Classification ofpsychiatric disability
The blurring of the boundaries between health and illness in psychiatry has been recognized for centuries. Recently, as part of the general questioning of traditional assumptions, this problem has again become a focus of critical attention.
The concept of an illness or a disease is an essential element of traditional medicine. The ultimate goal of diagnostic procedures is the identification of a symptom complex with a predictable course and outcome which can be correlated with demonstrable pathology and rationally treated. When does mental suffering become an illness or a disease? Why do we feel obliged to label the complexities of human behaviour which confront us with the diagnostic terms in current use? Many have disputed the need for them. Prinzhorn (1932) had little regard for disease entities in psychiatry, preferring the personal formulation to the abstract category. 'Diagnosis', he wrote, 'is concerned with the constitution, the character and the conflicts of the patient; the prognosis with the latent capacities of the patient and the therapist: the "neurosis" as a disease, passes practically into the background'. Adolf Meyer, who was criticized for being heuristically sterile, took a similar view although he was certainly not opposed to broad diagnostic groupings. Are, then, diagnoses in general medicine real and in psychiatry fictitious? Is treatment in general medicine concerned with the correction of a demonstrable lesion and in psychiatry with social interaction? Are we, as Szasz (1972) asserts, shamefully labelling our patients with mythological tags?
Disease entity and personality reaction
What are the fundamentals? In any illness there are at least two groups of symptoms (and signs) to be disentangled: those related to a defined disease and those which reflect the patient's unique personal response or reaction to stress. The first is abstract in the sense that it is less connected with the personality than with the clinical features of an independent diagnostic group. On this account it can be handled more easily in a way which approximates to practice in general medicine. The second group of symptoms is personality linked and represents the patient's unique response to a specific constellation of events. The formulation becomes more personal; the therapeutics may be a form of social interaction, as Szasz (1972) suggests, provided social interaction is defined comprehensively to include a range of therapeutic procedures and the theories which underlie them. Between these two diagnostic positions lies a continuous series of variables. While the emphasis in general medicine is vastly different, the basic position is not dissimilar. The physician applies his medical knowledge to the diagnosis and treatment of a disease entity and his psychological insight to the understanding and management of his patient as a person (Steele 1955). Mental illness or disease, personality reaction or response, mental suffering or abnormal behaviour, are all properly within the psychiatrist's specialized field. There are no mythological tags. Equally there is no cause for complacency.
Current knowledge in psychiatry is limited and this seriously restricts the elaboration of a satisfactory classification system. Diagnostic groupings must of necessity be broad. Inevitably within each group there are wide variations in symptom patterns and their time relationships. Similarly, in the course of each person's illness there may be substantial alteration in symptom emphasis. Nevertheless, there are some reasonably well defined clinical entities which justify diagnostic labelling in the abstract - a procedure which facilitates communication and comparison in clinical work and research. An essential requirement of such diagnostic labelling in psychiatry's provisional state is that the data of each case should be regularly revalued in the light of the total clinical context, bearing in mind that at any time the clinical picture is a cross-sectional view of an ongoing process of interaction between personality and circumstance.