Abstract

In lieu of an abstract, here is a brief excerpt of the content:Deflating Psychiatric ClassificationClaudio E. M. Banzato (bio)Keywordsnosography, comorbidity, utility, pragmatismSystems of classification bring order into the world. They are a key part of the informational working infrastructure of the world we inhabit (Bowker and Star 1999). Thus, much of the human interaction hinges on these ordering—pattern identifying and creating—systems. Formal or informal, standardized or ad hoc, visible or invisible, enforced or optional, there are a myriad of classifications we necessarily live by.Typically, classifications convey representations of states of affairs to make interventions on them feasible and, to some extent, predictable. In other words, classificatory systems and schemes try to confer intelligibility to the world. By succeeding in such task, they may provide rational grounds to human operation on reality (toward the most diverse ends). This account fully applies to medical classifications, which struggle to sort out all kinds of diseases, ailments, complaints, and sufferings that can possibly be targeted by medical interventions. This means classifications are instrumental to the ends pursued by medicine, quintessential modificatory activity. In sum, classifications are cognitive tools devised to build up knowledge by making relevant distinctions, which may prove helpful to guide human action.By working well, classifications eventually tend to become invisible. They end up looking just natural, as if they were carved by nature itself. But indeed purpose is the touchstone here. Even if a given class of objects fully qualifies as a 'natural kind' and necessary and sufficient criteria for class membership can be definitely established, it does not entail that it constitutes the best way to classify these objects irrespective of the context. Peter Zachar (2002) offers a compelling example from natural sciences, the utmost practical importance of distinguishing between hydrogen and its isotopes (hydrogen, deuterium, and tritium). In this case, the classificatory thrust stretches beyond the shared atomic number. In his words, "A crucial factor in recognizing them as distinct is that they are used in distinct activities and practices. We get a better neutron bounce with heavy water or D2O. Deciding what aspects of internal structure are important therefore cannot be isolated from external factors." (p. 220)In contemporary psychiatry, diagnostic classification has been center stage for several reasons. But before addressing them, however, a brief historical detour is necessary. Back in the nineteenth century, putting forward a new classification of mental diseases was taken somewhat as a token of psychiatric proficiency according to the witty remark by the French physician and publicist Philippe Buchez: "Upon believing that they have [End Page 23] completed their studies, rhetoricians will compose a tragedy and alienists a classification" (Berrios 1999, 152). By the middle of the twentieth century, many psychiatric classifications (based on diverse principles and underlying theoretical orientations) were still used across the world. The British psychiatrist Erwin Stengel (1959), in his influential report on classification of mental disorders, pointed out that the issue of difficulty of communication was then the order of the day for psychiatry, because it was widely perceived as one of the most serious obstacles to the progress in the field.The broad, worldwide survey carried out by Stengel made it clear that classifications of all shapes were used in different contexts, but they were seldom appealing outside the boundaries of the respective centers that generated them. Such diversity of classifications reflected not only different functions or purposes they were meant to serve, but also the role played by the history of a given problem within a particular medical tradition and cultural background. Thus, Stengel's aims for an acceptable statistical international classification were relatively modest: it should simply ground epidemiological work.Stengel's stance on classification was frankly pragmatic and utilitarian. He understood well the difficulties posed by the 'disease entity' assumption in psychiatry and asked the straight question: "Firstly, what do we classify in this field? Are we classifying diseases or people?", to which he offered a compromised answer: "It may be said that the material the psychiatrist has to classify consists neither of diseases nor of people but of a variety of disorders or reactions, a material which does not readily lend itself to classification" (Stengel 1959, 612). For him, the pursued agreement on the...