Section on Classification, Diagnostic Assessment and Nomenclature

Newsletter Section Committee Members

Chair December 20, 2004 Carlos E. Berganza. Clínica de Psiquiatría Infantil Editorial Avenida La Reforma 13-70, Zona 9, Suite 11-B Guatemala, Guatemala C.A. The active role of the WPA Section on Classification, Diagnostic Assessment and Tel: (502) 2331-5806 Nomenclature in fostering the development and refinement of psychiatric diagnostic tools Fax: (502) 2331-6773 E-mail: [email protected] has been widely acknowledged. This issue of our Newsletter gives us a good picture of the international collaborative work that has been carried out lately under the auspices of the Co-Chair Yan-Fang Chen Section. Beijing Huilongguan Hospital Department of Psychiatry Chang Ping Road The reader will find in these pages an important report on the ongoing cooperation Beijing 100096, China. between WPA and WHO towards the revision of the ICD-10 Mental Health Component, the Tel: +10-627-18744 program and all the abstracts from the very timely WPA-WHO Symposium on Nosological Fax: +10-627-15354 E-mail: [email protected] and Diagnostic Validity (Florence, November 2004), as well as reports on inter-sectional activities and some recent developments regarding psychiatric diagnosis in Latin America. Secretary and Newsletter Editor Cláudio E. M. Banzato Department of Psychiatry, Furthermore, you are all invited to participate of the upcoming Inter-Sectional Symposium State University of Campinas (Unicamp) – PO Box 6111 in Athens (March 12-15, 2005), which rich scientific program is featured in this issue (e- Campinas, SP, Brazil, 13081-970. mail: [email protected]; www.wpanet.org; www.era.gr/wpa2005athens.htm). Tel: 55 19 3788-7206 E-mail: [email protected] Next year, the Section will also have a strong presence at the 13th World Congress of [email protected] Psychiatry in Cairo (September 10-15, 2005), the planned activities will be announced in due time. Finally, we would like to let you know that the issue of Psychopathology with Other Committee Members: the concise proceedings of the symposium on Philosophical and Methodological Sergio J. Villaseñor (México) Foundations of Psychiatric Diagnosis (New York, May 2003) is expected to come out E-mail: [email protected] Michel Botbol (France) soon. E-mail: [email protected] Michael First (USA) Season’s Greetings! E-mail: [email protected] Christian Haasen (Germany) E-Mail: [email protected] Hamburg.De Featured in this issue:

WPA Secretariat 1. Report from the presentation of the Blueprint for ICD-11 MHC in the WHO Family of Metropolitan Hospital Center 1901 First Avenue, Suite 4M-3 International Classification (FIC) Network Meeting in Reykjavik, by Juan E. Mezzich New York, New York 10029, USA Tel: +1 (212) 423-7001 2. Report from the WPA-WHO Symposium on Nosological Validity and Diagnostic Validity Fax: +1 (212) 876-3793 E-mail: [email protected] 3. Report from the Inter-Sectional Symposium, WPA Philosophy and Classification Sections: Ethical

and conceptual issues in early diagnosis and treatment WPA Executive Committee 4. Report from the presentation in Lima of the Latin American Guide for Psychiatric Diagnosis, by President: Ahmed Okasha (Egypt) Enrique Macher President Elect Juan E. Mezzich (USA) 5. The Latin American Guide of Psychiatric Diagnosis (GLADP) presented during the XXIII Congress Secretary General: John Cox (United Kingdom) of the Latin American Psychiatric Association (APAL), by Ángel O. Ojeda & Ricardo O. Testa Secretary for Finance Samuel Tyano (Israel) 6. Program of the Inter-Sectional Symposium on The Construction of Future International Secretary for Education: Roger Montenegro (Argentina) Classification and Diagnostic Systems: The Role of the WPA Scientific Sections (Athens, 2005) Secretary for Sections: 7. A note on a project of tying operational definitions of psychiatry to theory: On the tentative George Christodoulou (Greece) Secretary for Meetings IRF-diagnosis, by Johan Eriksson Pedro Ruiz (USA) Secretary for Publications: Mario Maj (Italy) Report from WHO Family of Classifications Meeting in Reykjavik By Prof. J.E. Mezzich (WPA President-Elect)

On October 24-29, 2004 the WHO Family of International Classification (FIC) Network Meeting took place in Reykjavik, Iceland. The meeting included presentations by Bedirhan Üstün on the WHO Business Plan for Classifications and on the ICD Revision Process, which were largely endorsed by the WHO FIC Network. The presentations of the Blueprint for the ICD-11 Mental Health Component at both a session of the Update & Reference Committee (URC) and at a plenary session were well received, with positive comments immediately after the presentation and again later on. There were also several interesting presentations on related topics, including one from the World Organization of Family Doctors (WONCA) on the International Classification for Primary Care which was discussed as relevant not only to ICD but to the whole FIC. In line with this, Prof. Rosemary Roberts (Australia), Chair of the URC, expressed the view that the Blueprint proposals presented could be worked on to become an integral part of ICD and, indeed, of the whole FIC.

L to R: Drs. J.E. Mezzich (WPA President-Elect) L to R: Drs. T.B. Üstün (WHO), M. Kimura and R.M. Roberts (WHO FIC Update and Reference (Japan ICD Office) and Prof. J.E. Mezzich at Committee Chair) at Reykjavik Meeting, Oct. 2004. Reykjavik Meeting, Oct. 2004.

The WHO FIC Network recommended that the ICD-11 developmental process start soon and identified six areas for initiating developmental work. One of these was Mental Health, which was recommended to be assigned to WHO and WPA. A progress report on this work is expected at the next WHO FIC Network Meeting on October 16-21, 2005 in Tokyo.

Special WPA-WHO Symposium on Nosological and

Diagnostic Validities

WPA International Congress: Treatments in Psychiatry: An Update

Florence, November 13, 2004

Participants of the Symposium on Nosological and Diagnostic Validities

The one-day symposium focused on the review and discussion of the validity of two distinct and related fundamental concepts in health care: nosology, as the classification of mental disorders, and diagnosis, conceptualized as comprehensive assessment of health. To this effect, first, an examination was conducted of conceptual perspectives in nosological and diagnostic validities, including historical, philosophical and clinical approaches. Second, the criteria for and the measurement of validity were discussed, including genetic/familial correlates, epidemiological correlates, as well as descriptive and therapeutic usefulness. Third, the validity of major diagnostic structures was then analyzed, including hierarchical nosology, diagnostic definitions, and comprehensive diagnostic schemas. And fourth, the nosological and diagnostic validity of challenging clinical conditions were examined, including illustratively comorbidity in mental and general medical disorders, perinatal disorders, and the interpersonal matrix (from personality to relational disorders). Juan E. Mezzich (USA), Carlos E. Berganza (Guatemala) and S. Chatterji (WHO, Switzerland) chaired the symposium, which was largely perceived by the participants as a very timely and important development towards the revision of the current diagnostic systems. Symposium Program

8:30 – 8:45 hours Introduction: J.E. Mezzich, C.E. Berganza, S.. Chatterji

8:45 – 10:30 hours A. Conceptual Perspectives on Nosological and Diagnostic Validities

1. Historical Perspectives on Nosological and Diagnostic Validities: P. Hoff (Switzerland)

2. Philosophical Perspectives on Nosological and Diagnostic Validities: K. Schaffner (USA)

3. Cultural Perspectives on Nosological and Diagnostic Validities: L. Kirmayer (Canada)

Discussion: C. Banzato (Brazil) and H. Herrman (Australia)

11:00 – 13:00 hours B. Criteria and Measurement of Nosological and Diagnostic Validity

1. Do Genetic and Familial Correlates Provide Validity Criteria of Diagnostic Categories in Psychiatry?: A. Jablensky (Australia)

2. Epidemiological Correlates as Criteria and Measures of Nosological and Diagnostic Validities: R. Kessler (USA)

3. Descriptive and Therapeutic Usefulness as Criteria and Measures of Diagnostic Validities: G. Mellsop (New Zealand)

Discussion: H. Akiskal (USA)

15:00 – 17:00 hours

C. Validity of Nosologic and Diagnostic Structures 1. The Validity of Hierarchical Nosologies: C. Berganza (Guatemala)

2. The Validity of Nosologic Definitions: Categorical, Dimensional & Hybrid Models: C. Pouncey (USA)

3. Nosological and Diagnostic Validities under Comprehensive Diagnostic Schemas: J.E. Mezzich (USA)

Discussion: S. Saxena (WHO) and A. Kraus (Germany)

17:30 – 19:00 hours D. Nosological and Diagnostic Validity in Challenging Clinical Conditions

1. Nosological and Diagnostic Validities and the Comorbidity of Mental and General Medical Disorders: I. Salloum (USA/Syria)

2. Postnatal Mental Disorder: An Appraisal of Nosological and Diagnostic Validities: J. Cox (U.K.)

3. Nosological and Diagnostic Validity and the Interpersonal Matrix: From Personality to Relational Disorders: L. Küey (Turkey)

Discussion: M. Botbol (France)

19:00 – 19:30 hours Conclusions: J.E. Mezzich, C.E. Berganza Symposium Abstracts

Historical Perspectives in Nosological and Diagnostic Validities Paul Hoff (Professor of Psychiatry, University of Zurich, Switzerland)

This paper outlines three major historical approaches to the concept of mental disorders: Mental illness as real “natural” object (realistic approach), as predominantly psychopathological convention

(nominalistic approach), and as result of biographical and other individual factors (biographical approach). The significant impact of these different pathways on the function of psychiatric diagnosis and on the conceptualization of psychiatric research will be discussed.

Philosophical Perspectives on Nosological and Diagnostic Validities Kenneth F. Schaffner (Professor of Medical Humanities and of Philosophy, George Washington University, USA)

In addition to the four traditional concepts of face, descriptive, predictive, and construct (external) validity, two more philosophical aspects of nosological validity will be explored in this paper. The first, "clinical" validity, borrows from predictive validity, and also from other components of clinical "utility," but does not accept the sharp distinction recently urged by Kendell between utility and validity. The second, "reductive etipathogenic" validity, is characterized as strong integration of disorders with etiological and pathophysiological knowledge, anticipated to be based on genetic and neurophysiological mechanisms. It is closely related to a reductionist approach to construct validity, and may be identical with it under some interpretations of "realism." I argue that robust etipathogenic validity is almost certainly a premature goal for the emerging ICD-11 and DSM-V nosologies for a variety of reasons. Clinical validity can be facilitated by evidence-based methodology, though whether nosologies that are clinically valid will prevail as etipathogenic valid assessments will only be resolved empirically. The paper concludes with a discussion of diagnostic validity, against the backdrop of the nosological account above. Here the emphasis is on the creative tensions between an individualized, empathetic, biopsychosocial approach to a patient in the context of both clinical and etipathogenic based nosologies.

Cultural Perspectives on Nosological and Diagnostic Validities Laurence J. Kirmayer (James McGill Professor and Director, Division of Social and Transcultural Psychiatry, McGill University, Canada)

Although recent years have seen increased attention to culture in psychiatric nosology and diagnosis, important conceptual and practical problems remain. This presentation will consider the extent to which cultural difference can be meaningfully integrated into psychiatric nosology.

Current strategies for incorporating culture into nosology will be reviewed. These include modifications to the textual presentation or clinical application of the diagnostic system (e.g. adding qualifying comments or caveats, modifying diagnostic criteria); changes in basic architecture (e.g. adding new disorders, reorganizing broad categories); and the creation of parallel systems of assessment (e.g. the cultural formulation, relational diagnoses). The merits and drawbacks of each approach will be reviewed along with the sort of evidence needed to establish each type of change.

Ultimately, success in integrating culture into nosology depends on taking seriously both the epistemological dilemmas of cultural research and the pragmatic issues that arise in the diverse clinical and social contexts where psychiatric diagnosis is applied.

Do Genetic And Familial Correlates Provide Validity Criteria Of Diagnostic Categories In Psychiatry? Assen Jablensky (School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia)

Advances in molecular biology and genetics have a growing impact on classifications in medicine and neurology, where genetic discoveries are generating new organising principles for the clustering of disorders, such as mitochondrial diseases or disorders due to nucleotide triplet expansion. Although the majority of psychiatric disorders are genetically far more complex than previously assumed, genetic research is likely to play a role in redefining their boundaries and, to a limited extent, in their diagnosis. At present, this is more of a promise than actual performance, except for a small number of disorders with a simpler genetic architecture, including Huntington dementia, familial Alzheimer disease, Rett syndrome, and several of the sleep disorders. However, complementing the current diagnostic categories with carefully selected potential endophenotype markers and traits should further research aiming at a biologically better validated nosology of the complex psychiatric disorders.

Criteria and Measurement of Diagnostic Validity: Epidemiological Correlates Ronald Kessler (Professor of Health Care Policy, Harvard University, USA)

In the absence of definitive biological data, decisions about criteria and diagnostic validity hinge largely on the analyses of naturalistic patterns in phenotypic data and of information regarding differential treatment response related to variation in these naturalistic patterns. The current report reviews opportunities for the first of these two types of analyses for the development of ICD-11.

The presentation is divided into two parts. The first part briefly reviews available strategies for the analysis of naturalistic patterns in phenotypic data. This part of the presentation highlights the importance of establishing a data collection system that allows rapid iteration between analysis and targeted collection of new data. The second part of the presentation outlines a proposal for establishing a data collection system of this type for ICD-11 that features the creation of an internet- based international practice network of clinicians who participate in an iterative series of short targeted surveys designed to refine criteria and measurement of diagnostic validity.

Criteria and Measurement of Diagnostic Validity: Descriptive and Therapeutic Usefulness Graham Mellsop (Professor of Psychiatry, University of Auckland, New Zealand)

This paper will review the difference that perspective can make to an apparently value free concept such as validity, in relation to our psychiatric classificatory systems. The views of pathologists, surgeons and Humpty Dumpty will be discussed. It will then explore the role of therapeutic usefulness as a determinant of diagnostic validity. The paper will also consider and appraise specific criteria and measures of nosological and diagnostic validity as they have been proposed in the past and will offer suggestions for the future.

Validity of Diagnostic Structures: Hierarchical Nosology Carlos E. Berganza (Professor of Psychiatry, San Carlos University, Guatemala)

The hierarchical organization of the ICD-11 mental health component is a critical theoretical and clinical challenge because it concerns the internal consistency of the classification of mental disorders, and its nosological validity and clinical usefulness. For example, the adequacy of the number of major classes in ICD-10 must be reviewed. The current grouping of 10 two-character major classes to be divided by 10 three-character categories and so on has shown more difficulties than the ones it intended to resolve. Human mental morbid conditions nowadays included in this classification do not happen in groupings of 10. An illustration of this dilemma is F1, Mental and behavioral disorders due to psychoactive substance use. Here, trying to accommodate the number of potential drugs acting as etiological factors and the number of syndromes that they may cause in groupings of 10 results an impossible task. A review should be included of the current types of major classes composing the current system and their internal organization. In this presentation, we discuss the major caveats of the current hierarchical organization of ICD-10 and propose alternatives to increase the internal consistency of the system as well as to promote the research needed to resolve questions of nosological groupings.

Nosologic Definitions: Categorical, Dimensional, and Hybrid Models Claire Pouncey (University of Pennsylvania, USA)

The choice between a categorical or a dimensional nosology is often viewed as a fundamental decision that precedes psychiatric classification, and this decision has been named as a research priority by groups such as the Nomenclature Work Group for DSM-V. However, categorical classification and dimensional diagnostic considerations are not mutually exclusive. While a tension does exist between the two approaches, they can be – and often are – used together. If we recall what philosophers call the “theory-ladenness of observation”, we can see that the statistical methods used to investigate mental disorders presuppose either a categorical or a dimensional approach to classification. We use these methods to clarify or challenge aspects of a classification that already exist. We then modify that classification in whole or in part according to ongoing research. By looking to the statistical methods used for classification we will see that (1) a nosology need not be uniformly categorical or dimensional, and (2) the decision to use a categorical or dimensional nosology need not precede classification but can modify an existing one.

Nosological and Diagnostic Validities under Comprehensive Diagnostic Schemas Juan E. Mezzich (Professor of Psychiatry, Mount Sinai School of Medicine, New York University, USA)

As preparations are starting to develop a new generation of international classification and diagnostic systems, such as ICD-11, the concept of diagnosis and its validity are receiving pointed attention. This includes an analysis of alternative notions of diagnosis, from a conventional classification of mental disorders to a full description of health status. The latter notion involves an appraisal of the complexity of mind and health from various perspectives. One refers to the domains to be assessed, from mental disorders to a full panel of existing illnesses and health-related problems to a consideration of both ill and positive health aspects. Another refers to the descriptive tools to be employed, including standardized typologies and dimensional approaches as well as idiographic narratives. A third perspective is concerned with the evaluators involved, including clinicians, the consulting person (patient), and the family and significant others. Furthermore, one should consider whether the concept of diagnosis is fundamentally a formulation or an interactive process. The concept of diagnostic validity is also being re-examined. Competing notions include attempts at and results from “carving nature at its joints” to the fulfillment of the expected purposes of diagnosis for clinical care and public health actions.

Nosological and Diagnostic Validity in Challenging Clinical Conditions: Comorbidity in Mental and General Medical Disorders Ihsan M. Salloum (Associate Professor of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh, USA)

Comorbidity, or the co-existence of more than one morbid condition, is the rule and not the exception in regular clinical practice. The presence of comorbidity poses significant challenges to diagnostic ascertainment and treatment choices, and has significant impact on treatment response and outcome. The prognostic significance of comorbid conditions has been recognized for general medical disorders. Comorbidity in mental disorders presents additional hurdles due to the lack of fully validated psychiatric disorders. The challenge of comorbidity is yet to be adequately addressed by modern classification systems. This presentation will review evidence on the prognostic significance of comorbidity and its relevance for enhancing the clinical utility or usefulness of current diagnostic systems.

Postnatal Mental Disorder: An Appraisal of Nosological and Diagnostic Validities John Cox (Emeritus Professor of Psychiatry, Keele University and Secretary General, World Psychiatric Association)

This paper is based on the author’s proximity to the review of existing international classifications

(ICD-10; DSM-IV) being undertaken by WHO and the World Psychiatric Association and the

American Psychiatric Association. The recommendations of the Satra Bruk classification of Postnatal Mental Disorder will be summarised within the context of the drive towards a more whole person approach, and the need for classifications to take into account policy imperatives. The WPA

International Guidelines on Diagnostic Assessment (IGDA) which emphasise descriptive and narrative understanding and include quality of life and disability measures will also be outlined with regard to their possible usefulness for the greater understanding of Perinatal Mental Disorder.

Nosological and Diagnostic Validity and the Interpersonal Matrix: From Personality to Relational Disorders Levent Küey (WPA Southern Europe Zonal Representative Associate Professor in Psychiatry, Beyoglu Training Hospital and Psychology Department, Istanbul Bilgi University, Istanbul, Turkey)

Why does the description of the ill and healthy aspects of “the interpersonal” constitute a challenging clinical condition in terms of validity? On which bases can the concepts of nosological validity and diagnostic validity be discussed and utilized in the context of human interpersonal relations? How can a scientific psychiatric classification system and a comprehensive clinical description attain the power of validity in defining distress, disability or deviance in interpersonal relations? How much may the scientific evidence accumulated in this field help us to differentiate between the patterns of normality and abnormality in interpersonal relations? Do we need new empirical data or do we need new epistemological and methodological means? In an effort to provide a framework for the discussion of these questions, basic conceptual approaches and relevant research data on the classification and description of “the interpersonal and relational issues and disorders” will be reviewed in this presentation.

Inter-Sectional Symposium

WPA Philosophy Section and WPA Classification Section

Ethical and conceptual issues in early diagnosis and treatment

Florence, November 10, 2004

The WPA Section on Philosophy and Humanities and WPA Section on Classification and Diagnostic Assessment organized a very timely symposium, at the framework of the WPA International Congress (Florence, November, 10-13, 2004), on the several conceptual and ethical issues around early detection and intervention of psychiatric disorders. Giovanni Stanghellini (Italy) and Claudio Banzato (Brazil) chaired the symposium.

From L to R: Claudio Banzato, Giovanni Stanghellini and Bill Fulford

Kenneth Schaffner (George Washington University, USA) was the first speaker and he addressed some ethical issues regarding safety, efficacy, informed consent, and stigma that are often raised by the research in early detection and intervention in psychosis. The focus of his presentation was the process of development of the instrument called MacCAT-CR, its several versions and the prospects for their validation in empirical trials at different sites. The following speaker, Claire Pouncey (University of Pennsylvania, USA) argued that some ethical issues might prove ultimately epistemic. She criticized certain assumptions made about the risk of false positives in these studies, as in psychiatry there is no diagnostic gold standard to allow us independent diagnostic testing. The chair of the WPA Philosophy Section, Bill Fulford (University of Warwick, UK), stressed the role of value judgements in psychiatric diagnosis by exploring the several difficulties related to the distinction between spiritual experience and psychotic illness and their differential diagnosis at the early stages of a possible psychotic illness. Finally, Matthew Broome (Institute of Psychiatry, London UK) extensively reviewed the historical conceptions of “prodrome” and the empirical evidence available about the phase prior to transition to first-episode of psychosis, including the transition rates based upon various neuroimagining measures. Furthermore, he presented his own data from a clinical cohort in South London. The symposium counted also on the active participation of audience, what resulted in a lively debate. The presence of Patrick McGorry (University of Melbourne, Australia), a leading researcher in this area, contributed as well to deepen the discussion. Presentation in Lima of the Latin American Guide for Psychiatric Diagnosis Enrique Macher, MD (Lima, Perú)

On June 25, 2004, during the ‘Golden Anniversary’ XVIII Congress of the Peruvian Psychiatric Association (APP) and III Regional Meeting of the Latin American Psychiatric Association (APAL), which took place in Lima, from June 24 – 27, 2004, an important meeting on psychiatric diagnosis was held. The panelists were Dr. Juan E. Mezzich, President Elect of the World Psychiatric Association (WPA), Dr. Elizabeth Rivera, Vice President of the Chapter on Classification and Diagnosis of the APP, Dr. Gabriela Kuroiwa, General Coordinator of the Congress, and Enrique Macher, President of the Chapter on Classification and Diagnosis of the APP.

Seated L to R: Drs. G. Ginnari, E. Belfort, R. Cordoba, E. Sanchez and J.E. Mezzich, and standing L to R: Drs. J. Acha, M. Brasil, N. Koldobsky, G. Kuroiwa, E. Rivera, and E. Macher, all leaders of Latin American psychiatric associations meeting with the WPA President-Elect at the Golden Jubilee Congress of the Peruvian Psychiatric Association, June 2004, where the Latin American Guide of Psychiatric Diagnosis was presented.

Dr. Mezzich presented an overview of what the WPA has been doing regarding classification and diagnosis around the globe; he mentioned, for instance, the Thematic Conference on Psychiatric Diagnosis (Vienna, June 2003), where Dr. Heinz Katschnig defined diagnosis as a “process”. The WPA President elect also mentioned the noticeable increase in the affiliation with the WPA by many countries, especially from the East, like Sri Lanka. Thus, the number of nations affiliated with WPA has risen up to 127. Dr. Mezzich stressed the active role played by the 58 WPA Scientific Sections as well.

The WPA has been a consultant to the WHO for ICD 10, but now has a leading and central role for the production of the 11th revision, to be released, hopefully, by the year 2011. The WHO has, through Dr. Bedirhan Üstün, requested our President Elect, Dr. Mezzich, to lead the preparation of a Blueprint for the development of the mental health component of ICD-11/Family of International Classifications and, consequently, a WPA-WHO Workgroup on International Classification and Diagnostic Systems (ICDS) was created to perform such task.

Another important recent development, one that I think may represent a great contribution to the process outlined above was the launching of the Latin American Guide for Psychiatric Diagnosis (GLADP). The GLADP “…is an effort to optimize the use and utilization of the Chapter on mental disorders… therefore, it represents a critical evaluation of the international standards and the formulation of a model of evaluation and diagnostic formulation… including adjustments to the ICD…” within the realm of Latin-American countries. As much as it is formulated to serve our specific population, there is the need to “capture the cultural as well as the particular elements of each patient, due to the uniqueness of his/her context and his/her experience”. This need makes for the urgency to create the different national diagnostic classifications, like those of the APA (DSMs), the Chinese Medical Association (CCMD) and the Ministry of Health, Havana Psychiatric Hospital (GCP [Cuban Glossary of Psychiatry]).

In the GLADP’s introduction, the volume quotes Professor Carlos Acosta Nodal, from the second edition of the Cuban Glossary of Psychiatry: “We do not intend to disdain the collaboration coming from the highly developed countries, capable of transmitting their skills and to inform about scientific theory. But we have to be very alert to avoid the overprotective tutelage that sterilizes and deforms the growth that must be consistent with the social economic context of each nation”. The introduction goes on to state: “The needs of Latin America in matters of psychiatric nosology are particular, if only for the undeniable fact that the manner in which its population gets ill is strongly influenced by its culture…. in a way that the diagnosis has to take into in account if it is to serve its true purpose/aim of informing treatment effectively, orienting the prevention programs and facilitating the efforts to promote mental health”. Naturally, this development should “… increase communication amongst professionals of the region…” and “… contribute to impulse the development of a psychiatric science of the region, more autonomous and participative, which is not only a consumer of the knowledge generated in other latitudes, but one that generates its own and that contributes in a significant fashion to the development of an international psychiatry. In this sense, “Intellectual independence is a fundamental condition for scientific creativity.”

Those of us who have had the opportunity to participate in the elaboration of this Guide – albeit, in my case, in a rather modest way – should be very proud to have our names printed in a document that will prove historical. That is not to say that it will not have to go through the amendments that we all can think of consensually, but the volume itself, prepared by our friends and colleagues from Mexico, is an excellent piece of work.

The GLADP (in Spanish) is freely available online at the WPA website (http://www.wpanet.org/home.html). The Latin American Guide of Psychiatric Diagnosis (GLADP) presented during the XXIII Congress of the Latin American Psychiatric Association (APAL)

The APAL Section on Diagnosis and Classification held the following five activities within the XXIII Latin American Congress of Psychiatry in Punta del Este, Uruguay, November 13 – 20, 2004:

1. Official presentation of the GLADP:

The diagnostic manual was introduced by Professor Angel Otero-Ojeda, coordinator of the Section. He emphasized the meaning of the GLADP as a version (not a substitute) for Latin America of ICD- 10 and as an educational, investigative and organizational project devised to achieve the integration of this region with the projects the World Health Organization (WHO) and the World Psychiatric Association (WPA) are developing cooperatively in matters of international nosology.

Professor Juan E. Mezzich, President-elect (Vice President) of WPA welcomed both (manual and project), expressing his high appreciation for this potential Latin American contribution to the future versions of the mental health component of ICD. He congratulated the Latin American community of psychiatrists for the successful culmination of this task, which he proposed as one of the most meaningful contribution of the region to universal nosology. Professor Mezzich also pointed out the paramount importance of the project perspectives, and exhorted Latin American psychiatrists to continue this endeavor and to work in close partnership with the WPA Section on Classification, Diagnostic Assessment and Nomenclature and with the WHO – WPA efforts to construct ICD-11.

2. Symposium on The Latin American Guide for Psychiatric Diagnosis

This Symposium took place on Wednesday November 17. Professor Carlos E. Berganza, Past Chair of the GLADP’s Executive Committee, and current Chair of the WPA Section on Classification, was designated Honorary President of the activity. The Symposium was chaired by Professor Angel Otero-Ojeda (Cuba) and Co-chaired by Professor Ricardo Testa (Argentina).

The activity began with the introductory words of Dr. Vicente Pardo (Uruguay) on behalf of Dr. Angel Valmaggia, President of APAL. They were followed by the intervention of Professors: Juan Mezzich (USA - Peru) [Meaning, educational and investigative perspectives of the GLADP], Ricardo Testa [Comprehensive Diagnostic Formulation], Angel Otero [Components of the GLADP], Carlos Rojas-Malpica (Venezuela) [Historical framework], Sergio J. Villaseñor (Mexico) [Culture bound syndromes within GLADP], Dr. Gabriela Kuroiwa [discussion of a patient’s clinical record] and final commentaries about the symposium by Professor Edgard Belfort (Venezuela), APAL Administrative Secretary.A wide discussion with the audience was held at the end of activity

3.Theoretical - Practical Course about Psychiatric Diagnosis Latin-American Guideline (GLADP) A 4-hour Theoretical - Practical Course on the GLADP was held on Friday 19. This course was projected to introduce and train mental health workers in the use of the GLADP diagnostic manual.

It was planned to be presented in two different parts. One hour was devoted to theoretical aspects: Manual structure and its correct use, GLADP Axes meaning, characteristics of diagnostic assessment, comprehensive diagnostic formulation and treatment plan format in GLADP. Finally, an Illustrative Clinical Case was exhibited in order to be discussed

From left to right: Professors Sergio Villaseñor using the GLADP guidelines. (México), Carlos Rojas Malpica (Venezuela), Ángel Otero (Cuba), Vicente Pardo (Uruguay), Juan E. Mezzich (USA / Peru), Ricardo O. Testa

During the practical part, a medical interview video was played in order to be analyzed through the GLADP format. Furthermore, small groups worked with the manual on the diagnostic formulation of several medical records of patients from local and international settings. This material was offered by the GLADP’s Project professors. In the future, these cases will be assembled to complete a GLADP Casebook. Several manuals were distributed free among the attendants. A brief survey showed that, most of them rated the workshop as excellent and very useful for their dally practice.

Other conclusions were delineated, among them:

1. There were an acceptable number of participants (more than 25). This fact shows their interest in diagnostic procedures. Not only Congress fellows were present, but also senior psychiatrists and distinguished colleagues from Argentina, Chile, Costa Rica, Ecuador, Mexico, Peru, Uruguay and Venezuela. 2. Several issues for debate were raised: a. Quality Life Assessment b. Disabilities (Social Functioning) Assessment 3. Most participants (99%) manifested to be using some standardized diagnostic system in their daily clinical practice (e.g., CIE-10 and DSM-IV). 4. More than 50% were interested in becoming members of the staff for the GLADP future projects and to become trainers about meanings, characteristics and use of GLADP in their respective countries.

All these data were compiled from a systematic course assessment process, which is carried out in every country were the GLADP project has been presented.

4. Participation in the APAL Sections Meeting A detailed report of the Section activities presented by Professor Otero was approved during the meeting. Professors Angel Otero, Ricardo Testa and Vicente Molina, were ratified as Coordinator, Secretary and Treasurer of the Section respectively.

5. Meeting of the GLADP’S Executive Committee

A new GLADP Steering Committee was designated, as follows: Angel Otero (president) Carlos Berganza, Miguel Jorge, Juan Mezzich, Ricardo O. Testa Sergio Villaseñor

All members of the steering Committee evaluated the results of the activities formerly summarised in this report, and agreed to rate them as very successful. Personal contacts were held by leaders of GLADP Project with Presidents of National Psychiatric Associations, and PAHO and WPA representatives in order to coordinate efforts, achieve the official recognition of GLADP as the Latin American version of ICD-10 and promote the creation of Diagnostic and Classification Sections in each one of the Latin American National Psychiatric Associations. Changes and complementary actions necessary to improve educational and administrative activities were also discussed. Ways to approach the most immediate commitments of the Section concerning the dissemination of the GLADP (Workshops and Symposia in Costa Rica and Mexico –March 2005 and Argentina – April 2005, and National Sections of D&C Meeting – Argentina April 2005) were also coordinated.

Dr. Ángel Otero Ojeda Dr. Ricardo O. Testa APAL Section on Diagnosis and Classification APAL Section on Diagnosis and Classification Coordinator Secretary

The Construction of Future International Classification and Diagnostic Systems: The Role of the WPA Scientific Sections

WPA Classification Section

Regional and Inter-Sectional Congress of the World Psychiatric Association

Athens, March 12-15, 2004

Introduction:

This will be a two half-day (4 hours each) symposium addressed at discussing with some of the WPA scientific Sections their relevant concerns and prospective contributions to the development of an international classification and diagnostic system for psychiatry that may best serve the needs of stakeholders around the globe. The first half-day will be devoted to discussing epistemological and strategic issues with sections that may be mostly concerned with these areas of diagnosis. The second half-day will be devoted to the discussion of more specific nosological issues with sections concerned with the study of more specific clinical disorders and conditions.

Chairs:

Prof. Carlos E. Berganza, Chair, Section on Classification, Diagnostic Assessment and Nomenclature (Guatemala); Co-Chair: Prof. Juan E. Mezzich, President Elect, WPA (USA)

Participants:

Part I. Methodological and Strategic Issues: 1. Yan Fang Chen, Co-Chair, Section on Classification, Diagnostic Assessment and Nomenclature (China) 2. Cláudio Banzato, Secretary, Section on Classification, Diagnostic Assessment and Nomenclature (Brazil) 3. Michel Botbol, Secretary, Section on Psychoanalysis in Psychiatry (France) 4. Mohammed T. Abou-Saleh, Chair, Section on Biological Psychiatry (UK) 5. James C. Anthony, Chair, Section on Epidemiology and Public Health (USA) 6. K.W.M. Fulford, Chair, Section on Humanities and Psychiatry (UK) 7. Assen Jablensky, Chair, Section on Measurement Instruments in Psychiatric Care (Australia) 8. Dusica Lecic-Tosevski, Chair, Section on Preventive Psychiatry (Serbia & Montenegro) 9. Helen Herrman, Chair, Section on Public Policy and Psychiatry (Australia)

Part II. Specific Nosological Issues: 1. Tarek Abdul Gawad, Secretary, Section on Addiction Psychiatry (Canada) 2. Christopher Thompson, Chair, Section on Affective Disorders (UK) 3. Joseph Zohar, Chair, Section on Anxiety & Obsessive-Compulsive Disorders (Israel) 4. Barry Nurcombe, Chair, Section on Child and Adolescent Psychiatry (Australia) 5. Luis Salvador-Carulla, Chair, Section on Mental Retardation (Spain) 6. Erik Simonsen, Chair, Section on Personality Disorders (Denmark) 7. Wolfgang Gaebel, Chair, Section on Schizophrenia (Germany) 8. Donna Stewart, Chair Section on Women’s Mental Health (Canada) 9. Miguel R. Jorge, Vice Chair, Section on Urban Mental Health Program of Presentations:

Morning: Part I. Methodological and Strategic Issues:

Time in No. Topic Speaker Minutes Introduction: International diagnostic systems and the role of 1. J. E. Mezzich 15 WPA Introduction: ICDS: Critical issues of concern to WPA 2. C. E. Berganza 15 sections Validity and Values: Conflicting or Complementary in a 3. KMW Fulford 15 Scientific Classification of Mental Disorders? Can epidemiological data contribute a theory for psychiatric 4. J. Anthony 15 nosology 5. Discussant Y. F. Chen 15 Questions and Comments from the Audience ALL SPEAKERS 30

Break 15

How psychiatric nosology can advance prevention in mental 6. D. Lecic-Tosevski 15 health How psychodynamic variables can increase clinical validity of 7. M. Botbol 15 psychiatric diagnosis and classification What nosology may provide for sound public policy in 8. H. Herrman 15 psychiatry? How can biological variables can truly inform a valid 9. M.T. Abou-Saleh 15 psychiatric nosology 10 Discussant A. Jablensky 15 Questions and Comments from the Audience ALL SPEAKERS 30

Afternoon: Part II. Specific Nosological Issues:

1. How the classification of anxiety disorders can be improved J. Zohar 15 How to incorporate new research in the classification of 2. C. Thompson 15 affective illnesses 3. Schizophrenia: A new nosological model for an old illness W. Gaebel 15 Advances and limitations in the current classification of 4. E. Simonsen 15 personality disorders 5. Discussant C. Banzato 15 Questions and Comments from the Audience ALL SPEAKERS 30

Break 15

How to improve the classification of substance use disorders: 6. T. Gawad 15 Conceptual and strategic issues Do current diagnostic systems truly reflect the needs of female 7. D. Stewart 15 psychiatric patients? 8. Main pitfalls in the current classification of mental retardation L. Salvador-Carulla 15 How to improve the nosography of childhood and adolescent 9. B. Nurcombe 15 psychiatric disorders 10 Discussant M. Jorge 15 Questions and Comments from the Audience ALL SPEAKERS 30

A note on a project of tying operational definitions of psychiatry to theory: On the tentative IRF-diagnosis

Johan Eriksson1

In Copenhagen (1) I discussed the tentative diagnosis IRF (Impaired Recovery Function). It is based on “four parameters of health” presented last year (2). They are results of an attempt to conceptualise health-related conditions out of an understanding of “recovery”. IRF is a theoretically defined condition where the general level of function of the organism/individual (it is not settled whether or not the IRF-concept is unique for human conditions) no longer is enough to handle the accumulated need of recovery (fig. 1). It is postulated that general level of stress upon the organism is positively correlated with need of recovery and at the same time negatively correlated with the ability to perceive signals of need of recovery. At a crucial point, therefore, the inability to perceive the signals of need of recovery, and the drive to keep those signals unnoticed, explains the tendency to sustain or even raise, the level of stress (fig. 2 right). Since the need of recovery is not manageable the level of stress is destructive.

Figure 1 Figure 2 Ability to perceive Preventive The natural movement health care signals of need of Need of is downwards: recovery recovery Level of Towards Away from function High resting and painful performance recovery. signals Optimal level of Overstressed stress Medical care Low Low performance IRF performance

Level of stress

The IRF-project permits an integrative view on psychiatric matters. One concerns a definition of health: “health is an intact recovery function (balance among needs)”. Since the recovery function (RF) is the system that enables the individual to recover, it is related to culture as well as tradition; the RF is contextual. In health care, it is also possible to define preventive health care as interventions maintaining the RF. Medical care in turn could be defined as interventions restoring the RF (fig 2 left).

The IRF-diagnosis perhaps can be used to tie theory to operational definitions. A clinical instrument is to be evaluated the coming year at the Center for Family Medicine, Karolinska Institute, Stockholm, Sweden, within a preliminary research methodology course. In this phase the value of the tentative diagnosis is to be estimated as to identify a

1 Psychologist, the primary health care in Brandbergen, Stockholm, Sweden. Jungfruns g 416-419, SE-136 60 Haninge, Sweden. risk group for prolonged negative health development. Additional evaluations for future research concern definitions of panic disorders, obsessive-compulsive disorders, chronic fatigue syndrome, depression and impaired cognitive function.

On the issue of nosology further development of the theory has been made regarding personality-related matters. That line of theory involves the integration of the concept of “psychic energy” and is planned to be presented in New Haven in 2005 (3). This line opens up for integration of concepts as neurotic, borderline and psychotic personality organisations and melancholia and calls for evaluations of operational definitions of those. Conceptually, also, the effect of SSRI can be explained within the developed model.

If the IRF-project has anything to contribute to the projects of the Section is of course written in the future. Hopefully this presentation though can promote evaluation of the model. There is a huge gap between theory and our diagnostic manuals and the tentative IRF-diagnosis is an example of that it perhaps can be bridged. The later developments of the model, based as it is on most simple connections, leads to traditional bodies of theory. The psychodynamic concept of “psychic energy” has been mentioned. I also would like to mention that the later developments are based on the assumption that the experiencing subject is an integrated need-governed set of inner psychic objects. It also permits a deeply human perspective on psychiatry, that it should assess and categorize the individuals’ ability to restore their systems of the recovery function. Treatment, then, should be guided by the aim of the restoration.

References

1. Eriksson, J (2004) ”Pain, Fatigue and Anxiety - Exploring Prolonged Negative Health Development I: A Theoretical Structure – On Impaired Recovery Function”. Nordisk Psykolog Kongres (Nordic psychologist conference) 2004. Copenhagen 18- 20/8 2004.

2. Eriksson , J. (2003) ”A Psycho-Pedagogical Model for Rehabilitation in Exhaustion Syndrome – a Cognitive Tool” (Psykopedagogisk Modell för Rehabilitering vid Utmattningssyndrom – ett Kognitivt Verktyg). Svensk Rehabilitering 1/2003

3. 8th International Conference on Philosophy and Psychiatry, Philosophies for Community Psychiatry: Recovery-Oriented, Evidence Based, and Beyond. New Haven, Conneticut, USA, 2005.