer un ensemble de signes et symptômes à des mécanismes psychopathologiques sous-jacents supposés. L’enjeu reste alors de raccrocher de manière cohérente ces mécanismes psychopathologiques à la physiopathologique des troubles mentaux dans une perspective intégrative des troubles mentaux.
... Les signes et les symptômes sont considé ré s comme des é lé ments indé pendants des autres signes et symptômes et du contexte mais dé pendants du substrat physiologique causal qui n'est pas forcé ment identifié [6]. Il s'agit du modè le sous-tendant la construction du DSM-III -comme cela a é té souligné par Robert Spitzer dans les travaux pré paratoires du DSM-III [26] -et trè s explicitement du projet HiTOP. ...
... De celle-ci, le patient sera amené , pour communiquer cette expé rience préconceptuelle et pré -linguistique, à construire un vé cu subjectif dont l'expression dans un processus dialogique avec autrui sera contrainte par la pré sence des « configurateurs » sociaux, culturels, familiaux et personnels (Fig. 2). Le modè le de Cambridge souligne la place de la sé miologie psychiatrique entre contrainte biologique et contrainte sociale ; il est donc d'une certaine façon au niveau sé miologique ce que Wakefield a proposé comme modè le hybride au niveau nosologique avec le Harmful Dysfunction Analysis [26,41,42]. De plus, le modè le de Cambridge souligne que le registre sé miologique en psychiatrie n'est pas une « description » simple et neutre de la ré alité mais une double interpré tation par le patient et par autrui (que ce soit un membre de l'entourage ou un mé decin) des manifestations mentales des perturbations du fonctionnement cé ré bral situé dans un environnement donné . ...
Article
Résumé Ce deuxième article, d’une série de deux portant sur l’approche physiologique de la sémiologie psychiatrique, propose d’explorer la place de la physiologie et de la sémiologie clinique suivant une approche de biologie systémique. Alors que l’approche de la sémiologie psychiatrique a été intiment liée à la construction des classifications contemporaines des troubles psychiatriques, deux approches tendant à se détacher des nosographies classiques ont été proposées : le projet psychosystems et le modèle de Cambridge. Pour chacune de ces approches seront présentés le principe général, le lien avec la physiologie et la sémiologie, et les limitations principales. Il sera proposé d’englober le projet psychosystems ainsi que le modèle de Cambridge suivant une perspective de biologie systémique qui pourrait permettre de réintégrer la sémiologie comme un niveau essentiel de l’approche des troubles mentaux, entre fait biologique et valeur sociale. Les enjeux de telles contraintes biologiques et sociales seront abordés suivant une approche épistémologique, notamment à travers les questions soulevées par la neurophénoménologie, afin de proposer une perspective de neurophysiologie clinique à la psychiatrie : c’est-à-dire d’une neurophysiologie qui prenne au sérieux le savoir clinique historiquement constitué de la psychiatrie, mais aussi d’une clinique qui ne dénigre pas les avancées en neurophysiologie sur la compréhension du fonctionnement cérébral.
... Le deuxième enjeu est celui du lien entre la sévérité des symptômes reliés à l'hypersomnolence évalués par des outils psychométriques valides et le retentissement sur le fonctionnement dans la vie quotidienne, dans le but de relier le niveau du dysfonctionnement cérébral supposé avec celui du handicap [50]. Cet enjeu implique de pouvoir évaluer un niveau de sévérité d'hypersomnolence qui soit prédictif du degré de handicap comportemental et cognitif en situation de vie quotidienne (Fig. 4). ...
Article
Résumé La définition de l’hypersomnolence est restée longtemps imprécise, à l’origine de difficultés dans sa reconnaissance, avec des chiffres de prévalence variables suivant les études. Cette extrême variabilité de prévalence s’explique en particulier par la nature et le nombre de dimensions symptomatiques étudiées. Cet article propose donc, après avoir clarifié et défini les usages des termes somnolence, hypersomnolence, trouble hypersomnolence et hypersomnie, de faire la revue de la littérature internationale et une description des outils psychométriques d’évaluation de la somnolence, de l’hypersomnolence et des hypersomnies chez l’adulte. Leur pertinence clinique ainsi que leurs principales propriétés psychométriques seront présentées. Par ailleurs, trois enjeux de mesure de l’hypersomnolence seront mis en avant à l’issue de cette revue, afin d’ouvrir les pistes des recherches futures. Le premier enjeu sera celui du lien entre la sévérité des symptômes reliés à l’hypersomnolence, évaluée par les outils psychométriques, et les corrélats neurophysiologiques ou neuropsychologiques reliés à la vigilance. Les avantages d’une approche dans la perspective du projet récent des Research Domain Criteria (RDoC) développé au National Institute for Mental Health (NIMH) seront présentés. Le deuxième enjeu sera celui du lien entre la sévérité des symptômes reliés à l’hypersomnolence évalués par des outils psychométriques valides et le retentissement sur le fonctionnement dans la vie quotidienne, en particulier le risque accidentel, dans le but de relier ensemble le niveau du dysfonctionnement cérébral supposé avec celui du niveau du handicap. Le troisième enjeu porté par les outils psychométriques de l’hypersomnolence sera de permettre l’établissement de seuils normatifs et de profils dimensionnels en fonction des pathologies. Ce travail de synthèse, mettant en avant la complexité de la mesure de l’hypersomnolence et ses limites, fixe les objectifs du développement futur de nouveaux outils psychométriques, avec des standards méthodologiques adaptés pour l’amélioration de la qualité des soins dans le champ de l’hypersomnolence, du diagnostic à la prise en charge, basés sur l’expérience vécue par le sujet, sur les mécanismes physiologiques sous-jacents et sur les répercussions fonctionnelles de l'hypersomnolence.
... Le DSM-III propose une définition des maladies, appliquée aux troubles psychiatriques, associant trois critères : une sémiologie spécifique, un mécanisme physiopathologique supposé (identifié ou non), un handicap ou une détresse. 6 Cette conception est celle suggérée par Jerome Wakefield, qui a proposé une théorie pour délimiter le normal et le pathologique, appelée l'« analyse de dysfonction préjudiciable » (harmful dysfunction analysis, ou HDA). 7,8 Ainsi, un trouble psychiatrique est considéré comme une modification du fonctionnement cérébral et mental associée à une répercussion sur les activités du sujet (un préjudice, notion rattachée à celle de « handicap »). ...
Article
Definition of somatoform disorders: somatic symptoms or mental symptoms? Somatoform disorders, which used to be considered as mental disorders, are frequent, especially in the context of non-psychiatric medical consultations. The absence of an identifiable organic cause for these disorders often leads clinicians to underestimates their harmful consequences or even challenge their validity as disease. However, they are real disorders that may have a major impact on the quality of life and functional outcomes of the subject and whose mechanisms can be targeted by therapeutic interventions. Although psychiatric classifications support a unitary approach (i.e. the "somatic symptom disorder and related disorders" of the American Psychiatric Association's DSM - Diagnostic and Statistical Manual of Mental Disorders - or the "bodily distress disorder" of the World Health Organization), each non-psychiatric specialty has described some "functional somatic syndromes", which are deemed more specific and less severe regarding psychiatric severity, and thus more often remain in the field of non-psychiatric specialties. In this article, we have presented the initial stage of any medical approach of suffering: a clarification of the issues involved in the delimitation of the normal and the pathological, and the organization of the different categories between them. These nosographic aspects are the condition of a rigorous approach in medicine, and of a relationship with the patient that is useful to understand and relieve his or her genuine suffering.
Thesis
Full-text available
Ce mémoire en philosophie de la médecine propose une analyse des critiques ciblant la thèse de Thomas Szasz selon laquelle la psychiatrie n'est pas une discipline médicale au sens strict. Ce mémoire poursuit trois objectifs de nature historique, épistémologique et philosophique. Sur le plan historique, l'examen des critiques vise à réévaluer l'importance de Szasz dans l'histoire récente de la psychiatrie en montrant son rôle clef dans l'histoire de la psychiatrie américaine et la place qu'il continue d'occuper en psychiatrie et en philosophie de la psychiatrie. Sur le plan épistémologique, cet examen cherche à identifier les réfutations possibles de sa conception des troubles mentaux afin d'éviter les conclusions sceptiques qui en découlent. Sur le plan philosophique, enfin, l'examen des critiques permet de clarifier la conception szaszienne des troubles qui, bien qu'elle soit souvent citée par les philosophes de la psychiatrie, est souvent mal comprise et résumée à grands traits. Approfondir l'articulation entre les différentes thèses de cette conception permettra de pallier cette lacune dans la littérature en philosophie de la santé et ouvrir de nouvelles pistes de recherche sur l'héritage de la pensée de Szasz au vingt-et-unième siècle. This thesis in philosophy of medicine offers a review of the criticisms targeting the idea that psychiatry is not a medical discipline in the strict sense put forward by Thomas Szasz. From a historical perspective, the review of the criticisms seeks to reevaluate Szasz's importance in recent history of psychiatry by showing the key role he played in the history of American psychiatry and the one he still occupies today in psychiatry and philosophy of psychiatry. From an epistemological perspective, this review seeks to identify arguments likely to refute the szaszian analysis of disorders to prevent the skeptical challenges that flow from it. From a philosophical perspective, the review of the criticisms helps clarify the szaszian analysis of disorders which, although it is often cited by philosophers of psychiatry, is often misunderstood, and grossly summarized. Deepening the links between the different theses of the szaszian analysis of disorders will help fill this gap in philosophy of health literature and open up new avenues of research on the legacy of Szasz's thought in the twenty-first century.
Article
Résumé La place de la physiologie dans le renouveau kraepelinien de la psychiatrie est centrale. En affirmant que « la psychiatrie est une spécialité médicale » le credo « néo-kraepelinien » soulignait déjà que l’attention du psychiatre devait « particulièrement se porter sur les aspects biologiques de la maladie mentale ». C’est ce qu’ont d’ailleurs fait les différentes définitions de trouble mental que l’on peut retrouver dans les évolutions du Manuel diagnostique et statistique des troubles mentaux (DSM). Cependant, le projet de fiabilité du DSM s’est révélé insuffisant pour la validité des diagnostics. Ainsi un projet concurrent a été développé : le projet des critères pour des domaines de recherche (RDoC), par l’Institut National de Santé Mentale (NIMH). La confrontation entre clinique et physiologique est donc inhérente à l’histoire des conceptions récentes de la psychiatrie, et a été particulièrement présente dans la structuration institutionnelle de la psychiatrie française entre médecin asilaire et médecin hospitalier.
Article
Full-text available
This article analyzes whether psychiatric disorders can be considered different from non-psychiatric disorders on a nosologic or semiologic point of view. The supposed difference between psychiatric and non-psychiatric disorders relates to the fact that the individuation of psychiatric disorders seems more complex than for non-psychiatric disorders. This individuation process can be related to nosologic and semiologic considerations. The first part of the article analyzes whether the ways of constructing classifications of psychiatric disorders are different than for non-psychiatric disorders. The ways of establishing the boundaries between the normal and the pathologic, and of classifying the signs and symptoms in different categories of disorder, are analyzed. Rather than highlighting the specificity of psychiatric disorders, nosologic investigation reveals conceptual notions that apply to the entire field of medicine when we seek to establish the boundaries between the normal and the pathologic and between different disorders. Psychiatry is thus very important in medicine because it exemplifies the inherent problem of the construction of cognitive schemes imposed on clinical and scientific medical information to delineate a classification of disorders and increase its comprehensibility and utility. The second part of this article assesses whether the clinical manifestations of psychiatric disorders (semiology) are specific to the point that they are entities that are different from non-psychiatric disorders. The attribution of clinical manifestations in the different classifications (Research Diagnostic Criteria, Diagnostic Statistic Manual, Research Domain Criteria) is analyzed. Then the two principal models on signs and symptoms, i.e. the latent variable model and the causal network model, are assessed. Unlike nosologic investigation, semiologic analysis is able to reveal specific psychiatric features in a patient. The challenge, therefore, is to better define and classify signs and symptoms in psychiatry based on a dual and mutually interactive biological and psychological perspective, and to incorporate semiologic psychiatry into an integrative, multilevel and multisystem brain and cognitive approach.
Article
Full-text available
The medical student may have difficulties using accurate and organized terms of psychiatric semiology in order to structure its medical reasoning. The lack of consensus on the organization of psychiatric semiology as well as psychiatric syndromes is one reason for these difficulties. This article proposes a minimum psychiatric semiology of adult that should be used by a medical student. In the first part, called analytic semiology, it will be proposed an organization of psychiatric signs and symptoms based wherever possible on the current data of neuroscience and international consensus. A summary of the different terms of psychiatric semiology that the medical student should known will be proposed with a summary table. In the second part, called syndromic semiology, it will be examined one by one the basic syndromes that psychiatric semiology can identify without prefiguring their psychiatric and non-psychiatric aetiology. The medical reasoning applies in psychiatry will be summarized in as a synthetic support card.
Article
Full-text available
Background Current diagnostic systems for mental disorders rely upon presenting signs and symptoms, with the result that current definitions do not adequately reflect relevant neurobiological and behavioral systems - impeding not only research on etiology and pathophysiology but also the development of new treatments. Discussion The National Institute of Mental Health began the Research Domain Criteria (RDoC) project in 2009 to develop a research classification system for mental disorders based upon dimensions of neurobiology and observable behavior. RDoC supports research to explicate fundamental biobehavioral dimensions that cut across current heterogeneous disorder categories. We summarize the rationale, status and long-term goals of RDoC, outline challenges in developing a research classification system (such as construct validity and a suitable process for updating the framework) and discuss seven distinct differences in conception and emphasis from current psychiatric nosologies. Summary Future diagnostic systems cannot reflect ongoing advances in genetics, neuroscience and cognitive science until a literature organized around these disciplines is available to inform the revision efforts. The goal of the RDoC project is to provide a framework for research to transform the approach to the nosology of mental disorders.
Article
Full-text available
Questions concerning both the ontology and epistemology of the “psychiatric object” (symptoms and signs) should be at the forefront of current concerns of psychiatry as a clinical neuroscience. We argue that neglect of these issues is a crucial source of the stagnation of psychiatric research. In honor of the centenary of Karl Jaspers’ book, General Psychopathology, we offer a critique of the contemporary “operationalist” epistemology, a critique that is consistent with Jaspers’ views. Symptoms and signs cannot be properly understood or identified apart from an appreciation of the nature of consciousness or subjectivity, which in turn cannot be treated as a collection of thing-like, mutually independent objects, accessible to context-free, “atheoretical” definitions or unproblematic forms of measurement (as is often assumed in structured interviewing). Adequate and faithful distinctions in the phenomenal or experiential realm are therefore a fundamental prerequisite for classification, treatment, and research. This requires a multidisciplinary approach, incorporating (among other things) insights provided by psychology, phenomenological philosophy, and the philosophy of mind.
Article
Full-text available
There is a glaring gap in the psychiatric literature concerning the nature of psychiatric symptoms and signs, and a corresponding lack of epistemological discussion of psycho-diagnostic interviewing. Contemporary clinical neuroscience heavily relies on the use of fully structured interviews that are historically rooted in logical positivism and behaviorism. These theoretical approaches marked decisively the so-called “operational revolution in psychiatry” leading to the creation of DSM-III. This paper attempts to examine the theoretical assumptions that underlie the use of a fully structured psychiatric interview. We address the ontological status of pathological experience, the notions of symptom, sign, prototype and Gestalt, and the necessary second-person processes which are involved in converting the patient’s experience (originally lived in the first-person perspective) into an “objective” (third person), actionable format, used for classification, treatment, and research. Our central thesis is that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects. We claim that in order to perform faithful distinctions in this particular domain, we need a more adequate approach, that is, an approach that is guided by phenomenologically informed considerations. Our theoretical discussion draws upon clinical examples derived from structured and semi-structured interviews. We conclude that fully structured interview is neither theoretically adequate nor practically valid in obtaining psycho-diagnostic information. Failure to address these basic issues may have contributed to the current state of malaise in the study of psychopathology.
Article
Full-text available
Patients with mental disorders show many biological abnormalities which distinguish them from normal volunteers; however, few of these have led to tests with clinical utility. Several reasons contribute to this delay: lack of a biological 'gold standard' definition of psychiatric illnesses; a profusion of statistically significant, but minimally differentiating, biological findings; 'approximate replications' of these findings in a way that neither confirms nor refutes them; and a focus on comparing prototypical patients to healthy controls which generates differentiations with limited clinical applicability. Overcoming these hurdles will require a new approach. Rather than seek biomedical tests that can 'diagnose' DSM-defined disorders, the field should focus on identifying biologically homogenous subtypes that cut across phenotypic diagnosis-thereby sidestepping the issue of a gold standard. To ensure clinical relevance and applicability, the field needs to focus on clinically meaningful differences between relevant clinical populations, rather than hypothesis-rejection versus normal controls. Validating these new biomarker-defined subtypes will require longitudinal studies with standardized measures which can be shared and compared across studies-thereby overcoming the problem of significance chasing and approximate replications. Such biological tests, and the subtypes they define, will provide a natural basis for a 'stratified psychiatry' that will improve clinical outcomes across conventional diagnostic boundaries.Molecular Psychiatry advance online publication, 7 August 2012; doi:10.1038/mp.2012.105.
Article
Full-text available
Although the concept of mental disorder is fundamental to theory and practice in the mental health field, no agreed on and adequate analysis of this concept currently exists. I argue that a disorder is a harmful dysfunction, wherein harmful is a value term based on social norms, and dysfunction is a scientific term referring to the failure of a mental mechanism to perform a natural function for which it was designed by evolution. Thus, the concept of disorder combines value and scientific components. Six other accounts of disorder are evaluated, including the skeptical antipsychiatric view, the value approach, disorder as whatever professionals treat, two scientific approaches (statistical deviance and biological disadvantage), and the operational definition of disorder as "unexpectable distress or disability" in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987). The harmful dysfunction analysis is shown to avoid the problems while preserving the insights of these other approaches.
Article
Full-text available
The author traces the history of the development of DSM-III within the larger context--intellectual, economic, scientific, and ideological--of the development of American psychiatry since World War II. Data were obtained through a literature review, investigation of archival material from the DSM-III task force and APA, and interviews with key participants. This research indicates that from the end of World War II until the mid-1970s, a broadly conceived biopsychosocial model, informed by psychoanalysis, sociological thinking, and biological knowledge, was the organizing model for American psychiatry. However, the biopsychosocial model did not clearly demarcate the mentally well from the mentally ill, and this failure led to a crisis in the legitimacy of psychiatry by the 1970s. The publication of DSM-III in 1980 represented an answer to this crisis, as the essential focus of psychiatric knowledge shifted from the clinically-based biopsychosocial model to a research-based medical model. The author concludes that while DSM-III, and the return to descriptive psychiatry which it inaugurated, has had positive consequences for the profession, at the same time it represents a significant narrowing of psychiatry's clinical gaze.
Article
Full-text available
What do we mean when we say that a mental condition is a medical disorder rather than a normal form of human suffering or a problem in living? The status of psychiatry as a medical discipline depends on a persuasive answer to this question. The answers tend to range from value accounts that see disorder as a sociopolitical concept, used for social control purposes, to scientific accounts that see the concept as strictly factual. I have proposed a hybrid account, the harmful dysfunction (HD) analysis, that incorporates both value and scientific components as essential elements of the medical concept of disorder, applying to both physical and mental conditions. According to the HD analysis, a condition is a disorder if it is negatively valued ("harmful") and it is in fact due to a failure of some internal mechanism to perform a function for which it was biologically designed (i.e., naturally selected). The implications of this analysis for the validity of symptom-based diagnostic criteria and for challenges in cross-cultural use of diagnostic criteria are explored, using a comparison of the application of DSM diagnostic criteria in the U.S. and Taiwan.
Article
Psychiatry as a discipline should no longer be grounded in the dualistic opposition between organic and mental disorders. This non-dualistic position refusing the partition along functional versus organic lines is in line with Jean Delay, and with Robert Spitzer who wanted to include in the definition of mental disorder discussed by the DSM-III task force the statement that “mental disorders are a subset of medical disorders”. However, it is interesting to note that Spitzer and colleagues ingeniously introduced the definition of “mental disorder” in the DSM-III in the following statement: “there is no satisfactory definition that specifies precise boundaries for the concept “mental disorder” (also true for such concepts as physical disorder and mental and physical health)”. Indeed, as for “mental disorders”, it is as difficult to define what they are as it is to define what constitutes a “physical disorder”. The problem is not the words “mental” or “organic” but the word “disorder”. In this line, Wakefield has proposed a useful “harmful dysfunction” analysis of mental disorder. They raise the issue of the dualistic opposition between organic and mental disorders, and situate the debate rather between the biological/physiological and the social. The paper provides a brief analysis of this shift on the question of what is a mental disorder, and demonstrates that a mental disorder is not more “organic” than any other medical condition. While establishing a dichotomy between organic and psychiatry is no longer intellectually tenable, the solution is not to reduce psychiatric and non-psychiatric disorders to the level of “organic disorders” but rather to continue to adopt both a critical and clinically pertinent approach to what constitutes a “disorder” in medicine.
Article
There was a need for a definition of mental disorder in the preparation of the Third Edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III). Decisions had to be made on a variety of issues that seemed to us to relate to the fundamental question of the boundaries of the concept of mental disorder. Without some definition of mental disorder, there would be no explicit guiding principles that would help to determine which conditions should be included in the nomenclature, which excluded, and how conditions included should be defined. This article describes a definition of and criteria for medical disorders. The definition of mental disorder proposed here is merely a subset of the definition of medical disorder, it contributes to the continuing debate concerning the appropriateness of the medical model as applied to psychiatric disturbance. The proposed definition is: “A medical disorder is a relatively distinct condition resulting from an organismic dysfunction which in its fully developed or extreme form is directly and intrinsically associated with distress, disability, or certain other types of disadvantage. The disadvantage may be of a physical, perceptual, sexual, or interpersonal nature. Implicitly there is a call for action on the part of the person who has the condition, the medical or its allied professions, and society. A mental disorder is a medical disorder whose manifestations are primarily signs or symptoms of a psychological (behavioral) nature, or if physical, can be understood only using psychological concepts”. Operational criteria are proposed to provide sufficient evidence for both an organismic dysfunction and justification for societal recognition of the appropriateness of the sick role. A condition must meet all criteria to be considered a medical disorder. Each of the criteria follows with explication of key concepts.
Chapter
Health and disease are cardinal concepts of the biomedical sciences and technologies. Though the models of health and disease may vary, these concepts play a defining role, indicating what should and what should not be the objects of medical concern. The concepts are ambiguous, operating both as explanatory and evaluatory notions. They describe states of affairs, factual conditions, while at the same time judging them to be good or bad. Health and disease are normative as well as descriptive. This dual role is core to their ambiguity and is the focus of this paper. In this paper I shall examine first the concept of health; second, the concept of disease; and third, I will draw some general conclusions concerning the interplay of evaluation and explanation in the concepts of health and disease.
Article
When a medical student is learning psychiatric, he has the opportunity to understand the patient as an individual that reacts to his illness according to his personal history, backgrounds, personality traits and socio-cultural context. Yet, the concepts of psychopathology that can be transmitted to him seem often unreachable and unusable to him. Health psychology would instead provide the medical student with an easily psychological knowledge base transferable in the rest of the medical field. This paper proposes a minimal knowledge of health psychology. In the first part, the representations of the disease, the major determinants of the development of health behaviors and coping strategies to illness, will be presented. In the second part, the mechanisms of implementation of these strategies and behaviors will be presented. A synthetic support card containing all the proposed concepts will be proposed.
Article
Diagnostic criteria for 14 psychiatric illnesses (and for secondary depression) along with the validating evidence for these diagnostic categories comes from workers outside our group as well as from those within; it consists of studies of both outpatients and inpatients, of family studies, and of follow-up studies. These criteria are the most efficient currently available; however, it is expected that the criteria be tested and not be considered a final, closed system. It is expected that the criteria will change as various illnesses are studied by different groups. Such criteria provide a framework for comparison of data gathered in different centers, and serve to promote communication between investigators.
Article
When a medical student is learning psychiatric semiology and nosology, he is sometimes like a stranger in a strange land. Heterogeneous use of references in the symptomatic description of the disorder and in the nosographic classifications is problematic from a pedagogical point of view because it can be confusing for the student. This article proposes a minimal nosography of mental disorders in adults for a medical student. Nosological diagnostic approach in psychiatry will be presented to then be adapted to the principal mental disorders in adults. Synthetic support cards with decision trees will be proposed.
Article
In 2008, the National Institute of Mental Health (NIMH) included in its new Strategic Plan the following aim: "Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures". The implementation of this aim was named the Research Domain Criteria project, or RDoC. RDoC is a programmatic initiative that will fund grants, contracts, early-phase trials, and similar activities for the purpose of generating studies to build a research literature that can inform future versions of psychiatric nosologies based upon neuroscience and behavioral science rather than descriptive phenomenology. RDoC departs markedly from the DSM and ICD processes, in which extensive workgroup meetings generate final and finely-honed sets of diagnoses that are modified in field tests only if problems with clinical utility arise. Rather, in keeping with its provenance as an experimental system, the RDoC provides a framework for conducting research in terms of fundamental circuit-based behavioral dimensions that cut across traditional diagnostic categories. While an important aim of the project is to validate particular dimensions as useful for eventual clinical work, an equally important goal is to provide information and experience about how to conceive and implement such an alternative approach to future diagnostic practices that can harness genetics and neuroscience in the service of more effective treatment and prevention. This paper summarizes the rationale for the RDoC project, its essential features, and potential methods of transitioning from DSM/ICD categories to dimensionally-oriented designs in research studies.
Article
A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC). The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria.
Article
Phenomenology is a word much abused in psychiatry. It has come to mean the objective description of the symptoms and signs of psychiatric illness, a synonym for clinical psychopathology as opposed to that other psychopathology which derives from psychoanalytic theory. Thus it is sometimes stated that the phenomenology of a condition is remarkably consistent although its psychopathology is varied. In truth, phenomenology is a technical term in psychiatry with a specific meaning quite distinct from and in a way opposite to that of objective psychopathology. The inappropriate use of the word is unfortunate not only for semantic reasons but also because there is a real danger that the concept to which it refers will be forgotten.
Article
The Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R) operationally defines disorder essentially as "statistically unexpectable distress or disability." This definition is an attempt to operationalize 2 basic principles: that a disorder is harmful and that a disorder is a dysfunction (i.e., an inability of some internal mechanism to perform its natural function). However, the definition fails to capture the idea of "dysfunction" and so fails to validly distinguish disorders from nondisorders, leading to invalidities in many of DSM-III-R's specific diagnostic criteria. These problems with validity are traced to DSM-III-R's strategies for increasing reliability.
Article
Spitzer and Endicott (1978) proposed an operational definition of mental disorder that is a more rigorous version of the brief definitions that appeared in the 3rd and revised 3rd editions of the Diagnostic and Statistical Manual of Mental Disorders. The heart of their proposal is a translation of the concept of dysfunction into operational terms. I argue that their definition fails to capture the concept of dysfunction and is subject to many counterexamples. I use my harmful dysfunction account of disorder (Wakefield, 1992a, 1992b), which interprets dysfunction in evolutionary terms, to explain both the appeal and the problems of Spitzer and Endicott's definition and to provide support for the harmful dysfunction view. I conclude that the failure of Spitzer and Endicott's sophisticated attempt at operationalization indicates that nonoperational definitions that use functional concepts must play a role in formulating valid diagnostic criteria.
Article
During the 19th century and early 20th century, American psychiatry shared many intellectual traditions and values with Great Britain and Europe. These include principles derived from the Enlightenment concerning the dignity of the individual and the value of careful observation. During the 20th century, however, American psychiatry began to diverge, initially due to a much stronger emphasis on psychoanalytic principles, particularly in comparison with Great Britain. By the 1960s and 1970s, studies such as the US-UK study and the International Pilot Study of Schizophrenia demonstrated that the psychodynamic emphasis had gone too far, leading to diagnostic imprecision and inadequate evaluation of traditional evaluations of signs and symptoms of psychopathology. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) was developed in this context, under the leadership of representatives from institutions that had retained the more traditional British-European approaches (eg, Washington University, Iowa). The goal of DSM-III was to create a comprehensive system for diagnosing and evaluating psychiatric patients that would be more reliable, more valid, and more consistent with international approaches. This goal was realized in many respects, but unfortunately it also had many unintended consequences. Although the original creators realized that DSM represented a "best effort" rather than a definitive "ground truth," DSM began to be given total authority in training programs and health care delivery systems. Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation that is targeted to the individual person's problems and social context and that is enriched by a good general knowledge of psychopathology. Students are taught to memorize DSM rather than to learn complexities from the great psychopathologists of the past. By 2005, the decline has become so severe that it could be referred to as "the death of phenomenology in the United States."
Définition du trouble mental
  • Demazeux
Demazeux S. Dé finition du trouble mental. EMC -Psychiatrie 2016;13:1-8.
La classification psychiatrique de demain?
  • S Demazeux
  • V Pidoux
  • Le
  • Rdoc
Demazeux S, Pidoux V. Le projet RDoC. La classification psychiatrique de demain? Med Sci 2015;31:792-6.
Les concepts de santé et de maladie
  • Engelhardt
Engelhardt H. Les concepts de santé et de maladie. In: Giroux E, Lemoine M, editors. Philosophie de la mé decine, Santé, Maladie, Pathologie. Paris: Vrin; 2012.
Soigner la souffrance psychique des enfants
  • B Falissard
Falissard B. Soigner la souffrance psychique des enfants.. Paris: Odile Jacob; 2018.
Philosophie de la mé decine
  • E Giroux
  • M Lemoine
Giroux E, Lemoine M. Philosophie de la mé decine, Santé, Maladie, Pathologie. Paris: Vrin; 2012.
Classification internationale des handicaps : dé ficiences, incapacité s et dé savantages. Un manuel de classification des consé quences des maladies
  • Inserm
Inserm. Classification internationale des handicaps : dé ficiences, incapacité s et dé savantages. Un manuel de classification des consé quences des maladies. Paris: CTNERHI; 1989.
Vion Dury J. From clinic to the ''foul and exciting field of life'': A psychiatric point of view on clinical physiology
  • J A Micoulaud-Franchi
  • G Dumas
  • C Quiles
Micoulaud-Franchi JA, Dumas G, Quiles C, Vion Dury J. From clinic to the ''foul and exciting field of life'': A psychiatric point of view on clinical physiology. Ann Med Psychol 2017;175:0-85.
Proposition d'une organiation minimale de la sé miologie psychiatrique pour l'é tudiant en mé decine
  • J A Micoulaud-Franchi
  • P A Geoffroy
  • A Amad
  • C Quiles
  • Le
Micoulaud-Franchi JA, Geoffroy PA, Amad A, Quiles C. Le jardinier et le botaniste. Proposition d'une organiation minimale de la sé miologie psychiatrique pour l'é tudiant en mé decine. Ann Med Psychol 2015;173:460-9.
Connaissance minimale en psychologie de la santé à l'usage de l'é tudiant en mé decine
  • J A Micoulaud-Franchi
  • C Lancon
  • L'inaccessible Presque
  • Touché
Micoulaud-Franchi JA, Lancon C. L'inaccessible presque touché. Connaissance minimale en psychologie de la santé à l'usage de l'é tudiant en mé decine. Ann Med Psychol 2015;173:377-83.
Action Capacité et Santé
  • Nordenfelt
Nordenfelt L. Action Capacité et Santé. In: Giroux E, Lemoine M, editors. Philosophie de la mé decine, Santé, Maladie, Pathologie. Paris: Vrin; 2012.
Le concept de trouble mental. À la frontière entre faits biologiques et valeurs sociales
  • Wakefield
Wakefield J. Le concept de trouble mental. À la frontiè re entre faits biologiques et valeurs sociales. In: Giroux E, Lemoine M, editors. Philosophie de la mé decine, santé, maladie, pathologie. Paris: Vrin; 2012. p. 127-76.
Le projet RDoC. La classification psychiatrique de demain?
  • Demazeux
From clinic to the “foul and exciting field of life”: A psychiatric point of view on clinical physiology
  • Micoulaud-Franchi