Typifications: The first step for clinical diagnosis in psychiatry

Abstract

Reigning views on psychiatric nosology regard as "too subjective " certain features of diagnosis which respected psychiatrists have reported and several empirical studies have confirmed. We describe two of these persistent "mysteries " of psychiatric nosology: rapid diagnoses and the praecox feeling. We then demystify these mysteries by explicating the workings of "typification " in the diagnostic process. The criteria of disorders which are provided by classification manuals, such as DSM-III, are shown to presuppose such typifications. Psychiatric typification, although a preconceptual skill, can be rendered fully scientific and objective. The Journal of Nervous and Mental Disease 175:65-77, 1987 In recent years we have witnessed a remarkable resurgence of interest in psychiatric diagnosis and classification. Only two decades ago psychiatrists were seriously discussing Menninger's recommendation that classification systems be abandoned altogether and that psychiatric diagnoses by replaced by formulations (Menninger, 1963). Now, following the successful reception of DSM-III (American Psychiatric Association, 1980) and in anticipation of preparations for DSM-111R and ICD-10, the methodological, theoretical, and practical issues involved in nosology are being probed and debated by psychiatrists of different persuasions and viewpoints (Freedman, 1984; Mc- Hugh and Slavney, 1983; Kendell, 1984; Klerman et at., 1984; Spitzer et at., 1983). Such a change reflects a growing concern for the scientific stature of psychiatry. In the 1950s and 1960s, criticisms of psychiatry as a science, such as those of Szasz (1961) and Laing (1968), were augmented by discouraging findings from investigations into the reliability of psychiatric diagnoses (Beck, 1962; Katz et at., 1968; Zubin, 1967, 1968). This crisis in psychiatry was worldwide. Thus a report to the World Health Organization in 1959 concluded that the attitude of psychiatrists toward conventional classificatory schemata had become "one of ambivalence, if not cynicism " (Stengel, 1959, p. 602), and that there was "almost general dissatisfaction with the state of psychiatri