Fra DSM-I til DSM-V Psykopatologibegrebet 1952 - 2007

1. Gretty Mirdal - Institut for Psykologi Fra DSM-I til DSM-VPsykopatologibegrebet 1952 - 2007 Gretty Mirdal Institut for Psykologi

2. Gretty Mirdal - Institut for Psykologi Klinisk Psykologi � anno 1965 �S�ledes som den praktiseres i Danmark� sagde Lise �stergaard i en forel�sning i 1965, �bygger den kliniske psykiatri sin sygdomsl�re p� et oprindeligt medicinsk sygdomsbegreb med udgangspunkt i Kraeplins klassifikation af objektive iagttagelige symptomer. P� den anden side�, fortsatte hun, �er den psykiatriske diagnostik ogs� pr�get af en anden tradition, som har sin oprindelse i Freuds arbejder. Denne sygdomsopfattelse f�lger en psyko-dynamisk og udviklingspsykologisk model. Det er en kunst at finde balancen�. Det vidste hun alt om, hun var nemlig lige ankommet til universitetet efter mange �r i psykiatrien.

3. Gretty Mirdal - Institut for Psykologi Klinisk psykologi i Danmark � anno 1965 I 40 �r er faget klinisk psykologi blevet undervist p� baggrund af l�reb�ger baseret p� de forskellige udgaver af DSM. �r efter �r er psykologistuderende p� dette universitet g�et op til eksamen efter dette system, selv om den danske kliniske psykologi aldrig har taget det til sig. �

4. Gretty Mirdal - Institut for Psykologi Danske psykologer og DSM Alligevel har DSM, p� trods af vores modvilje, haft en meget stor indflydelse, ikke kun fordi den bliver brugt i de allerfleste engelsksprogede l�reb�ger, men ogs� fordi denne klassifikation er grundlaget for mange af de m�leinstrumenter vi bruger i forskning, og danner basis for ca. 3/4 dele af de tidsskrifter vi l�ser og publicerer i. Hvorom alting er, m� man sige, at de forskellige udgaver af DSM b�de har pr�get opfattelsen af, og har afspejlet den vestlige verdens syn p� psykopatologi i den sidste halvdel af vort �rhundrede. Jeg har derfor valgt at tale om forandringer�ne i opfattelsen af psykisk sygdom ved at f�lge udviklingen af et bestemt begreb, nemlig psykosomatik i de successive udgaver af DSM, fra 1952 til 2007 + den nye revision, der er p� vej. �

5. Gretty Mirdal - Institut for Psykologi Kritik af klassifikationer: Enkelte citater The mind is not �an organ of the body therefore it cannot be diseased� and furthermore argued that any benefits from diagnosis were offset by the dehumanising aspects of disease classification and treatment� (Szasz, 1970). Szasz (1974) 'Strictly speaking disease or illness can affect only the body; hence there can be no mental illness...Minds can be 'sick' only in the sense that jokes are 'sick' or economies are 'sick'' (p. 267) Laing (e.g. 1960) Cooper (1970): i) the symptoms of 'mental illness' could be understood in terms of the life history, sets of experiences, family circumstances of the person who ended up diagnosed as in 'Sanity Madness and the Family' (Laing 1970). ii) The symptoms were a way of trying to cope with and transcend the circumstances which gave rise to them - a 'breaking through' rather than a 'breaking down'.

6. Gretty Mirdal - Institut for Psykologi DSM-I (1952) DSM-I bestod af 60 kategorier, der faldt i to hovedomr�der: - sygdomme med fysiske �rsager og - sygdomme med psykiske �rsager, (eller i hvert fald med ikke-kendte fysiske �rsager). De sidste, alts� de psykisk betingede, er igen inddelt i psykotiske forstyrrelser, psykosomatiske forstyrrelser, psykoneurotiske forstyrrelser, �personality-� eller �character disorders� (m.a.o. antisociale og sexuelle forstyrrelser) og s� en sidste kategori ben�vnt �transient personality disorders�, (i det store og hele det vi i dag ville kalde stress-reaktioner).

7. Gretty Mirdal - Institut for Psykologi DSM-II (1968) Mental Retardation (Mental retardation refers to subnormal intellectual functioning which arises durtag develop-ment. The subdiagnoses - borderline, mild. moderate, severe. and profound-are deflned in terms of IQ ranges. Diagnoses further specify the apparent etlologlcal factors invol-ved.) Organic Braln Syndromes (These reflect Impairment of braln-tissue function. Psychoses A.�� Psychoses assoclated with organic braln syndromes l . senile and presenlle dementia 2. alcoholic psychoses 3. psychoses assoclated with intracranial infectlon 4. psychoses assoclated with other cerebral condltlons (e.g., arteriosclerosis. epilepsy, tumor) 5. psychoses associated with other physlcal conditlons (e.g., endocrine. metabollc. or nutritlonal disorder; infectlon or polson-ing; during childblrth) B.�� Nonpsychotic organic braln syndromes B. Psvchoses Not Attributed to Physlcal Condltlons Listed Prevtously C.��Paranoid states D.�Other psychoses

8. Gretty Mirdal - Institut for Psykologi DSM-II forts. Personality disorders (long-standing rnaladaptlve behavlor patterns wlthout the speciflic symptoms and usually without the disablllty of neuroses or psychoses.) 1. paranoid personality 2. cyclothymlc personality (characterized by alternating moods of depression and elatlon) 3. schizoid personality 4. explosive personality 5. obsessive-compulsive personality 6. hysterical personality 7. asthenic personality 8. antisocial personality 9. passive-aggressive personality 10. inadequate personality 11. other specifled types (e.g., miniature personality) 12. other unspecified types B. Sexual deviations

9. Gretty Mirdal - Institut for Psykologi DSM-II forts. Neuroses (In contrast to the psychoses. there is neither gross distortion of external reallty, nor major personality disorganizatlon. Anxlety and the symptomatic evldence of excessive defensi�ve activitles �re the prime characteristics). A.�� Anxety neurosis B.�� Hysterical neurosis Type:�� l. converslon 2. dissociatlve C.�� Phobic neurosis D.�� Obsessive compulsive neurosis E.�� Depressive neurosis F.�� Neurasthenic neurosis G.�� Depersonalization n eurosis H.�� Hypochondriacal neurosis J.�� Other neuroses

10. Gretty Mirdal - Institut for Psykologi DSM-II forts. Psychophysiological Disorders (Included here are physlcal diseases of presumably psychogenic origln. often called psychoso-matic diseases. They are grouped in terms of the physiological system or organs involved; thus. psychophyslologlcal skin disorder. cardiovascular disorder, gastrointestlnal disorder, etc.) Special Symptoms (Here are included symptoms not elsewhere classlfied which do not result from other organic or mental disorders. Illustrations would include speech disturbances, learning disabillities. sleep disturbances, among others.) Transient Situational Disturbances (These are acute reactions which occur in otherwise well-functloning indlvlduals in the face of overwhelming envlronmental stress. They �re expected to recede as the stress reduces. They �re grouped by the patlent's developmental level; thus. the types include adjust-ment reaction of infancy, childhood. adolescence, adult life, and late life.)

11. Gretty Mirdal - Institut for Psykologi Forskel mellem II og III There were two major consequences of the change from DSM-II to DSM-III: (1) a marked reduction in the diagnosis of schizophrenia and a corresponding increase in the diagnosis of affective disorders, and (2) a marked increase in the diagnosis of personality disorders.  Loranger, 1990

12. Gretty Mirdal - Institut for Psykologi DSM-III, 1980. Her er antallet af mentale forstyrrelser udvidet voldsomt ud fra devisen jo mindre enheder, jo st�rre eksakthed. Der er 60 kategorier i DSM-I; 145 i DSM-II og 230 i DSM-III. Dette resulterer i et stort antal af meget sm� klasser af diagnoser, der hver udg�r en s�rskilt sygdom. Beskrivelserne bliver mere eksakte, mere og mere reliable men er de klinisk meningsfulde? Vi ber�rer her det st�rste problem i klinisk forskning, og kilden til splittelsen mellem den kliniske og den akademiske psykologi. N�r man simplificerer og inddeler virkeligheden i overkommelige st�rrelser, der egner sig til en systematisk forskning, mister f�nomenerne ofte deres mening.

13. Gretty Mirdal - Institut for Psykologi En bivirkning man stadig d�jer med: Co-morbiditet N�gleordet igennem DSMs revisioner er reliabilitet. Sprogbrugen siger meget. Det er ikke l�ngere kliniske billeder, vi har med at g�re, men kriterier. Nu specificeres helt eksakt de adf�rdsformer og antal symptomer, som m� v�re tilstede for at udl�se en diagnose. Al subjektiv vurdering er s� vidt muligt afskaffet, i en grad, hvor det analoge er erstattet af det digitale. Der er ikke l�ngere tale om gradsforskelle i patologi, men om man har en bestemt sygdom, ja eller nej. Og har man b�de angst og depression, hvad man ofte har, er der tale om co-morbiditet, hvorefter man fejler ikke �n men to ting.

14. Gretty Mirdal - Institut for Psykologi DSM-IV � 1996 (revideret i 2000)

15. Gretty Mirdal - Institut for Psykologi DSM-IV � Hvad er nyt? A descriptive text accompanies each disorder. The text of DSM-IV systematically describes each disorder under the following headings: "Diagnostic Features"; "Subtypes and/or Specifiers"; "Recording Procedures"; "Associated Features and Disorders"; "Specific Culture, Age, and Gender Features"; "Prevalence"; "Course"; "Familial Pattern"; and "Differential Diagnosis."

16. Gretty Mirdal - Institut for Psykologi En fornyelse: axis-systemet The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability: Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders: e.g., depression, anxiety disorders, bipolar disorder, ADHD, and schizophrenia. Axis II: underlying pervasive or personality conditions, as well as mental retardation:e.g. borderline personality disorder, schizotypal personality disorder, antisocial personality disorder, narcissistic personality disorder, and mild mental retardation. Axis III: Acute medical conditions and physical disorders. Axis IV: psychosocial and environmental factors contributing to the disorder Axis V: Global Assessment of Functioning or Children�s Global Assessment Scale for children under the age of 18. (on a scale from 100 to 0)

17. Gretty Mirdal - Institut for Psykologi �Psykosomatiske sygdomme� som eksempel I DSM-I var der en sygdomskategori ben�vnt som Psychosomatic Disorders. Den forsvinder i de f�lgende udgaver: PSYCHOPHYSIOIOGIC AUTONOMIC AND VISCERAL DISORDERS ("PSYCHOSOMATIC DISORDERS") (1952) Structural change following chronic, exagger-ated physiological expression of emotion; the emotion is repressed and discharged through viscera, A Skin reaction, such as atopic dermatitis. B� Musculoskeletal reaction, as tension head-aches. C Respiratory reaction, as hiccoughs. D Cardiovascular reaction, as hypertension. E� Hemic and lymphatic reaction, as diffuse changes in blood systems. F� Gastrointestinal reaction, as chronic gas�tritis. G Genitourinary reaction, as menstrual dis-turbances. H Endocrine reaction, as obesity. l�� Nervous system reaction, as general fa-tigue. J� Reaction of organs of special sense, as physical changes in retinae or eardrums.

18. Gretty Mirdal - Institut for Psykologi Skjulte antagelser Den teoretiske model bag ved denne klassifikation er inspireret af psykoanalytiske teorier. If�lge denne inddeling findes der fysiske sygdomme, der er psykisk betinget (psykosomatiske sygdomme) og s� findes der sygdomme, der ikke har noget med det psykiske at g�re. Denne primitive indstilling �ndres i DSM-III og IV. Det er m�ske den st�rste fordel ved denne revision. Ikke godt men bedre end f�r!

19. Gretty Mirdal - Institut for Psykologi Psykosomatik i DSM-IV I DSM-IV fra 1990, er �medicinsk uforklarlige sygdomme� kategoriseret under Somatoforme forstyrrelser, med f�lgende undergrupper: Somatization Disorder Undifferentiated Somatoform Disorder Conversion Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Somatoform Disorder not otherwise specified

20. Gretty Mirdal - Institut for Psykologi Psychological factors affecting medical conditionsEn ny m�de at betragte psykosomatik p� Listen over de psykologiske faktorer, som menes at kunne p�virke helbredet best�r af: psykiske forstyrrelser; psykologiske symptomer; personlighedstr�k og coping-stil; uhensigtsm�ssig helbredsm�ssig adf�rd; livsstil; stress-relateret fysiologiske reaktioner; og uspecificeret �andet�.� Denne liste er en bio-psyko-social p�rev�lling.� Men fordelen er, at man nu begynder at se p� alle sygdomme (fysiske s�vel som psykiske) som v�rende p�virkelige af psykiske forhold.

21. Gretty Mirdal - Institut for Psykologi En kogebog? Disorders Usually First Diagnosed in Infancy, Childhood,�or�AdolescenceDelirium, Dementia, and Amnestic and Other Cognitive�DisordersMental Disorders Due to a General Medical ConditionSubstance-Related DisordersSchizophrenia and Other Psychotic DisordersMood DisordersAnxiety DisordersSomatoform DisordersFactitious DisordersDissociative DisordersSexual and Gender Identity DisordersEating DisordersSleep DisordersImpulse-Control Disorders Not Elsewhere ClassifiedAdjustment DisordersPersonality DisordersOther Conditions That May Be a Focus of Clinical AttentionAdditional Codes

22. Gretty Mirdal - Institut for Psykologi V�sentlige kritikpunkter: gyldighed Despite historical and recent assumptions to the contrary, there is little evidence that most currently recognized mental disorders are separated by natural boundaries. Researchers are increasingly assuming that variation in symptoms is continuous (ja/nej kontra kontinuerlige dimensioner) It is important to distinguish between validity and utility in considering psychiatric diagnoses. Diagnostic categories defined by their syndromes should be regarded as valid only if they have been shown to be discrete entities with natural boundaries that separate them from other disorders. Although most diagnostic concepts have not been shown to be valid in this sense, many possess high utility by virtue of the information about outcome, treatment response, and etiology that they convey. They are therefore invaluable working concepts for clinicians. Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry. 2003 Jan;160(1):4-12

23. Gretty Mirdal - Institut for Psykologi Andre kritikpunkter 1. construct validity and practical reliability of the diagnostic categories system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. symptom-based diagnostic criteria fail to adequately take into account the context in which a person is living, and whether there is real internal disorder of an individual or simply a response to an ongoing situation 4. The political context of the DSM:is The potential for conflict of interest has been raised because roughly 50% of the authors who previously selected and defined the DSM psychiatric disorders have had or have financial relationships with pharmaceutical industries and drug companies. Some argue that the expansion of disorders in the DSM has been influenced by profit motives and represents an increasing medicalization of human nature while others argue that mental health problems are still under-recognized and under-treated. 5. "Gender Identity Disorder" criticize the DSM, citing the APA's decision to remove homosexuality from the DSM as evidence of the APA incorrectly referring to diverse states of being or orientations as mental illnesses.

24. Gretty Mirdal - Institut for Psykologi Psykopatologibegrebet: en dekonstruktion Hvad har denne lynhurtige sk�jtetur vist os? - at den samme forstyrrelse f�r forskellige etiketter,� bliver tillagt forskellige �rsager, og behandles p� forskellige m�der� til forskellige tider - at diagnoser er �arbejdshypoteser, og ikke egenskaber hos patienten�, (�stergaard, 1992)� - at man nu anerkender, at en lang r�kke psykiske forhold kan p�virke forl�bet af alle mulige fysiske sygdomme� - at man, inden for alle teorier, og nosologier har forst�else for, at en overbelastning af psyken ofte medf�rer overbelastning� af kroppen - at der n�ppe findes fysiske sygdomme, hvor det psykiske ikke spiller en rolle i �tiologi, forl�b og/eller behandling � Mirdal, 2000

25. Gretty Mirdal - Institut for Psykologi Gik �nskerne i opfyldelse? Hvor bev�ger vi os hen imod, og hvad kan man h�be, at der bliver mere forst�else for i fremtiden? -� at� psykiske f�nomener p� en og samme tid ogs� er sociale og biologiske -� at der� ikke er tale om gensidig p�virkning� imellem psyke og soma, men om to sider af samme sag, at psykiske og fysiske processer er manifestationer af det samme f�nomen p� to forskellige niveauer - at �rsagsforholdene er s� komplicerede,� at line�re forklaringer p� sundhed og sygdom er meningsl�se� Mirdal, 2000

26. Gretty Mirdal - Institut for Psykologi Sammenv�vede sl�jfer i bev�gelse og endelig kan man udtrykke det �nske, at vi ikke lader os friste til at reducere komplekse f�nomener, fordi det giver os en fornemmelse af kompetence, fordi vi tror vi forst�r, n�r vi forenkler forhold, som i virkeligheden er s� indviklede som sammenv�vede sl�jfer i bev�gelse. 

27. Gretty Mirdal - Institut for Psykologi Bev�gelser mod liv og bev�gelser mod d�d

28. Gretty Mirdal - Institut for Psykologi Desorganisering og reorganisering Jo bedre individet er i stand til at modst� sp�dningstilstande, (coping), til at regulere f�lelser, og foretage korrekte kognitive vurderinger, jo mildere bliver desorganiserings- processen og jo mindre alvorlig syg bliver man. Og det g�lder b�de det vi stadig i dag betragter som �fysiske� og �psykiske� sygdomme. Men vi er p� vej mod st�rre kompleksitet, st�rre integration mellem neurovidenskab og psykologi, mellem kognition og emotion, og hjernen og kroppen.

29. Gretty Mirdal - Institut for Psykologi Ignorering af biologisk etiologi �Psychoanalysis dominated American psychiatry for much of the last century and even today has some residual influence on the field. Diagnosis was not a principal concern of psychoanalysts. In fact, they viewed it as somewhat irrelevant because they believed that they knew what caused psychiatric illness and had the treatment. According to their theory, psychiatric illness resulted from a breakdown of psychic defense mechanisms and from unresolved psychosexual developmental issues. In their view, the nature and the severity of psychopathology was a function of how regressed the patient was in terms of the breakdown of psychic defense mechanisms. Given their confidence in their theories and their treatment, it is easy to see why the patient's psychiatric diagnosis was not a concern for psychoanalysts. � The Overlap of DSM IV Syndromes: Potential Implications for the Practice of Polypsychopharmacology, Psychiatric Drug Development, and the Human Genome ProjectSHELDON H. PRESKORN, MDBRYAN BAKER, RN, MSM, CCRCJournal of Psychiatric Practice, May 2002, 170-177

30. Gretty Mirdal - Institut for Psykologi Forberedelser til DSM-V: V�r med til at pr�ge debatten � �