Classification of Mental Disorders

Bull. Org. mond. Sante 1959, 21, 601-663 Bull. Wld Hlth Org.

Classification of Mental Disorders

E. STENGEL, M.D., F.R.C.P.1

One of the fundamental difficulties in devising a classification of mental disorders is the lack of agreement among psychiatrists regarding the concepts upon which it should be based: diagnoses can rarely be verified objectively and the same or similar conditions are described under a confusing variety of names. This situation militates against the ready exchange of ideas and experiences and hampers progress. As a first step towards remedying this state of affairs, the author of the article below has undertaken a critical survey of existing classifications. He shows how some of the difficulties created by lack of knowledge regarding pathology and etiology may be overcome by the use of " operational definitions " and outlines the basic principles on which he believes a generally acceptable international classification might be constructed. If this can be done it should lead to a greater measure of agreement regarding the value of specific treatments for mental disorders and greatly facilitate a broad epidemiological approach to psychiatric research.

INTRODUCTION

Psychiatry has made considerable strides during aware of it. It is sometimes argued that this is the past three decades. There has been great thera- inevitable in the present state of psychiatric know- peutic activity and an enormous intensification ledge, but it is doubtful whether this is a valid of research work. Medical men, public authori- excuse. ties, and the community at large have become The lack of a common classification of mental alive to the magnitude of the problems of mental disorders has defeated attempts at comparing disorders. Conditions for a concerted attack on psychiatric observations and the results of treat- mental ill health ought, therefore, to be highly ments undertaken in various countries or even propitious at the present time. Yet, in many res- in various centres of the same country. Possibly, pects, psychiatrists find themselves ill-prepared to if greater attention had been paid to these diffi- meet the challenge. This is partly due to the culties, there might be a greater measure of agree- incomplete integration of the various approaches ment about the value of specific treatments than to the study of mental illness, though there are exists today. Another field in which the lack of signs that this process has been gaining momentum a common language threatens to defeat the pur- of late. A more serious obstacle to progress in pose of much valuable effort is that of experi- psychiatry is difficulty of communication. Every- mental psychiatry where research has been very body who has followed the literature and listened active of late. In recent years the epidemiological to discussions concerning mental illness soon dis- approach has been used in the study of mental covers that psychiatrists, even those apparently disorders to an increasing degree. To be fruit- sharing the same basic orientation, often do not fully employed on a broad front it requires a speak the same language. They either use different common basic terminology and classification. terms for the same concepts, or the same term There is a real danger that the lack of such a for different concepts, usually without being vehicle of communication will lead to confusion and to a waste of precious resources. * Paper submitted to WHO Expert Committee on Mental Health, June 1959 These are only some of the reasons why a l Professor of Psychiatry, University of Sheffield, England thorough review, on an international level, of the

838 -601- 602 E. STENGEL present state of the classification of mental dis- situation is capable of improvement. As the first orders has become an urgent necessity. It is sub- step in this direction, a survey and critical mitted that the present chaotic state of the classi- examination of the classifications used in psy- fications in current use for clinical and statistical chiatry today have been carried out. The results purposes is not wholly warranted by the incom- of this study are presented here. plete knowledge of mental disorders and that the

SOME HISTORICAL NOTES

A history of psychiatric classification would be not be said of other contemporary attempts at almost tantamount to a history of psychiatry. classification, some of which, though more Zilboorg (1941) devoted a large chapter of his His- consistent regarding the underlying criteria, were tory of medical psychology to the subject of classi- almost wholly speculative, such as those of Mey- fication. Other historical studies, though more nert (1890) and Wernicke (1900). Kraepelin's clas- limited in scope than Zilboorg's, are those of Birn- sification is closely associated with the concept of baum (1928), Gruhle (1932), Ey (1954) and Men- disease entities which he believed he had estab- ninger et al. (1958). No such presentation is lished. Criticism has been directed against this intended here. However, the present state of the concept rather than against the clinical founda- problem cannot be understood, nor can possible tions of the Kraepelinian system, the core of remedies be contemplated, without some historical which has survived many changes of psychiatric considerations. orientation. It represented a clinical nosology Long before the " era of systems " during which based on the methods of descriptive psychiatry, the basis of most present-day classifications was including long-term observation and follow-up. laid, there were physicians who tried to bring or- Its intrinsic value, as far as the psychoses were der into the variety of manifestations of mental ill- concerned, was borne out by its usefulness in ness, and others who warned against rash systema- genetic research. However, its failure to establish, tization. Zilboorg (1941) quoted Nasse as having to the clinician's satisfaction, disease entities simi- observed in 1818 that in his day practically every lar to that of general paralysis, and the artificia- worker dealing with mental diseases felt he had to lity of any attempt at classifying the almost infi- offer a classification of his own, while Pinel in nite variety of abnormal behaviour, have led to a 1809 had insisted that medical science was not decline in the prestige of psychiatric classification. sufficiently advanced to allow of any change in Recently, the attitude of many psychiatrists the simple classification which he himself had pro- towards the conventional type of classification has posed. In the latter part of the nineteenth cen- become one of ambivalence, if not of cynicism. tury, to produce a well-ordered classification This attitude derives partly from a low estimation seemed to have become the unspoken ambition of of diagnosis, which in large areas of psychiatry almost every psychiatrist of industry and promise has remained imprecise and has proved a poor (Zilboorg). guide to prognosis and therapy. Also, the con- The centrepiece of the classifications in use at cept of mental disorder, which in Kraepelin's view present is the part concerning the so-called endo- closely approximated that of physical disease, has genous psychoses. It owes its existence primar- changed in such a way that a conventional medical ily to the work of Falret (1854), Baillarger diagnosis no longer seems applicable. In many (quoted by Zilboorg, 1941), Kahlbaum (1874), schools, especially in America, mental disorders Hecker (1877), and Kraepelin (1920) " whose are viewed as reactions of the personality to nosology presented the culmination of efforts in known or unknown pathogenic factors. The first both France and Germany" (Zilboorg, 1941). who tried to replace Kraepelin's system by a His "empirical dualism" (de Boor, 1954), which scheme of this type was perhaps Hoche (1912) combined cerebral pathology with psycho-patho- with his theory of syndromes, and his arguments logy, was the strength of his system. It was based were impressive enough to make even Kraepelin on clinical observations and took account of the himself revise his earlier conceptions. Later devel- lack of knowledge of etiology. The same could opments were due partly to psychoanalysis, partly CLASSIFICATION OF MENTAL DISORDERS 603 to the concept of psychobiology introduced by more recent development. Many doctors who con- Adolf Meyer (1916), both of which stress the cerned themselves with these conditions did not uniqueness of the individual. Such an approach enter psychiatry through the mental hospital, but has tended to discourage the categorization of via the out-patient clinic and consulting room, mental disorders. where psychoses were comparatively rare. They Throughout the ages, there has existed a con- were investigating and treating small numbers of cept of mental disorders diametrically opposed to patients, in marked contrast to their colleagues the Kraepelinian idea of disease entities. It is the working in mental hospitals and reception wards. unitary concept which holds that there is only one The differences in the types of observational basic mental illness taking various forms. This material from which psychiatrists drew their concept was most clearly defined by Neumann experience and developed their theoretical orien- (1859) a century ago. It has found a modern sup- tation now became an important source of ideo- porter in Karl Menninger, who views the various logical divergencies. It created an apparent anti- types of mental disorders as different only in their thesis between a psychiatry mainly concerned with quantitative aspects, i.e., in the degree of disinte- individuals and one mainly concerned with mental gration of the personality. He discerns a strong disorders. This cleavage was bound to add to the trend towards this concept in modern psychiatry. disagreements on classification. During the last However, opposition to the Kraepelinian classifi- two decades the divisions in psychiatry have been cation did not come from the "psychodynamic " considerably reduced through the gradual merging schools only. The work of Kretschmer (1919) of the different areas of psychiatric work. A great revealed the importance of the personality type number of workers of various orientations have for symptom formation and prognosis in the psy- come to favour a multidimensional approach, and choses, while Kleist (1953), following in Wernicke's the need for classifying the variety of mental (1900) footsteps, rejected the basic principles of disorders is again generally recognized. 1 the Kraepelinian system. He has remained the In spite of doubts and opposition, classifications chief protagonist of the purely somatic orientation based on the Kraepelinian system have continued introduced into clinical psychiatry by Griesinger to be used in some form or other all over the (1861). world. Many psychiatrists have done so under Descriptive psychiatry, which reached its peak protest and expressing their disbelief in the work- with Kraepelin, was for a long time mainly con- ing hypotheses underlying that system. If an cerned with the psychoses ; it was chiefly institu- essential tool is used grudgingly by workers who tional psychiatry in which a small number of doc- have a poor opinion of it, it is unlikely to prove tors were dealing with large numbers of patients. useful and may even do more harm than good. The systematic study of the neuroses and persona- This can be said of psychiatric classification lity disorders, which, from the beginning, were today. the most controversial areas of classification, is a

AN INQUIRY INTO THE PRESENT STATE OF PSYCHIATRIC CLASSIFICATION The World Health Organization has collected countries no registration of psychiatric morbidity information about the psychiatric classifications in had, at the time of the inquiry, been carried out at use in a number of countries. No attempt was all, while in others it was done very thoroughly. made to carry out a complete survey. The aim One of the questions to be investigated was that was to obtain samples which would illustrate pre- sent trends in psychiatric classifization used for 1 Some workers, especially in the English-speaking coun- clinical, tries, have recently used the term " taxonomy " in preference statistical and research purposes. Inquiries to " classification ". Taxonomy means " classification, espe- were sent to the statistical departments of national cially in relation to its general laws or principles " (Shorter health authorities as well as to a number of Oxford English Dictionary). It is therefore not quite correct lead- to use this term as co-terminous with classification. There ing psychiatrists. The information received may be psychological advantages in using a new term for showed that the interest in and the provisions for an old one, especially if the latter has fallen into some dis- repute, but they are likely to be offset by the misunderstand- statistical classification varied greatly. In some ings arising from duplication of terms for the same concept. 604 E. STENGEL of the use and usefulness of the existing Interna- However, the majority of those in the second tional Statistical Classification of Diseases, Injuries, group were proposed with the aim of meeting and Causes of Death (World Health Organization, some of the dissatisfaction felt about the classifi- 1957), as far as it concerned psychiatry. This cations in use. In comparing these classifications classification had been adopted in a small number it has to be kept in mind that some are very of countries only. In several countries special recent, while others, having been in use for many committees concerned with classification and years, are recognized in their countries as obsolete aiming at establishing uniformity within their and are due to be replaced before long. national boundaries, were at work at the time of the inquiry. There was almost general dissatis- 1. OFFICIAL, SEMI-OFFICIAL OR NATIONAL faction with the state of psychiatric classification, CLASSIFICATIONS (ANNEX 1) national and international. International Statistical Classification of Diseases, The classifications which were received in the Injuries and Causes of Death (ICD) (Annex 1, course of the inquiry are listed in the annexes at page 622) the end of this article. At first glance, they may Although all Member States of the World not seem to differ greatly from each other, but on Health Organization had recommended this classi- closer examination they show considerable diver- fication for use, it has been adopted in only a gencies. These might be due to differences in the small number of countries. However, in some functions various classifications were meant to of them it is used only by the bureaux of statis- serve, as well as to differences in the underlying tics, while the hospitals use one or more different theoretical orientation. Factors of a more tech- systems of classification which, for statistical pur- nical nature, such as the medical manpower and poses, have to be converted into the ICD, often at the administrative apparatus available, are also the price of some loss of identity between the likely to have played a part. Many classifications, concepts. The ICD is in use in Finland, New especially those serving large geographical areas, Zealand, Peru, Thailand and the United Kingdom. show features indicative of compromises between In addition, there are several countries where only different orientations and purposes. The history of List B of the ICD (Abbreviated list of 50 causes the problem in a particular locality or country for tabulation of mortality) is used in psychiatry. must also have played an important part. There The above list of countries which have adopted exists a strong conservatism in matters of classi- the ICD is probably incomplete, as inquiries were fication. In some countries, a certain type of not sent to all Member States. There can be no classification may have become part of the medical doubt, however, about the failure of the ICD to tradition, while in others, where no such heritage find general acceptance as far as psychiatry is existed, it may have fallen to a committee to concerned. The causes of this failure require to choose or to work out a system of classification. be carefully studied by all those concerned with All this must be taken into consideration in trying a classification which could serve as an inter- to understand differences between classifications national tool of communication. In view of the in use in various countries. special importance of the ICD it will be fully There are several criteria according to which discussed in a separate chapter (page 606). classifications can be grouped, all of them arbi- The ICD differs from all other classifications trary. For the purpose of this study it would referred to in this report in that it does not group seem appropriate to divide them first of all into all mental disorders together. Section V is the two groups: only part of the ICD solely concerned with psy- (1) those which have been used or recom- chiatric conditions, but it does not contain all of mended by public health authorities or learned them. A considerable number of mental disor- societies (i.e., official, semi-official, or national ders are listed in the context of other sections. classifications); The pros and cons of this arrangement will be discussed later. No general principles for drawing (2) those which have not been used for this up the various categories are explicitly stated, but purpose, either because they have not yet been wherever applicable reference is made to organic adopted, or because they were not meant to serve etiological factors. In some categories psycho- this function. genic etiology is referred to. CLASSIFICATION OF MENTAL DISORDERS 605

Classification of the American Psychiatric Asso- chiatrists. Proposals for a new classification are ciation (APA) (Annex 1, page 628). under active consideration. This classification has been in use in the United The French standard classification is compre- States, with the exception of the State of New hensive. Its main orientation is that of clinical York, since 1952. It is based on a revised psychia- nosology. tric nomenclature which is part of the American Standard Nomenclature of Diseases and Opera- The Wiirzburg Scheme (Annex 1, page 631) tions, 1952. Unlike Section V of the ICD, it There is no official or standard classification in provides the psychiatrist with a comprehensive Germany, but the majority of hospitals are using system covering all psychiatric conditions. The the diagnostic scheme recommended by the Deut- users of this classification are greatly assisted by scher Verein fur Psychiatrie at Wurzburg in 1933. the Diagnostic and Statistical Manual for Mental Several modifications of this classification have Disorders issued by the American Psychiatric been proposed recently. Some of them will be Association (1952). This manual also contains a referred to later in this survey. glossary of psychiatric terms. The APA classifi- The main criterion employed in this classifica- cation is the best documented among recent tion is organic etiology, either established or classifications. Its adoption by some other coun- postulated, and consisting in structural disease of tries of the Western Hemisphere has been under the brain or other organs, or in constitutional consideration for some time. In view of its special factors. It differs from the classifications referred importance, the distinctive features of the APA to earlier in that the neuroses are not placed in an classification will also be discussed in a special independent group but are included in the two chapter (page 610). Here it will only be mentioned categories of "psychopathic personalities" and that this classification is based on etiological " abnormal reactions ". considerations; psychogenic etiological factors are accorded equal status with organic causes. Classification of the Dutch Association for Psy- chiatry and Neurology (Annex 1, page 632) The Canadian Classification (Annex 1, page 630) This classification exemplifies the clinical-noso- This is a shortened version of Section V of the logical approach in a simplified form. The prin- ICD. The twenty-five psychiatric categories of ciples underlying it are similar to those of the the latter have been reduced to twenty-one. This French and German systems listed above. The reduction has been achieved by merging the cate- 14 categories of mental disorder fall into two gories for senile and arteriosclerotic psychoses, by groups: in the first four categories a constitutional dropping one of the miscellaneous categories of or unknown structural cause is implied; in the psychosis, by making " psychoneuroses with soma- rest an organic disease or physiological process is tization reactions" into a single category instead regarded as the etiological factor. Neuroses and of three, and by grouping together "pathological personality disorders are not separated. and immature personalities", which are separate categories in the ICD. The category " phobic reac- Classifications in use in the Scandinavian countries tion" has been dropped. On the other hand, Only the official Danish classification is of recent epilepsy, and psychiatric conditions associated with origin (Annex 1, page 632). The statistical classifi- it, have been given independent status in this sys- cations used in Norway and Sweden are regarded tem, contrary to Section V of the ICD, which as obsolete and are to be replaced before long. provides for psychosis resulting from epilepsy only Although both are of a rather simple nosological in a miscellaneous category. These modifications type they show considerable differences which are are of interest because they indicate some points all the more remarkable as the two countries share of criticism of the ICD. a common basic psychiatric orientation. It would appear that medico-legal and administrative con- The French Standard Classification (Annex 1, page siderations played an important part in the drawing 631) up of the Swedish statistical classification. This is This was introduced in 1943 and made conver- suggested by the broad division of the material tible into the ICD in 1948. It is regarded as into insanities and disorders not thus classifiable. unsatisfactory and obsolete by many French psy- A new Norwegian classification (Annex 2, page 606 E. STENGEL

642) which has not been officially introduced, will only in the arrangement of the material, which be listed among proposed classifications. It is was divided into nine categories by Kerbikov et appropriate in this context to point out that epi- al. and into thirteen by Giljarovskij. The are demiological, especially demographic, research has based on classical European nosology to which been among the chief interests of the Scandinavian Pavlovian concepts are applied. Koupernik (1958), psychiatric schools. It can therefore be assumed commenting on the textbook by Kerbikov et al., that the classifications have been designed with a pointed out that anxiety neurosis did not figure in view to their usefulness for this kind of research. the list. He also observed that in the concept of psychogenesis of the Russian authors, traumatism Classification of the Danish Psychiatric Society, rather than conflict was assumed to be the patho- 1952 genic agency. Lustig drew attention to the low The orientation of this classification, like that importance accorded by Russian psychiatrists to of other classifications of the Scandinavian psy- hereditary factors. Their basic approach is neuro- chiatric schools, is frankly clinical-behaviouristic. logical and neurophysiological. From this orien- Where the etiology is unknown and controversial, tation they are aiming at an etiological classifi- i.e., in the psychoses, neuroses and personality cation of psychiatric disorders. disorders, this classification is not committed to one particular kind of causation. It therefore has Classifications in use in Japan special categories for predominantly psychogenic Professor Tsuneo Muramatsu of the University psychoses and personality disorders. Another of Nagoya approached the Mental Health Section feature peculiar to this classification is the main of the Ministry of Health for information about category of " isolated abnormal reactions " occur- the classifications in use in Japan. He was in- ring in people who cannot be fitted into any other formed that so far " four different systems " had main class. been employed by the Mental Health Section. The guiding principle inderlying this type of 1. Classification used in the " Mental Hygiene classification appears to be that, in the present Law" (1950). state of psychiatry, differentiation and classification 2. Classification used in the national survey in should be based mainly on clinical observation, 1954. unbiased by theoretical generalizations. 3. Classification used in the national survey of H. Bersot's statistical classification (Annex 1, page hospitalized psychiatric patients in 1956. 634) used in Portugal and Switzerland 4. International Statistical Classification of The Instituto Nacional de Estatistica of Portugal Diseases (World Health Organization, 1957), and the Swiss Bureau Federal de Statistique used, Section V, but only with three-digit categories. at the time of this inquiry, a classification proposed The classifications 1, 2 and 3 were not reported for international use by Bersot in 1937. It is a in detail, but according to Professor Muramatsu shortened version of the French standard classi- they were relatively simple and each of them was fication (page 605 and Annex 1, page 631), the adapted to its special purpose. number of main categories having been reduced In the five most popular Japanese textbooks of to eight. psychiatry, modifications of the Kraepelinian Classifications in use in the USSR system are used. According to Professor Mura- matsu, the classification reproduced on page 635, The two relevant classifications reproduced in Annex 1, represents a composite picture of those Annex 1, pages 634 and 635, are taken from systems. current textbooks. The authors of the first are Kerbikov, Ozeretskij, Popov & Snezhnevskij (1958), the author of the second is Giljarovskij 2. INTERNATIONAL CLASSIFICATION OF DISEASES (1954). The first textbook was available in the This classification is a relatively new venture, original, while the classification contained in although demands for such a classification had Giljarovskij's textbook was available only in the been expressed as early as the beginning of this German translation by Lustig (1957). The two century when an international classification of classifications did not differ fundamentally but causes of death was first introduced. The present CLASSIFICATION OF MENTAL DISORDERS 607

ICD was introduced by the World Health Organ- tric Association (1952), the following criticisms are ization in 1948 and adopted for use by all Mem- made of the International Classification: ber States. This decision was reaffirmed in 1956 following the 1955 Revision. However, the classi- It does not provide for coding Chronic Brain Syn- drome associated with any disease or condition with fication has been implemented only in a small neurotic reaction, behavioural reaction or without number of states as far as psychiatry is concerned. qualifying phrase except in title 083.1-postencephalitic, It is true that there are other areas of morbidity, personality and character disorders. Nor does it provide for instance that of cardiovascular diseases, where for coding Acute Brain Syndrome within the group of the ICD has met with difficulties, but nowhere psychotic conditions, except alcoholic delirium (included have they been as serious as in psychiatry." The in 307) and exhaustion delirium (included in 309). Seventh Revision Conference (1955) recommending ... the International Statistical Classification contains the renewed adoption of the classification was no some categories which may be too inclusive for adequate doubt aware of the controversial character of some tabulation of diagnostic data, especially with respect to diagnostic distribution of patients under treatment in sections. In the introduction to the revised list mental hospitals. (page xxxi) reference was made to these difficulties: It is recognized that certain sections of the Classifica- The extracts below represent samples of replies tion are not entirely satisfactory. Such shortcomings, to the inquiry concerning the ICD received from however, are the reflexion of a persisting division of psychiatrists who have not adopted it. opinion on nosological approach and disease etiology, and amendment of the Classification should preferably Professor 0. 0degard, Oslo: not be attempted till substantial agreement has been 1. There is no room for reactive or psychogenic reached among clinicians and pathologists not only at the depressions of psychotic degree, which means that such national level but also internationally. The section, conditions will have to be classified under manic-depres- " Mental, psychoneurotic and personality disorders ", sive psychosis or under neuroses. represents a typical example of this kind. In view of the 2. Reactive or psychogenic psychoses with predomin- variety ofclinical classifications in use in various countries,- antly confusional (or " hysterical ") symptomatology are which differ from each other both in terminology and in in the same way hard to place within the system. the concepts of classification, any major change in the Classification at this stage would not necessarily prove 3. The same applies to the frequent and often atypical more satisfactory internationally than the present psychotic reactions in imbeciles or other mental defectives. provisions. Another example is the large group of which, for administrative purposes, should be singled out degenerative vascular conditions manifesting themselves in a separate group. as hypertension, arteriosclerosis, cardiac and renal 4. It seems inconvenient that symptomatic psychoses affections or lesions of the central nervous system. should be classified only under the basic disorders- general paresis, for instance, under syphilis. The sub- This paragraph has been quoted in full because groups under schizophrenia as well as under pathological it stated the policy of WHO at the time. The and immature personality are controversial and too opinion that there would be no advantage in numerous. changing unsatisfactory sections of the Classifica- tion before substantial additions to knowledge have Professor V. Lunn, Copenhagen: accrued is reasonable enough for a classification Regarding our views about the International Clas- which has been generally adopted with all its sification, I can only state that it is based on diagnostic imperfections ; it is hardly applicable, however, if and nosological considerations different from ours, and those who were expected to use the classification that it is, from our point of view, so unmanageable that have, with very few exceptions, refused to adopt I do not think it will ever be accepted in this country. it. It was incumbent on this review to investigate Professor E. Stromgren, Aarhus: the reasons for this refusal and also to find out how the ICD has been working where it has been The two main objections to the ICD are that so many adopted for use. psychiatrically significant states are not to be found in the Manual for the psychiatric part of the list, and that the terminology In Diagnostic and Statistical of the neuroses differs very much from that in use in Mental Disorders issued by the American Psychia- Scandinavia. 1 Personal communication from Dr M. Cakrtova, Dr J. Meyer, Munich: Chief, International Classification of Diseases and Develop- ment of Health Statistical Services, WHO The ICD is too complicated and unwieldy. 608 E. STENGEL

Dr Henri Ey, Paris, in an essay on psychia- rate, the fact that Section V cannot be used as a tric classifications (1954), criticized the ICD for its comprehensive psychiatric classification has been incoherence and inconsistency with regard to basic strongly resented by many psychiatrists and has principles. In his view, most classifications in no doubt been one of the main reasons for its current use were mere enumerations and nomen- rejection. clatures. Another criticism made against Section V is Section V of the lCD is headed " Mental, Psy- that several categories are too inclusive and lacking choneurotic and Personality Disorder". The in subcategories. An example is sexual deviation. wording is unfortunate as it implies that "mental It forms one of the subdivisions of "Pathological disorder" means "psychosis ". This use of the personality " (320) and all types of perversions are adjective "mental" is out of keeping with the listed as if they were of equal importance or differ- orientation of modern psychiatrists who have for ent names for one and the same disorder. The many years endeavoured to persuade their medical same criticism has been made of categories such colleagues and the public at large that in " men- as " Senile psychosis " (304), " Alcoholic psycho- tal" hospitals all kinds of conditions are treated sis " (307), etc. On the other hand, the subdivi- besides the " psychoses ", which are still generally sions of the categories concerning personality regarded as identical with the " insanities ". When disorders have been criticized for not being mu- psychiatrists talk of mental health today they no tually exclusive. Child psychiatrists have felt that longer mean simply freedom from insanity. It the ICD served their needs of classification very is surprising that such a blatant terminological inadequately. anachronism could have survived the recent re- vision of the ICD. The ICD in action Unlike the classifications used nationally and In the United Kingdom the ICD has been used regionally, Section V of the ICD does not lay unmodified since its adoption in 1948. This cir- down a definite terminology to the exclusion of cumstance has provided an opportunity to obtain any other. However, in its main headings it avoids the views of some of those who have worked with the term disease and speaks of disorders or reac- this system and also to examine certain aspects tions instead. As far as possible, it leaves the of its usefulness to the potential research worker. door open to a considerable variety of terms I am grateful to Dr W. Maclay, Senior Commis- ancient and modern. It is not self-contained as sioner of the Board of Control, Ministry of Health, far as the psychiatrist's requirements are con- and to Miss E. Brooke, General Register Office, cerned. A number of categories with an organic London, for valuable information. Data for sta- etiology are located outside Section V. There may tistical registration are received only from mental have been several reasons for this arrangement, hospitals concerning in-patients. This material, one of them considerations of convenience for therefore, does not include data from psychiatric general physicians who would not have to go departments and observation wards of general outside their sections when classifying a psychiatric hospitals; but they cater for only a very small complication of physical illness. It may also have proportion of the psychiatric patients, many of been the deliberate policy not to isolate psychiatry, whom enter mental hospitals after a short stay in but to emphasize the unity of medicine. If this the general hospital. The case material of the was the intention it was not carried out consist- psychiatric out-patient clinics is not reported for ently. Although it is stated first that " this section registration by the General Register Office. excludes transient delirium and minor mental In the light of ten years' experience, Dr Maclay disturbances accompanying definitely physical and Miss Brooke expressed themselves far from illness ", it also excludes such major psychiatric satisfied with the way the ICD had been working. disorders as general paralysis of the insane, puer- Their chief complaint was that the psychiatrists peral psychosis, and postencephalitic personality who supplied the data for classification very fre- disorders. Nor can Section V be regarded as quently used diagnostic terms which could not, or providing only for disorders of psychogenic or of could only with difficulty, be fitted into the categ- unknown organic origin, as it includes conditions ories of the ICD. This was happening although with known organic etiology such as senile, pre- all psychiatrists were provided with instructions senile and arteriosclerotic mental disorders. At any concerning the use of the ICD. The Register Office CLASSIFICATION OF MENTAL DISORDERS 609 had to work out special rules for their coding accordance with the nature of the psychotic symp- officers to enable them to fit individual diagnostic toms presented. This particular difficulty is no terms into the categories of the ICD. There was doubt due to the fact that most psychiatric obviously a widespread disregard for the official categories are based on symptomatic criteria, classification among psychiatrists. while the concept of puerperal psychosis is an It is not surprising, under these circumstances, etiological one. that some of the statistical data obtained with the The Registrar-General's (1958) Statistical review help of this classification were evidently wrong and of England and Wales for the 2 years 1952-1953 misleading. Table 13 in the Registrar-General's showed the same trends as that for 1949. The (1953) Statistical review of England and Wales for total number of admissions had risen from 55 785 the year 1949 throws some light on the way the to 67422 and most categories showed an increase ICD was used. There has been no material (Appendix to the review, Table M5). However, change in subsequent reports. It was obvious that there were some peculiar discrepancies, such as the several of the categories of the ICD were not rise in the number of paranoid states in the Man- recognized by the majority of psychiatrists respon- chester region from 14 to 79. The number of sible for the diagnoses. This was most striking cases classified under the heading " Psychoneurosis with regard to categories 315 to 317 (" Psychoneu- with somatic symptoms" (315-317) had decreased rosis with somatic symptoms "). Patients suffering to 88 for the whole country. In 1956 it had from the more severe forms of these conditions dropped to 56, according to Miss Brooke. are not at all rare among those treated in British This rather superficial examination of two statis- mental hospitals. It is quite unbelievable, there- tical reports shows that, in England and Wales at fore, that of 55 785 patients admitted to the least, as far as mental health is concerned the ICD mental hospitals in England and Wales in 1949 has largely failed in its purpose of providing only 114 should have fitted into this category. reliable information on the various types of Probably most of the patients who might have disorders. There are apparently two main reasons qualified for inclusion under this heading were for this failure: first, the system of classification placed in other categories, such as those of hyster- was only partly accepted by the psychiatrists who ical or anxiety reactions. The numbers of patients supplied the data; and secondly, there was insuffi- recorded for several other categories, such as cient agreement about the meaning and scope of schizoid, inadequate or immature personality, were the categories. The value of the statistical infor- so small that they indicate an insufficient usefulness mation thus obtained for epidemiological studies of these categories rather than an extreme rarity is extremely dubious. of those conditions among the admissions to the It is unfortunate that the recommendation made mental hospitals. in 1950 by the WHO Expert Committee on Mental Among the categories 300-309, which include Health for the compilation of a glossary of descrip- various types of psychoses, there were striking tive definitions of the 3- and 4-digit headings in discrepancies in the recorded figures, but these were that part of the ICD relevant to psychiatry has probably only terminological. This applies, for never been implemented. Such a glossary might example, to the categories " Involutional melan- have reduced the confusion arising from the in- cholia " (302) and " Paranoia and paranoid states " consistent use of terms. (303). Thus, it is noteworthy that the diagnosis Some of the difficulties arising from lack of of a paranoid state was made in the Manchester direct communication between coding officers and region only 14 times among 3212 admissions, while psychiatrists can be overcome where regular per- in other regions with approximately the same sonal consultation is practicable, as, for example, number of admissions it was made 43, 125, 100, in the case of the Institute of Psychiatry of the 82, 74 times respectively. Similar discrepancies University of London, and the associated Bethlem could be found in the case of involutional melan- Royal Hospital and Maudsley Hospital, which cholia. Another category in which there were together accommodate 450 patients. These insti- very marked discrepancies was puerperal psychosis tutions have their own recording office and every (688.1); the unexpectedly small numbers reported doctor working there is provided with a " Records suggest that many cases falling into this group handbook" containing Section V of the ICD and were classified under other headings, probably in careful instructions for its use. Mrs M. Perkins, 610 E. STENGEL the Transcription Officer, has informed me that, in or cerebral lipoidosis, should be classified under the using the ICD, she has encountered similar diffi- appropriate heading. culties to those described by Miss Brooke, and her (3) In the case of children, some appropriate test other complaints concerning Section V were along the than the Stanford-Binet may be used as a standard of same lines as those of other critics. She had had reference, such as the Wechsler Intelligence Scale for to work out subclassifications of several categor- Children for suitable ages. It should, however, be borne ies where they were lacking, for instance, in the in mind that in the case of children, intelligence tests case of hysterical reactions, drug addictions, and results, particularly with no chronological or mental ages, are of limited value and liable to change from time to sexual deviation. Not infrequently, the diagnoses time. have proved uncodable, but on every such occasion the psychiatrist concerned has been consulted and an agreement reached. Mrs Perkins expressed the 3. THE AMERICAN STANDARD NOMENCLATURE view that without easy access to the psychiatrists AND CLASSIFICATION (" THE STANDARD ) supplying the data for coding she would often be (ANNEX 1, PAGE 628) completely at a loss. Diagnoses received from the This system did not, like many other classifica- out-patient department are also coded, but, as a tions, develop by accretion. It is the result of rule, they prove simpler and less controversial than careful and lengthy deliberation by a committee those made in respect of in-patients. Conditions of experts. It shows unmistakable signs of the for coding are no doubt exceptionally favourable democratic process which tries to offer something in this particular hospital group. to every interest. The initiative for the introduc- Dr B. H. Kirman and Dr L. T. Hilliard of the tion of the new nomenclature had come chiefly Fountain Hospital, London, made some interesting from psychiatrists working in private practice and comments in their reply to an inquiry concerning clinics rather than from those working in public their experience with the ICD in the field of mental hospitals. Those pressing for a new nomenclature deficiency. They referred to earlier criticism con- were specially interested in the areas of personality tained in a report entitled " The mentally sub- disorders and transient reactions to psychological normal child" (World Health Organization, 1954). stress, i.e., the disorders that are not quite so In part this criticism had been met in the sub- common in institutional work. In Britain, the sequent edition of the ICD published in 1957, but ICD is used almost exclusively for hospital in- Dr Kirman and Dr Hilliard are still critical about patients. If this should apply to the " Standard " some of the subclassifications: also it would mean that those providing the bulk About the clinical classifications, it seems perhaps a of the data would be comparatively little interested little arbitrary to pick out mongolism for a special head- in what is one of its most characteristic features, ing under 325.4 though this can be justified on the score i.e., the sections concerning personality disorders that this is the biggest clinical group. We find that in our and neurotic reactions. series phenylketonuria ranks second after mongolism, The "Standard" is self-contained, i.e., it pro- though it is a long way behind numerically. There does vides categories for all psychiatric conditions. The not seem to be any very good reason for putting Tay first section includes all psychiatric disorders in Sachs disease under 325.5 whilst Schilder's disease is to be which an impairment of brain-tissue function can found under 355 as a disorder of the nervous system and be assumed, however transient and of whatever tuberous sclerosis appears under 753.1 as a congenital malformation lumped in with microcephaly and some origin. Although the involvement of the brain eye lesions. may be trivial and quite accidental to the main physical illness, it qualifies the case for inclusion Practical suggestions in the psychiatric section. For this technical It would probably be best to abolish categories 325.3, reason, the involvement of the brain is invariably 325.4 and 325.5, and to insert three notes: given first consideration, and not the main illness (1) Cases of borderline intelligence who come for which would often be much more important medi- advice should be classified according to the presenting cally than the psychiatric condition. The choice problem other than limited intellect, for example under of the common denominator of impaired cerebral neurosis. function made it possible to present all organic (2) Cases of mental deficiency falling into specific psychiatric conditions in one comprehensive sec- clinical categories such as mongolism, phenylketonuria, tion. The logical advantages of this arrangement CLASSIFICATION OF MENTAL DISORDERS 611 are obvious, though it resulted in the breaking up The main difficulty about the section concerning of traditional clinical groups of mental disorders. personality disorders seems to be the tendency of There was little left of mental deficiency outside the various subclasses to overlap. A personality the section of brain disorders, and of the psychoses can at the same time be inadequate, emotionally only the schizophrenic and manic-depressive reac- unstable, and aggressive. The " Standard " shares tion types remained as a separate group. this difficulty with the ICD and other classifica- The term " brain syndrome" might lend itself tions. to misinterpretation, especially by neurologically The Diagnostic and Statistical Manual for Men- orientated psychiatrists. They may be tempted to tal Disorders (American Psychiatric Association, use it for a variety of cerebral syndromes other 1952) offers valuable directions about recording than those to which it is meant to apply. However, and it enables the psychiatrist to indicate the role the glossary is supposed to obviate such mistakes. of external stress, the type of the premorbid per- The part concerning psychotic disorders shows sonality, and the degree of psychiatric impairment. the tendency to advance or at least to stimulate The Standard Nomenclature and Classification is etiological theories. " Involutional psychotic reac- based on a framework of established or hypotheti- tion" was singled out as a disorder due to disturb- cal etiological causes. The underlying philosophy ance of metabolism, growth, nutrition or endocrine is that of a single causal factor, or at least a function, which may be understood to imply that hierarchy of causal factors, one of which, the such etiological factors play no part in other con- involvement of the brain, is singled out as the ditions. Otherwise the section concerning psy- most important. The validity of this approach is choses follows on the whole the conventional debatable, even where the causative factors are pattern. Many psychiatrists will welcome a special known. category for " Psychotic depressive reaction " and Would the Standard Nomenclature and Classi- possibly also for " Schizophrenic reaction, schizo- fication be suitable for international use? To affective type". About the placing of the paranoid answer this question one would have to know first psychoses the "Standard" is as ambiguous as the how it has been working in the United States. ICD, and the glossary is, in this instance, un- Has it been used in the way it was intended to be helpful. and has its provided meaningful information ? The next section is entitled " Psychophysiologic No definite answer to these questions could be autonomic and visceral disorders ". This title seems obtained. They are at present under review by a to be based on a presumed etiology. Although the committee of the American Psychiatric Associa- glossary explains that this section comprises the tion. psychosomatic disorders it is not clear whether The "Standard" certainly meets one of the bronchial asthma and peptic ulcer are meant to be main criticisms levelled against the ICD, that of included. The glossary is ambiguous about it. It incompleteness. However, it is doubtful whether mentions bronchial spasm and peptic-ulcer-like the method by which all psychiatric conditions of reaction. organic origin were included would be generally The section devoted to psychoneurotic disorders acceptable. Other objections to the ICD, especially differs from the conventional classification in that those concerning neuroses and personality dis- the time-honoured term hysteria has been elimi- orders, apply equally to the " Standard ". nated.

PRINCIPLES OF PSYCHIATRIC CLASSIFICATION

1. GENERAL PRINCIPLES exclusive and jointly exhaustive. Each class comes to be specified by means of a corresponding con- Carl G. Hempel (1959) recently discussed the cept which represents the characteristics essential principles of classification in general and their for membership in the class. A classification, application to mental disorders. A classification, therefore, is a special type of scientific concept. he pointed out, divides a given set or class of Description and theoretical systematization are objects into subclasses which should be mutually two basic functions of scientific concepts and

15 612 E. STENGEL therefore of taxonomic systems, i.e., classifications. most important constituent is to be given pre- In medical science there has been a gradual devel- cedence over the less important, but this is an opment from a predominantly descriptive, i.e., arbitrary judgement which often proves mistaken. symptomatological, to a theoretical, i.e., etiological We have no means of measuring those consti- emphasis. Hempel discussed the difficulties of tuents objectively. Because of these difficulties, using objectively verifiable concepts in psychiatry. psychiatrists are still using simple diagnostic con- These difficulties are indeed so serious that many cepts. There is much to be said in favour of psychiatrists have despaired of classification. operational definitions in psychiatry. In fact, many However, similar difficulties existed, and still exist, of the present nosological concepts are operational in other fields. Hempel pointed out that one of definitions; this would not be readily admitted by the favourite remedies in such a situation had been many psychiatrists because the quest for disease to insist on agreed operational definitions the entities has created the idea that our diagnostic requirements of which should not be too rigid: concepts stand for biological realities with which it mere observation must be allowed to count as an would be wrong to tamper. Schizophrenia, then, operation. To be scientifically useful a concept as an operational concept, would not be an illness, must lend itself to the formulation of general prin- or a specific reaction type, but an agreed opera- ciples which would provide a basis for explanation, tional definition for certain types of abnormal be- prediction, and, in general, scientific understanding. haviour. It should be less difficult to agree about "A good taxonomic system is based on, and an operational definition than about a hypotheti- reflects, a more or less comprehensive system of cal illness. The same applies to such concepts as laws ... These systems will change with the psychopath, etc. The question, therefore, which a theoretical advance made in the field. Systems of person or group of persons trying to reach agree- classes defined in terms of manifest observable ment on a national or international classification characteristics, give way to systems whose defining ought to answer is not what schizophrenia or principles are couched in terms of theoretical con- psychopathy is, but what interpretation should be cepts ... This trend has also been in evidence in placed on these concepts for the purpose of diag- the development of taxonomic systems for mental nosis and classification, i.e., for the purpose of disorders." A further stage to be expected may communication. Those who find it difficult to be "a gradual shift from classificatory concepts accept this frankly practical and utilitarian attitude and methods to ordering concepts and procedure to psychiatric classification should be referred to both of the non-quantitative and quantitative Kraepelin's comments on the last version of his varieties ". The latter trend was illustrated by the classification: " Ich mochte nachdrucklich darauf growing interest in borderline cases, mixtures, hinweisen, dass manche der abgegrenzten Krank- transitional forms, etc. heitsbilder nur Versuche darstellen, einen gewissen In psychiatry, the application of the principles Teil des Beobachtungsstoffes wenigstens vorlaufig of classification outlined by Hempel meets with in eine lehrbare Form zu fassen ". (" I should like considerable difficulties. Firstly, what do we clas- to emphasize that some of the clinical pictures out- sify in this field? Are we classifying diseases or lined are no more than attempts at presenting part people? Psychiatrists could be divided into two of the material observed in a communicable form.") groups according to their answers to this question. It is most unlikely that Kraepelin himself would It may be said that the material the psychiatrist have disagreed with the recent statement by de has to classify consists neither of diseases nor of Boor (1954) that Kraepelin's groups of clinical pic- people but of a variety of disorders or reactions, a tures are no more than conventions ; they can be material which does not readily lend itself to classi- more precisely termed operational definitions. It fication. And there is the added complication appears, therefore, that many psychiatrists since that these disorders, or reactions, are not mutually have been more Kraepelinian than Kraepelin. exclusive, and that features of two or three reac- tion types often co-exist. This is why diagnostic 2. PRINCIPLES UNDERLYING THE PSYCHIATRIC formulations, within which all the main consti- CLASSIFICATIONS LISTED IN THIS SURVEY tuents of the disorder can be accommodated, have It is assumed that " the class of objects " to be often been found more satisfactory than a single subclassified in psychiatry is that of mental dis- diagnosis. In these formulations, the supposedly orders. This term is less controversial than that CLASSIFICATION OF MENTAL DISORDERS 613

of mental diseases or reactions. One ought to psychopathic personalities. Within this conceptual start by defining the concept of mental disorder, framework, Schneider's classification is based on but this would first require a definition of mental etiology. The concept of the neurosis as a psycho- health. There is no prospect of agreement on pathic reaction had a profound influence on psy- these concepts today. This difficulty is not specific chiatric theory and practice, especially in Germany. to psychiatry, although it is more serious here than However, in some recent German classifications in other fields of medicine where operational the neuroses and psychopathies are again treated definitions of health and disease seem easier. Psy- as separate categories. chiatrists, in designing their classifications, have Adolf Meyer's (1916) basic concept of mental not as a rule stated their general concepts of disorders as reactions to life situations led even mental disease within which the various elements further away from the concept of disease entities, were to be classified, but it is usually possible to which he recognized only in the case of some discern them from their classifications. The choice conditions of proven organic etiology. Although of criteria for subdividing the material depends Meyer would hardly have agreed with Schneider's on the underlying general concept of mental dis- classification, his group of reaction types (Annex 2, order. What have been those criteria, or prin- page 641), which includes the so-called endogen- ciples, or dimensions, or axes of subdivision in the ous psychoses, is ideologically akin to Schnei- classifications listed in this survey ? 1 der's "varieties of sane life ". Both systems tend Kraepelin's orientation (Annex 2, page 640) has to widen the borderland between normal and . been described as one of " empirical dualism " (de abnormal mental life. Meyer's classification, which Boor, 1954), i.e., he combined cerebral pathology differentiates mental disorders according to be- with psychopathology. At first, it seems, his havioural differences, follows logically from his approach was dualistic with regard to methods of concept of mental disorder which is fundamen- investigation rather than to his concept of mental tally psychopathological. disorder. His idea of disease entities was that of Kleist's (1953) system (Annex 2, page 638) is general medicine. His system of classification, consistently etiological. The assumed pathogenic which at first was mainly symptomatological, factors are lesions, degenerations, maldevelop- became more and more etiological, a psychogenic ments or defective dispositions of the nervous origin of neurotic and some psychotic disorders system, diffuse or localized. The schizophrenias being assumed. This broad division into three are regarded as manifestations of cerebral degener- groups, i.e., organic, probably organic and/or ative diseases, the manic-depressive group as due constitutional, and psychogenic, is still a basic to autonomous cerebral dysfunction. Neuroses feature of most classifications in use today. are supposed to be manifestations of abnormal It did not apparently occur to Kraepelin that cerebral disposition, with psychogenic factors diseases having a psychogenic etiology would be playing only a secondary role. Leonhard's (1957) disqualified from membership of the class of classification of the endogenous psychoses (Annex mental disorders. This is the characteristic feature 3, page 658) follows the same line ; his criteria of of K. Schneider's (1950) broad division of the differentiation are symptomatological with a neu- material (Annex 2, page 647). This author, who rological bias and an emphasis on heredity.2 was strongly influenced by Jaspers, contends that Rumke's (1959) division of the material into the concept of illness applies only where organic three main classes (Annex 2, page 646) is based on changes have been established or can be postulated the role of genetic-developmental pathogenic fac- with confidence. Other mental disorders are only tors. Within this main grouping, synmptomatology " abnormal varieties of sane mental life ". There- is the. chief criterion of differentiation. fore, " there are no neuroses, but only neurotics ". Thus, the neuroses and other psychogenic reac- Ey's (1954) system of classification (Annex 2, tions are placed outside the class of mental illness page 637) is fundamentally psychopathological with in the strictly defined sense, and included with the a psychophysiological basis and an existentialist philosophy. Mental disorder is viewed as a mani- festation of disturbances of two variables, viz., the 1 The classifications not included in the " official" group (Annex 1) have been listed in Annexes 2 and 3. Those used here for demonstrating basic principles are pre- 2 Fish (1958) has produced an English version of Kleist's sented in Annex 2, the rest in Annex 3. and Leonhard's classifications of schizophrenia. 614 E. STENGEL level of awareness 1 (? consciousness) and the func- system. They aim at the most careful categoriza- tioning of the personality. tion of symptoms and syndromes. Only a minor- In the classification of Bosch & Ciampi (Annex ity of the systems are consistent in respect of the 2, page 637) mental disorders are classified accord- principle of classification. The most common ing to the level on which mental activity is func- combination is that of etiological and symptoma- tioning. This is judged by the degree of " auto- tological criteria. It is noteworthy that all the nomy ", i.e., freedom of action possible in a " official " classifications reported here show com- particular disorder. This psychophysiological con- binations of various principles. cept is akin to Ey's. Both are in line with a ten- In many classifications, consistency is maintained dency towards a unitary concept of mental dis- by the postulation of a certain type of etiology, orders, as advocated by Menninger. If one divides e.g., of an organic cause for schizophrenia. The psychiatrists into " separatists " and " gradualists " kind of etiology implied in these classifications is according to their attitudes towards the boundaries that of a single causal factor. This has long been between the various mental disorders, Ey, Bosch recognized as inapplicable in psychiatry. There- & Ciampi and Menninger would fall into the fore, no etiological classification of this kind, second group. A limited " gradualism " can be however consistent in itself, can do justice to the observed in other classifications too, e.g., in that multifactorial origin of mental disorders. It can- of Pacheco e Silva (Annex 3, page 661) where not even be said that in all cases where reference neuroses are classed as minor psychoses. to etiology is made in a classification, the etiolo- Krapf's classification (Annex 2, page 640) ap- gical factor stated is the most important, i.e., the pears to be based on a concept of mental illness as one without which the disorders might not have disturbances of ego-function. Its main divisions arisen. are therefore psychopathological; within this broad Differences of opinion about the relative weight framework, pathophysiological subdivisions are of etiological factors singled out as criteria on introduced and a wide variety of pathogenic which to base definitions are responsible for a factors (organic, hereditary, psychodynamic) are number of divergencies between classifications. distinguished. The question of whether " psychogenic psychoses " Rado's (1953) system (Annex 2, page 646) pre- should be given the status of an independent categ- sents in parts an attempt at a psychodynamic clas- ory is a case in point. Such a category is likely sification in the psychoanalytical sense, but its to be opposed by the " organicist "-who would author had to make use of other frameworks too, accord psychogenic factors only a minor role in especially of clinical and social psychiatry. This the etiology of the psychoses-as well as by the classification is a highly personal product and does psychodynamically oriented psychiatrist. The not represent the views of the psychoanalytical latter would argue that such a category implies school. In fact, no comprehensive and detailed the absence of psychogenic factors in the etiology psychoanalytical classification of mental disorders of the psychoses not so designated. He would exists. also regard a differentiation of psychoses into The above are examples of the concepts and psychogenic and non-psychogenic solely on inform- principles underlying classifications. Only a few ation obtained in one or two interviews as unjusti- have been stated explicitly by the authors of the fied. Similar differences in basic concepts enter systems, and quite possibly different or additional into the question of the relationship between neu- principles could be discerned by other investiga- rosis and psychopathies. Here the problem is that tors. The other classifications reproduced in the of the relative etiological significance of constitu- Annexes are derived from or related to one or tional versus psychogenic factors. more of those basic systems. The Scandinavian A chiefly symptomatological approach is apt classifications, for instance, can be regarded as to create other types of dilemma. Such an orien- modifications and elaborations of Kraepelin's tation might have been responsible for the inclu- sion of anxiety neurosis in the group of affective I The French word " conscience" might in this context be better translated by " awareness" than by " conscious- disorders (Skottowe, 1953, Annex 3, page 662). ness ". While it is possible to see in manic-depressive illness In most classifications, descriptive-clinical, i.e., a restriction of the area of awareness, one can hardly regard it as a disturbance of consciousness, unless one symptomatological or syndromal criteria are used uses an ad hoc operational definition of " consciousness ". side by side with etiological ones, but this is fre- CLASSIFICATION OF MENTAL DISORDERS 615 quently done by implication rather than explicitly. within the category of abnormal personality reac- Essen-Moller and Wohlfahrt (1947) warned against tions. This means that a paranoid condition may mixing the two principles of classification. They have to be considered for inclusion into one or pointed out that, for many psychiatrists, the diag- two or three categories, depending on the system nosis " hysteria ", for instance, had etiological of classification.' implications, although it was usually made on Another mental disorder about whose status in symptomatological grounds. For this reason the the statistical classification there is striking dis- two authors recommend that a descriptive (symp- agreement is that of involutional depression or tomatological, syndromal) as well as an etiological melancholia. Only a minority of the classifica- diagnosis, or diagnoses, should be made in every tions presented have a special category of this case. They also find it sometimes useful to allo- name. Others include this condition among the cate a case to a broad grouping such as psychosis, presenile psychoses side by side with dementias of abnormal personality, etc. Their lists (Annex 3, that age period, while the rest include it among page 649) are, of course, capable of extension. the depressive psychoses. This lack of agreement The system of Lecomte et al. (1947, Annex 3, would defeat any attempt at a comparative epi- page 657) represents a similar attempt at classifying demiological study of this disorder. along two axes, i.e., the clinical and the etiological, at the same time. Langfeldt's (1956) system There is a similar disagreement in respect of (Annex 3, page 655) makes provision for classifica- the psychoses related to child-bearing. Some sys- tion according to main diagnosis, personality type, tems include in this particular category all serious and situational background of the mental disorder. mental disorders (psychoses) related to child- The "Standard" classification (Annex 1) makes bearing; the ICD refers to puerperal psychosis similar provision. No information is available as only. Other classifications obviously include these to whether any such device of classifying along conditions among a general category of symp- two axes at the same time has been used exten- tomatic psychoses or among one of the main sively. mental disorders as the case may be, i.e., manic- Many classifications show features that reflect depressive illness, schizophrenia, or organic confu- the special research interests of their authors, e.g., sional states. In this instance, nosological con- the schizophreniform types of schizophrenia siderations apparently caused the originators of (Langfeldt) and the existential neurosis of van most classifications to refrain from establishing or der Horst (Annex 3, page 650). preserving a special category. At any rate, it is A number of differences between classifications impossible at present to study the psychoses related are attributable not so much to disagreement on to child-bearing epidemiologically and to compare basic concepts of mental illness in general as to their incidence in different areas. differences of opinion on specific clinical concepts. The confusion becomes even more serious, as is The following examples show the measure of dis- to be expected, in those parts of the classificatory agreement in some important areas. systems which are not concerned with the so-called psychoses. Some systems differentiate neurosis from psychoneurosis, while others speak of Schizophrenia, paranoid states, paranoid reactions Erlebnisreaktionen instead, which may be under- stood to mean either reactions to experiences There is considerable variety in the number of or reactions consisting of certain experiences. schizophrenic sub-groups in the various classifica- This category largely overlaps with the neuroses tions. More serious from the point of view of medical statistics is the discrepancy concerning the 1 The difficulties arising for research from a disagreement place of the paranoid psychoses in the system; such as this are illustrated by the recently published book by only a minority of the classifications, including the Hollingshead & Redlich (1958), who studied the epi- demiology of schizophrenia in relation to different socio- ICD, has a special category for paranoid psychoses economic classes. These authors distinguish only one group of equal status with and independent of the other of schizophrenic conditions, which includes the paranoid states. However, it is far from certain whether this broad major categories of psychoses. Some of these category included all cases which some other investigators systems distinguish between paranoid schizophrenia would have listed among paranoid states and/or abnormal and paranoid states, while others do not. A num- personality reactions. This research cannot therefore be tested by those who have adopted a different statistical ber of classifications distinguish paranoid reactions classification. 616 E. STENGEL or psychoneuroses as well as with the psychopathic Annex 3 lists a number of further classifica- personalities of other classifications. The categ- tions not included in Annexes 1 and 2 (see ories serving the statistical classification of abnor- footnote, page 613). It was decided not to omit mal or psychopathic personalities reflect the pro- any classification received so as to enable the found diversities of views held amongst psychia- reader to form his own opinion about the merits trists about the clinical and etiological aspects of of the various systems and the differences those conditions. In some systems they include between them. Some can serve as illustrations for the neuroses. The number of sub-groups varies the criticism that the difference between the func- greatly and so do the principles on which the tion of a nomenclature and that of a statistical subdivisions have been based. classification has occasionally been overlooked. Only six of the classifications listed in this The difference has been clearly stated in the survey provide a category for so-called psycho- Introduction to volume 1 of the Manual of the somatic conditions; there are indications that this International Statistical Classification of Diseases, concept varies from place to place. It partly Injuries and Causes of Death (1957) ; a nomen- corresponds to the category "Psychophysiologic clature, being " a list or catalogue of approved autonomic and visceral disorders " of the "Stan- terms for describing and recording clinical and dard" classification which has ben subdivisions pathological observations ", has to be extensive according to organ systems. In the ICD the and unlimited in scope and detail to allow for arrangement is different; there are three categories the recording of the manifold varieties of ill for these conditions under the heading of " Psycho- health. A statistical classification, on the other neurosis with somatic symptoms ", one for the hand, is concerned with groups of conditions circulatory system, one for the digestive system, whose peculiarities have to be fitted into a limited and a third for other systems. number of categories chosen for their usefulness This list of differences between classifications in in the numerical study of disease phenomena. current use could be further extended, but the The functions of a nomenclature and a statistical examples quoted suffice to illustrate the existing classification are, therefore, in some respects confusion. opposed to each other.

THE PROSPECTS OF AN INTERNATIONAL CLASSIFICATION OF MENTAL DISORDERS AT THE PRESENT TIME

The arguments in favour of an agreed inter- ican textbooks on psychiatry (Noyes & Kolb, national statistical classification of mental disor- 1958): ders have been stated earlier in this review. The While classifications are necessary for statistical and question may well be asked whether, in view of other purposes, there has perhaps at times been too great the existing difficulties and the failure of the ICD a disposition in psychiatry of considering that its objective to find general acceptance, any other classification was obtained when a classificatory diagnosis had been would have prospects of success at the present made . . . The principal value of classification is not a time. Is there sufficient agreement about the need categorizing of disease entity, but in quickly eliminating for such a classification among those responsible those considerations which will be least useful in under- standing the patient and in directing attention to those for the mentally ill, and would there be sufficient which are likely to be relevant. willingness to adopt it internationally? Similar statements affirming the need for classi- It can be stated with confidence that the need fying the various manifestations of mental disor- for an up-to-date classification of mental disorders ders can be quoted from any other textbook of is generally recognized, although there is no com- psychiatry published in America or elsewhere. plete conformity of views about the functions of Special reference has been made to American such a classification. No psychiatrist, whatever views because it is sometimes assumed that there his orientation, could possibly have any quarrel exists a negative attitude to classification of mental with the following statement quoted from the disorders among the United States psychiatrists. most recent edition of one of the leading Amer- This is certainly not the case at present. CLASSIFICATION OF MENTAL DISORDERS 617

The question whether psychiatrists would be that such a solution should be adopted for psy- willing, even at the price of some inconvenience chiatry at present. There probably is sufficient and concessions, to adopt an international classi- basic agreement on terminology for a generally fication of mental disorders at the present time, acceptable list of categories to be drawn up. cannot be answered in the affirmative with equal Possibly, such an agreement would help to prepare confidence. It has still to be established that the ground for a common nomenclature. The psychiatrists and other workers in the field of latter would be a much more ambitious and com- mental health believe sufficiently strongly in the plex undertaking than the attempt to establish a importance of epidemiological research on an statistical classification which would have to be a international level and in the other advantages of relatively simple instrument of communication. It a common language, however limited. Their atti- may even be argued that a generally adopted tude will also depend on the classification recom- detailed psychiatric nomenclature might at the pre- mended for general adoption. sent time have an inhibiting effect on psychiatric If a drastic revision of the existing ICD relevant thought and thus hamper progress.' to psychiatry should be attempted, the reasons for The view is often expressed that the lack of the almost general rejection of its present version agreement about diagnostic concepts is bound to as well as the lessons learned from its use will have defeat the purpose of any national or international to be carefully considered. It will also be advis- statistical classification. Comparability of data is able not to recommend any such system for adop- indeed a serious problem in psychiatry. The relia- tion without a glossary containing definitions and bility of diagnosis in certain areas of psychiatric detailed instructions. Whoever, as an individual morbidity, especially in respect of the so-called expert or as a member of a group, is concerned endogenous psychoses, has sometimes been found with devising a psychiatric statistical classification to be very low. Some investigators, however, have will have to make up his mind on the following found a surprisingly high reliability, especially questions: where psychiatrists shared the same orientation. Psychiatrists have for some time paid too little 1. Is it essential for an international psychiatric attention to their diagnostic concepts which often classification to be preceded by, or even to be the differ considerably, even among members of the outcome of, a generally accepted international staff of the same hospital or institute. If, for psychiatric nomenclature? instance, some psychiatrists regard recovery as 2. Is it essential for such a classification to be incompatible with the diagnosis of schizophrenia preceded by an agreement on basic diagnostic and others do not hold this view, and if they have concepts ? not made it clear to each other that their diag- In considering these questions the possible need nostic concepts differ fundamentally, how can they for other classifications for regional purposes, be expected to agree ? But apart from these diffi- research, etc., will have to be kept in mind, as culties, which could be considerably reduced, the well as the temporary and utilitarian nature of any reliability of psychiatric diagnosis will remain such system of classification. limited in those categories where no objective cri- Desirable though the adoption of a common teria can be employed. Didgnostic judgement nomenclature might appear to most psychiatrists, 1 At the recent Work Conference on Problems of Field it does not seem to be essential for such an agree- Studies in the Mental Disorders held at New York, several speakers referred to the role which language had played in ment to precede a practicable and generally accept- psychiatry. Certain symptoms or mental disorders which to able statistical classification. Probably considera- psychiatrists using one language appear very important, do tions concerning nomenclature have in the past not exist for psychiatrists and patients using another language, because there are no words for them. Several interfered unduly with the requirements of statis- examples demonstrating the part language has sometimes tical classifications. Their respective functions, played in the creation of psychiatric symptoms were men- tioned. These considerations should not militate against a which are partly opposed to each other, have been common basic nomenclature, but they illustrate the com- discussed earlier in this review (page 616). It is plexity and limitations of such a task. They also suggest that the adoption of a detailed common international even conceivable in principle that a statistical nomenclature may deprive psychiatrists of means of com- classification could dispense with nosological terms munication with each other and with their patients which altogether and use numerical or other symbols only their own language can provide. It would, of course, be important for psychiatrists using the same language to only. However, it is not suggested at this stage have an agreed detailed nomenclature. 618 E. STENGEL often still depends on clinical symptoms about of an international classification, questions such as whose presence and significance in an individual these should not be treated as problems involving case opinions may differ. But these difficulties can scientific truth which allows of no concessions, but be overstated. The adoption of operational defi- as difficulties in the way of communication. The nitions should go some way towards reduction of answer, therefore, to the question posed above, disagreements on diagnosis. Earlier in this report whether an international psychiatric classification (page 615) reference has been made to misleading has to be preceded by agreement on basic diag- fluctuations in statistical data, probably due to nostic concepts, is that no such explicit agreement lack of consensus on terminology and basic diag- is necessary, provided that the existence of differ- nostic criteria, such as the status of paranoid ent diagnostic concepts is generally recognized states in relation to schizophrenia or of involu- and guarded against, and provided that opera- tional depression to the manic-depressive group. tional definitions are adopted for the purpose of Considering the provisional and practical nature the classification.

REQUIREMENTS OF AN INTERNATIONAL CLASSIFICATION OF MENTAL DISORDERS

The need for such a classification has been felt which was subsequently adopted in Switzerland for a long time. The urgency of the problem was and Portugal. It is a simple framework for all stressed very recently in the sixth report of the psychiatric conditions, basically different from the WHO Expert Committee on Health Statistics provisions made for psychiatry in the ICD in 1948. (1959) which draws attention to the lack of a Since Bersot proposed his classification for inter- " generally acceptable classification of mental dis- national use, psychiatry has advanced and epi- orders" and recommends that: demiological research has become more sophistica- ted. We also have more experience with statistical "(1) the World Health Organization keep in classifications than the psychiatrists had in 1937. close touch with and co-ordinate national efforts In the light of this experience, and of the lessons aimed at the revision of the section of the Inter- learned from the rejection of the ICD by the national Classification dealing with mental dis- majority of psychiatrists, what are the require- orders; ments of an international statistical classification (2) the World Health Organization provide in of mental disorders today? due course for one or more combined sessions of To be acceptable internationally, a statistical psychiatrists familiar with the principles of classi- classification of mental disorders will have to avoid fication for statistical purposes and of statisticians the impression that it aims at educating psychia- working in the mental health field to review deve- trists all over the world along certain lines which lopments and to suggest further action in respect many of them may not wish to follow. This of the revision." requirement of neutrality in the controversies between various schools of thought imposes con- In considering the requirements of a generally siderable limitations on an international classifica- acceptable psychiatric classification, it may be of tion. It has to be based on points of established interest to recall the last occasion when this prob- agreement. It must be a servant of international lem was fully debated on an international level. communication rather than its master. This is It was one of the main subjects at the Second why it cannot be ahead of its time. It can at International Congress for Mental Hygiene held present be no more than a tool of communication in Paris in 1937. Even then, the needs of for a limited range of data such as the incidence epidemiological research were in the foreground and prevalence of certain mental disorders. It of the discussion. Hubert Bond expressed the should not be the purpose of an international view that the inconsistency of the existing classi- psychiatric classification to oust and to take the fications was responsible for the confusion. H. place of regional or local classifications, many of Bersot proposed a classification (Annex 1. page 634) which have a valuable function in research and CLASSIFICATION OF MENTAL DISORDERS 619 administration. Such classifications may stimulate There is a further reason why an internationally the study of new relationships and thus advance acceptable psychiatric classification will have to be knowledge. The only proviso to be made for such relatively simple. The existing classifications have classifications would be that they should be readily in most places been used for hospital in-patients convertible into the international system. That only. This is highly unsatisfactory because the this is practicable has been proved in several coun- hospital population is not representative of those tries. An international classification, therefore, suffering from mental disorders. With the increase would have to be, in the first instance at least, of out-patient facilities and day hospitals, and with rather conservative and theoretically unenter- the growing trend against hospitalization, the bulk prising. This is inevitable for an international of the psychiatric patients will remain in the com- instrument to be used by people of various orien- munity. It is essential for epidemiological research tations and knowledge. It must not be forgotten to include these patients, who far outnumber those that in the majority of countries no recording of admitted to hospital. Out-patient material lends psychiatric disorders for statistical purposes exists. itself only to relatively simple classification. A glossary with operational definitions of the One of the recurrent criticisms of the ICD and various categories would have to be available similar classifications has been the lack of provi- from the beginning in as many languages as sion for recording diagnostic formulations. The possible. same difficulty exists in other fields of morbidity What should be the principles underlying such and it is doubtful whether a statistical classifica- a classification ? It has sometimes been said that tion which could serve this purpose can be a classification has above all to be consistent with designed at present. The ICD provides for related regard to the criteria of differentiation. But and unrelated additional diagnoses and can also however well conceived an international classifica- be adapted for multiple diagnoses when two sepa- tion may be, it is bound to reflect the patchiness of rate psychiatric conditions co-exist. The Amer- present knowledge and the lack of a consistent and ican Standard Classification makes provision for generally accepted nosology of mental disorders. the reporting of precipitating factors, premorbid Therefore, the demand for thoroughgoing consis- personality, and degree of psychiatric impairment. tency is unreasonable at the present state of Several of the classifications listed in Annex 3 psychiatry. No psychiatric classification can help allow for the recording of two or more dimensions being partly etiological and partly symptomato- of the clinical conditions. No information about logical, because these are the criteria by which the use of these arrangements has so far been psychiatrists distinguish mental disorders from available. each other. It appears that the requirement of Those concerned with a revision of the ICD consistency has been overstated by some psychia- will first have to decide whether Section V should trists. " The scientific purist who will wait for be made comprehensive, i.e., whether it should medical statistics until they are nosologically exact contain all psychiatric categories. The objections is no wiser than Horace's rustic waiting for the to this section in its present form have been so river to flow away." This general observation general anid emphatic that comprehensiveness has made by the late Professor Greenwood is particu- to be regarded as an essential requirement of an larly relevant to psychiatry. internationally acceptable international classifica- No classification can meet every criticism, but tion. Theoretical objections against such a change even the best classification cannot serve its func- are far outweighed by the practical disadvantages tion unless all those participating in its application of the present arrangement. In the American know it and want to make it work. All too often Statistical Classification of Diseases and Opera- the only person interested in a classification has tions, which contains a comprehensive psychiatric been the coding officer. It is essential that the section, this problem has been solved. psychiatrists supplying the diagnostic data should It is not proposed to present a specimen classi- be familiar with the statistical classification in use fication which would meet the requirements out- and with its purpose. Many psychiatrists seem lined above. It is hoped that this report will serve unaware that their diagnoses are more than pri- as a basis for discussion on a revision of the ICD vate observations concerning only themselves and relevant to psychiatry. Recently, J. E. Meyer their patients. (1959) has proposed a " diagnostic scheme " as a 620 E. STENGEL prototype for an international classification trists have only just started ordering their material (Annex 3, page 659). It meets the requirements and designing tentative classifications. It will be of comprehensiveness and relative simplicity. necessary to inquire into the present state of these During the last few decades, child psychiatry endeavours. The results of such an inquiry would has emerged as an important branch of psychiatry. serve as a basis for consideration of the require- There has been a growing tendency to specializa- ments of this field in a revised classification of tion in this field which has many problems of its mental disorders. The need for relative simplicity own. Child psychiatrists are generally dissatisfied of the sections of an international classification with the existing classifications. Of those listed in dealing with mental disorders in childhood is quite the Appendix to this report, only that of Selbach obvious, and so is the desirability of experimental (Annex 3, page 659) has a special and detailed classifications of a regional nature. section for mental disorders in childhood. The question arises how agreement on a drastic This survey has not been specially concerned revision of the ICD relevant to psychiatry could with child psychiatry. It has been taken for be reached. It will be necessary for suitable pro- granted that no satisfactory up-to-date classifica- posals to be submitted in time for the next revision tion serving the requirements of this special field conference of the World Health Organization. It exists. A comprehensive psychiatric classification may be advantageous if the results of pilot studies has to provide for those requirements, either in a with one or several classifications thought to be special subsection, or in the various categories suitable for international use are available before relevant to mental disorders of childhood. Child final recommendations are made. Proposals con- psychiatry, being a very new area of study, has cerning the technicalities of actions to be taken in not yet developed a tradition of classifications like this matter are outside the scope of this report. the psychiatry of adult age. In fact, child psychia-

ACKNOWLEDGEMENT

This work has been undertaken at the suggestion and is greatly indebted to him for his generous help, both under the guidance of Dr E. Eduardo Krapf, Chief, with the collection of the material and with its critical Mental Health, World Health Organization. The author analysis.

RJESUMI

Etablir une classification des troubles mentaux est en France, aux Pays-Bas, au Danemark, en URSS, au une entreprise ardue, car l'avis des psychiatres differe Japon. quant au choix des criteres sur lesquels elle doit reposer. II montre que les difficult6s creees par le d6faut des En effet, les diagnostics ne peuvent guere etre verifies connaissances sur la physiologie et 1'etiologie peuvent objectivement et les memes troubles sont decrits sous etre surmont6es par l'emploi de # definitions operation- des noms differents. C'est un obstacle A l'echange rapide nelles *. Il indique quels pourraient etre les principes d'idees et d'experience, donc au progres. fondamentaux d'une classification satisfaisante. Celle-ci L'auteur de cet article a entrepris une etude critique assurerait un accord plus general sur la valeur des traite- des classifications existantes, montrant en particulier ments des troubles mentaux. Elle permettrait d'aborder leurs c6tes faibles. It passe en revue les classifications sur un large front l'aspect epidemiologique de la recher- existantes, intemationales et nationales, notamment che psychiatrique. celles qui sont en vigueur aux Etats-Unis, au Canada,

REFERENCES

American Psychiatric Association (1952) Diagnostic and Bimbaum, K. (1928) Handbuch der Geisteskrankheiten, statistical manual for mental disorders, Washington Berlin, Allgemeiner Teil I, p. 11 Bersot, H. (1937) In: Comptes Rendus du Deuxieme Con- Bond, H. (1937) In: Comptes Rendus du Deuxieme gres International d'Hygiene Mentale, Paris, vol. 2, p. 313 Congres International d'Hygie'ne Mentale, Paris, vol. 2 CLASSIFICATION OF MENTAL DISORDERS 621

Boor, W. de (1954) Psychiatrische Systematik, Berlin, Leonhard, K. (1957) Aufteilung der endogenen Psychosen, Gottingen, Heidelberg Berlin Brooke, E. (1959) Principles of national statistics in the Lustig, B. (1957) Med. Folge, 31 epidemiology of mental illness, J. ment. Sci. (in press) Menninger, K. et al. (1958) Bull. Menninger Clin., 22, 4 Canada, Dominion Bureau of Statistics (1957) Mental Meyer, A. (1916) Brit. med. J., 2, 757 health statistics 1956, Ottawa Meyer, J. E. (1959) An internationally acceptable diag- Conrad, K. (1956) Fortschr. Neurol., 24, 231 nostic scheme suitable for comparative psychiatric Essen-Moller, E. & Wohlfahrt, S. (1947) Acta psychiat. studies. In: American Psychopathological Association. (Kbh.), Suppl. 47, p. 551 Report of work conference on problems offield studies Falret, S. (1854) Le_ons cliniques de medecine mentale, in mental disorders, New York (in press) Paris Meynert, T. (1890) Klinische Vorlesungen uber Psychiatrie, Fish, F. J. (1958) J. ment. Sci., 104, 34 & 943 Wien Giljarovskij, V. A. (1954) Uchebnikpsikhiatrii (Textbook Neumann, H. (1859) Lehrbuch der Psychiatrie, Erlangen ofpsychiatry), Moscow Noyes, A. & Kolb, L. (1958) Modern clinical psychiatry, Griesinger, W. (1861) Die Pathologie und Therapie der New York psychischen Krankheiten, Stuttgart Rado, S. (1953) Amer. J. Psychiat., 110, 406 Gruhle, H. (1932) Handbuch der Geisteskrankheiten, Registrar General, England and Wales (1953) Statistical Berlin, Bd 9, Teil 5, p. 18 review for England and Wales for the year 1949. Supple- Hecker, E. (1877) Allg. Z. Psychiat., 33, 602 ment on general morbidity, cancer and mental health, Hempel, Carl G. (1959) Some problems of taxonomy. In: London, HMSO American Psychopathological Association. Report of Registrar General, England and Wales (1958) Statistical work conference on problems offield studies in mental review of England and Wales for the two years 1952- disorders, New York (in press) 1953. Supplement on mental health, London, HMSO Henderson, D. K. & Gillespie, R. D. (1956) A textbook of Rumke, H. C. (1959) Nosology, classification, nomen- psychiatry, 8th ed., London clature. In: American Psychopathological Association. Hoche, A. (1912) Z. Neurol., 12, 540 Report of work conference on problems offield studies Hollingshead, A. B. & Redlich, F. C. (1958) Social class in mental disorders, New York (in press) and mental illness, New York Schneider, K. (1950) Amer. J. Psychiat., 107, 334 Kahlbaum, L. K. (1874) Die Katatonie, Berlin Skottowe, I. (1953) Clinical psychiatry for practitioners Kerbikov, 0. V., Ozeretzkij, N. I., Popov, A. & Snezhnev- and students, London skij, A. V. (1958) Uchebnik psikhiatrii (Textbook of Wernicke, C. (1900) Grundriss der Psychiatrie, Leipzig psychiatry), Moscow World Health Organization (1957) Manual of the Inter- Kleist, K. (1953) Mschr. Psychiat. Neurol., 125, 539 national Statistical Classification of Diseases, Injuries Kloos, G. (1951) Med. Klin., 46, 1 and Causes of Death, 1955 revision, Geneva Koupernik, C. (1958) Evolut. psychiat., 4, 769 World Health Organization, Expert Committee on Mental Kraepelin, E. (1920) Z. Neurol., 62, 1 Health (1950) Wld Hlth Org. techn. Rep. Ser., 9, 36 Kraepelin, E. & Lange, J. (1926) Lehrbuch der Psychiatrie, World Health Organization, Joint Expert Committee Leipzig, Bd 2 convened by WHO with the participation of United Kretschmer, E. (1919) Z. Neurol., 48, 370 Nations, ILO, and UNESCO (1954) Wld Hlth Org. Langfeldt, G. (1956) The prognosis in schizophrenia, techn. Rep. Ser., 75 Acta psychiat. scand., Suppl. 110 World Health Organization, Expert Committee on Health Lecomte, M. (1953) Sem. Hop. Paris, 29, 3386 Statistics (1959) Wld Hlth Org. techn. Rep. Ser., 164, 13 Lecomte, M., Donney, A., Delage, E. & Marty, F. (1947) Zilboorg, G. (1941) A history of medical psychology, Techn. hosp., 2, 5 New York 622 E. STENGEL

Annex I

OFFICIAL, SEMI-OFFICIAL OR NATIONAL CLASSIFICATIONS

1. International Classification of Diseases. V. Mental, Psychoneurotic and Personality Disorders ...... 622 2. The Standard Classification of Mental Disorders of the American Psychiatric Association ...... 628

3. Diagnostic Classification of the Dominion Bureau of Statistics, Canada . 630

4. French Standard Classification ...... 631

5. German Classification (Wurzburg Scheme) ...... 631

6. Classification of the Dutch Association for Psychiatry and Neurology . . 632

7. Classification of the Danish Psychiatric Society ...... 632

8. International Classification proposed by H. Bersot ...... 634

9. USSR Classification by Kerbikov et al...... 634

10. USSR Classification according to Giljarovskij ...... 635

11. Classification in use in Japan ...... 635

1. INTERNATIONAL CLASSIFICATION OF DISEASES V. MENTAL, PSYCHONEUROTIC AND PERSONALITY DISORDERS *

This section excludes transient delirium and minor 300 Schizophrenic disorders (denientia praecox) mental disturbances accompanying definitely phy- sical disease. Examples of this kind are transient 300.0 Simple type delirium of febrile reaction, transient intoxication Dementia: with uraemia, transient mental reactions with any primary systemic infection, or with brain infection, trauma, simplex degenerative disease, or vascular disease. Schizophrenia: primary PSYCHOSES (300-309) simple Numbers 300-309 exclude: juvenile neurosyphilis 300.1 Hebephrenic type (020.1); general paralysis of insane (025); post- Dementia, paraphrenic encephalitic psychosis (083.2); and puerperal Hebephrenia psychosis (688.1). Paraphrenia Schizophrenia: * World Health Organization (1957) Manual of the International Statistical Classification of Diseases, Injuries hebephrenic and Causes of Death, 1955 revision, Geneva, p. 115 paraphrenic CLASSIFICATION OF MENTAL DISORDERS 623

300.2 Catatonic type 301.2 Other Catatonia Affective psychosis Dementia, catatonic Insanity or psychosis, manic-depressive: Schizophrenia, catatonic NOS 300.3 Paranoid type any type except circular, depressive, or manic Dementia, paranoid Manic-depressive reaction: Schizophrenia, paranoid NOS stuporous 300.4 Acute schizophrenic reaction Schizophrenic reaction, acute 302 Involutional melancholia 300.5 Latent schizophrenia Insanity, climacteric Latent schizophrenic reaction Melancholia: Schizophrenia, latent climacteric Schizophrenic residual state (Restzustand) involutional menopausal 300.6 Schizo-affective psychosis Psychosis, involutional (any type) Mixed schizophrenic and manic-depressive psychosis 303 Paranoia and paranoid states Schizo-affective psychosis Paranoia Schizothymia Paranoid conditions, other than in dementia and schizophrenia 300.7 Other and unspecified Paranoid state NOS Dementia praecox ) NOS* or any type not Schizophrenia classifiable under 304 Senile psychosis Schizophrenic reaction) 300.0-300.6 Cerebral atrophy or degeneration with psychosis 301 Manic-depressive reaction at ages 65 and over This title excludes neurotic-depressive reaction (314) Dementia of old age Senile: 301.0 Manic and circular dementia Alternating insanity imbecility Circular: insanity insanity melancholia stupor psychosis (any type) Cyclothymia Hypomania 305 Presenile psychosis Alzheimer's disease Insanity or psychosis, manic-depressive: Circumscribed atrophy of brain circular Pick's disease of brain manic Presenile: Mania NOS dementia Manic-depressive reaction: psychosis agitated sclerosis circular manic 306 Psychosis with cerebral arteriosclerosis Dementia, arteriosclerotic 301.1 Depressive Psychosis due to arteriosclerosis Insanity or psychosis, manic-depressive, (cerebral) depressive This title is not to be used for primary death classi- Manic-depressive reaction, depressive fication (334). Melancholia NOS 307 Alcoholic psychosis * NOS = not otherwise specified; unspecified; un- Delirium tremens qualified Hallucinosis, alcoholic 624 E. STENGEL

307 Alcoholic psychosis (continued) 310 Anxiety reaction without mention of somatic symptoms Korsakoff's psychosis or syndrome, unless specified as non-alcoholic Anxiety: Polyneuritic psychosis, alcoholic neurosis NOS Psychosis, alcoholic (any type) reaction NOS state NOS This title excludes alcoholic addiction without Anxiety reaction with any condition in 311 psychosis (322). without mention of somatic symptoms 308 Psychosis of other demonstrable etiology 311 Hysterical reaction without mention of anxiety This title is not to be used for primary death reaction classification and will not generally be used for primary morbidity classification if the antecedent Anorexia nervosa condition is present. Compensation neurosis Dissociative reaction 308.0 Resulting from brain tumour (any) Psychosis: Hysteria, hysterical: resulting from brain tumour NOS with intracranial neoplasm amnesia anaesthesia 308.1 Resulting from epilepsy and other convulsive anorexia disorders anosmia Epileptic deterioration aphonia Psychosis with any condition classifiable under blindness without 353 mention catalepsy of Psychosis with other convulsive disorders conversion convulsions anxiety This title excludes epilepsy without psychosis (353). dyskinesia reaction 308.2 Other fugue mutism Organic brain disease with psychosis paralysis Psychosis, secondary or due to any disease or postures injury, not classifiable under 308.0-308.1 somnambulism 309 Other and unspecified psychoses tic Cerebral atrophy or degeneration with psycho- tremor sis, ages under 65, not specified as presenile other manifesta- dementia tions Dementia NOS Hystero-epilepsy J Deterioration, mental Exhaustion delirium 312 Phobic reaction Insanity NOS Fear reaction confusional Phobia NOS delusional Phobic reaction Psychosis NOS, or any type not classifiable under 020.1, 025, 083.2, 300-038, 688.1 313 Obsessive-compulsive reaction Neurosis: PSYCHONEUROTIC DISORDERS (310-318) compulsive impulsive Numbers 310-318 exclude simple adult maladjust- obsessional ment (326.4) and nervousness and debility (790). obsessive-compulsive CLASSIFICATION OF MENTAL DISORDERS 625

313 Obsessive-compulsive reaction (continued) 316.1 Irritability of colon specified as of psycho- Obsessional: genic origin ideas and mental images Functional diarrhoea specified as psychogenic impulses Any condition in 573.2 specified as psychogenic phobias 316.2 Gastric neuroses ruminations Cyclical vomiting state Functional dyspepsia specified as psychogenic Obsessive-compulsive reaction Gastric neurosis Any condition in 544 specified as psychogenic 314 Neurotic-depressive reaction Neurotic-depressive reaction 316.3 Other digestive manifestations specified as of Psychogenic depression psychogenic origin Reactive depression Aerophagy Disorder of digestive system specified as psycho- This title excludes manic-depressive reaction (301). genic, but not classifiable under 316.0-316.2 Globus 315 Psychoneurosis with somatic symptoms (soma- tization reaction) affecting circulatory system 317 Psychoneurosis with somatic symptoms (soma- This title excludes functional heart disease (433), unless tization reaction) affecting other systems specified as psychogenic. 317.0 Psychogenic reactions affecting respiratory 315.0 Neurocirculatory asthenia system Cardiac asthenia specified as psychogenic Disorder of respiratory system specified as Da Costa's syndrome psychogenic Disordered action of heart, specified as Psychogenic asthma psychogenic Effort syndrome 317.1 Psychogenic reactions affecting genito-uri- Neurocirculatory asthenia nary system " Soldier's heart" Disorder of: genito-urinary system micturition specified as psycho- 315.1 Other heart manifestations specified as of genic psychogenic origin sexual function Functional heart disease, specified as psycho- genic 317.2 Pruritus of psychogenic origin Any condition in 433 specified as psychogenic, Pruritus specified as psychogenic but not classifiable under 315.0 317.3 Other cutaneous neuroses 315.2 Other circulatory manifestations of psycho- Disorder of skin specified as psychogenic, genic origin excluding pruiritus Disorder of cardiovascular system specified as 317.4 Psychogenic reactions affecting musculo- psychogenic, but not classifiable under 315.0 skeletal system or 315.1 Disorder of: articulation (joint) 316 Psychoneurosis with somatic symptoms (soma- joint tization reaction) affecting digestive system limb specified as psycho- This title excludes ulcer of stomach (540) and of duo- muscle genic denum (541). It excludes functional disorders of oeso- musculosketelal sys- phagus (539.0), of stomach (544), and of intestines tem (573), unless specified as psychogenic. Paralysis 316.0 Mucous colitis specified as of psychogenic 317.5 Psychogenic reactions affecting other systems origin Disorders of parts of body not classifiable Any condition in 573.1 specified as psychogenic under 315-317.4, specified as psychogenic 626 E. STENGEL

318 Psychoneurotic disorders, other, mixed, and un- 320.3 Inadequate personality specified types Constitutional inferiority 318.0 Hypochondriacal reaction Inadequate personality NOS Hypochondria 320.4 Antisocial personality Hypochondriasis Antisocial personality 318.1 Depersonalization Constitutional psychopathic state Depersonalization Psychopathic personality: NOS 318.2 Occupational neurosis with Craft neurosis antisocial trend Miners' nystagmus 320.5 Asocial personality Occupational neurosis Asocial personality 318.3 Asthenic reaction Moral deficiency Asthenic reaction Pathologic liar Psychopathic personality with amoral trend Nervous: debility 320.6 Sexual deviation exhaustion Exhibitionism prostration Fetishism Neurasthenia Homosexuality Pathologic sexuality Psychogenic: Sadism asthenia Sexual deviation general fatigue 320.7 Other and unspecified 318.4 Mixed Pathological personality NOS Psychoneurotic disorders, mixed This title excludes mixed anxiety and hysterical reactions 321 Immature personality (310). 321.0 Emotional instability 318.5 Of other and unspecified types Emotional instability (excessive) Nervous breakdown 321.1 Passive dependency Neurosis NOS Dependency reactions Psychasthenia Passive dependency Psychoneurosis: 321.2 Aggressiveness NOS Aggressiveness other specified types not classifiable under 310-318.4 321.3 Enuresis characterizing immature personality Enuresis specified as a manifestation of imma- ture DISORDERS OF CHARACTER, BEHAVIOUR, AND INTELLI- personality GENCE (320-326) 321.4 Other symptomatic habits except speech impediments Numbers 320, 321, 325, 326 exclude residuals of Symptomatic habits other than enuresis and acute infectious encephalitis (083) speech impediments, specified as manifesta- tions of immature 320 Pathological personality personality 321.5 Other and unspecified 320.0 Schizoid personality Immature personality NOS Schizoid personality Immaturity reaction NOS 320.1 Paranoid personality Paranoid personality 322 Alcoholism This title excludes paranoia and paranoid states (303). This title excludes alcoholic psychosis (307) and acute poisoning by alcohol (E880, N961). For primary 320.2 Cyclothymic personality cause classification, it excludes cirrhosis of liver with Cyclothymic personality alcoholism (581.1). CLASSIFICATION OF MENTAL DISORDERS 627

322.0 Acute (753.1); gargoylism (289.0); hydrocephalus (344 and Alcoholism, acute 752); hypertelorism (758.2); and juvenile general para- Ethylism, acute lysis of the insane (020.1). 322.1 Chronic 325.0 Idiocy Alcoholic addiction Idiot, idiocy (congenital) NOS Alcoholism, chronic Severe mental subnormality Ethylism, chronic Mental deficiency in: 322.2 Unspecified adult with mental age 0-2 years * Alcoholism NOS child with I.Q. under 20 * Ethylism NOS 325.1 Imbecility Imbecile, imbecility NOS 323 Other drug addiction Moderate mental subnormality Addiction to, or chronic poisoning by: Mental deficiency in: amphetamine adult with mental age 3-6 years * barbituric acid (and compounds) child with I.Q. 20-49 * benzedrine 325.2 Moron bromides Feeble-mindedness Cannabis indica High-grade defect chloral Mild mental subnormality cocaine Moron codeine Mental deficiency in: demerol adult with mental age 7-9 years * diacetylmorphine child with I.Q. 50-65 * diamorphine ethylmorphine 325.3 Borderline intelligence hashish Backwardness heroin Borderline intelligence Indian hemp Deficientia intelligentiae morphine opium 325.4 Mongolism paraldehyde Mongolian idiocy pethidine Mongolism thebaine 325.5 Other and unspecified types other narcotic, analgesic, and soporific drugs Amaurotic family idiocy Drug addiction Cerebromacular degeneration Morphinism Mental deficiency NOS Mental retardation NOS 324 Primary childhood behaviour disorders Oligophrenia Behaviour disorder of childhood not identified Phenylpyruvic oligophrenia with psychopathic personality, mental defi- Tay-Sachs disease ciency, or any physical illness: 326 Other and unspecified character, behaviour, and jealousy intelligence disorders masturbation tantrum 326.0 Specific learning defects Juvenile delinquency Specific learning defects (reading) (mathematics) This title excludes personality disorders (320-321). (strephosymbolia) This title includes alexia (word blindness) of unspecified 325 Mental deficiency or non-organic origin.

This title excludes: cerebral spastic infantile paraplegia * According to the 1937 Stanford Revision of the Binet (351); birth injury (760, 761); epiloia, tuberous sclerosis Test

16 628 E. STENGEL

326.1 Stammering and stuttering of non-organic This title includes any condition in 781.6 of unspecified origin or non-organic origin. Balbutio 326.3 Acute situational maladjustment Stammering or stuttering NOS Abnormal excitability under minor stress due to specified non-organic cause Acute situational maladjustment Combat fatigue This title includes any condition in 781.5 of unspecified or non-organic origin. Operational fatigue 326.2 Other speech impediments of non-organic 326.4 Other and unspecified origin Simple adult maladjustment Any speech impediment, not in 326.1: Primary behaviour disorders and psycho- NOS neurotic personalities not classifiable under due to specified non-organic cause 083, 310-318, 320-326.3

2. THE STANDARD CLASSIFICATION OF MENTAL DISORDERS OF THE AMERICAN PSYCHIATRIC ASSOCIATION *

01-09 Acute Brain Disorders 09 Acute Brain Syndrome of Unknown Cause 01 Acute Brain Syndrome Associated with Infection 10-19 Chronic Brain Disorders 1 01.0 Intracranial infection, except epidemic 10 Chronic Brain Syndrome Associated with encephalitis Diseases and Conditions Due to 01.1 Epidemic encephalitis Prenatal (Constitutional) Influence 01.2 With systemic infection, NEC 10.0 With congenital cranial anomaly 10.1 With congenital spastic paraplegia 02 Acute Brain Syndrome Associated with 10.2 With mongolism Intoxication 10.3 Due to prenatal maternal infectious 02.1 Alcohol intoxication diseases 02.2 Drug or poison intoxication (except alcohol) 11 Chronic Brain Syndrome Associated with Central Nervous System Syphilis 03 Acute Brain Syndrome Associated with 11.0 Meningoencephalitic Trauma 11.1 Meningovascular 04 Acute Brain Syndrome Associated with 11.2 Other central nervous system syphilis Circulatory Disturbance 12 Chronic Brain Syndrome Associated with 05 Acute Brain Syndrome Associated with Intracranial Infection Other Than Syphilis Convulsive Disorder 12.0 Epidemic encephalitis 12.1 Other intracranial infections 06 Acute Brain Syndrome Associated with Metabolic Disturbance 13 Chronic Brain Syndrome Associated with Intoxication 07 Acute Brain Syndrome Associated with 13.0 Alcohol intoxication Intracranial Neoplasm 13.1 Drug or poison intoxication, except 08 Acute Brain Syndrome with Disease of alcohol Unknown or Uncertain Cause 1 To each category of " Chronic Brain Disorders " one of the following qualifying phrases can be added: with psychotic reaction (x 1) * American Psychiatric Association (1952) Diagnostic with neurotic reaction (x 2) and statistical manual for mental disorders, Washington with behavioural reaction (x 3). CLASSIFICATION OF MENTAL DISORDERS 629

14 Chronic Brain Syndrome Associated with 22 Schizophrenic Reactions (continued) Trauma 22.3 Schizophrenic reaction, paranoid type 14.0 Birth trauma 22.4 Schizophrenic reaction, acute undif- 14.1 Brain trauma, gross force ferentiated type 14.2 Following brain operation 22.5 Schizophrenic reaction, chronic un- 14.3 Following electrical brain trauma differentiated type 14.4 Following irradiational brain trauma 22.6 Schizophrenic reaction, schizo-affective 14.5 Following other trauma type 15 Chronic Brain Syndrome Associated with 22.7 Schizophrenic reaction, childhood type Circulatory Disturbance 22.8 Schizophrenic reaction, residual type 15.0 With cerebral arteriosclerosis 22.9 Other and unspecified 15.1 With circulatory disturbance other than 23 Paranoid Reactions than cerebral arteriosclerosis 23.1 Paranoia 16 Chronic Brain Syndrome Associated with 23.2 Paranoid state Convulsive Disorder 24 Psychotic Reaction Without Clearly Defined 17 Chronic Brain Syndrome Associated with Structural Change Other Than Above Disturbance of Metabolism, Growth or Nutrition 30-39 Psychophysiologic Autonomic and Visceral 17.1 With senile brain disease Disorders 17.2 Presenile brain disease 30 Psychophysiologic Skin Reaction 17.3 With other disturbance of metabolism, etc., except presenile brain disease 31 Psychophysiologic Musculoskeletal Reaction 18 Chronic Brain Syndrome Associated with 32 Psychophysiologic Respiratory Reaction New Growth 33 Psychophysiologic Cardiovascular Reaction 18.0 With intracranial neoplasm 34 Psychophysiologic Hemic and Lymphatic 19 Chronic Brain Syndrome Associated with Reaction Diseases of Unknown or Uncertain Cause; 35 Psychophysiologic Gastrointestinal Reaction Chronic Brain Syndrome of Unknown or 36 Psychophysiologic Genito-Urinary Reaction Unspecified Cause 37 Psychophysiologic Endocrine Reaction 19.0 Multiple sclerosis 19.1 Hutington's chorea 38 Psychophysiologic Nervous System Reaction 19.2 Pick's disease 39 Psychophysiologic Reaction of Organs of 19.3 Other diseases of unknown or uncertain Special Sense cause 19.4 Chronic brain syndrome of unknown 40 Psychoneurotic Disorders or unspecified cause 40 Psychoneurotic Reactions 40.0 Anxiety reaction 20-24 Psychotic Disorders 40.1 Dissociative reaction 40.2 Conversion reaction 20 Involutional Psychotic Reaction 40.3 Phobic reaction 21 Affective Reactions 40.4 Obsessive compulsive reaction 21.0 Manic depressive reaction, manic type 40.5 Depressive reaction 21.1 Manic depressive reaction, depressed 40.6 Psychoneurotic reaction, other type 21.2 Manic depressive reaction, other 50-53 Personality Disorders 21.3 Psychotic depressive reaction 50 Personality Pattern Disturbance 22 Schizophrenic Reactions 50.0 Inadequate personality 22.0 Schizophrenic reaction, simple type 50.1 Schizoid personality 22.1 Schizophrenic reaction, hebephrenic 50.2 Cyclothymic personality type 50.3 Paranoid personality 22.2 Schizophrenic reaction catatonic type 50.4 Personality pattern disturbance, other 630 E. STENGEL

51 Personality Trait Disturbance 54 Transient Situational Personality Disturbance 51.0 Emotionally unstable personality (continued) 51.1 Passive-aggressive personality 54.6 Other transient situational personality 51.2 Compulsive personality disturbance 51.3 Personality trait disturbance, other 52 Sociopathic Personality Disturbance 60-62 Mental Deficiencies 52.0 Antisocial reaction 60 Mental Deficiency (Familial or Hereditary) 52.1 Dyssocial reaction 60.0 Mild 52.2 Sexual deviation 60.1 Moderate 52.3 Alcoholism (addiction) 60.2 Severe 52.4 Drug addiction 60.3 Severity not specified 53 Special Symptom Reaction 61 Mental Deficiency, Idiopathic 53.0 Learning disturbance 61.0 Mild 53.1 Speech disturbance 61.1 Moderate 53.2 Enuresis 61.2 Severe 53.3 Somnambulism 61.3 Severity not specified 53.4 Other The following codes are to be used as the qualify- ing phrase x4 (cf. footnote page 628) and will be coded as separate diagnoses. They represent mental 54 Transient Situational Personality Disorders deficiency by grades of severity, associated with and 54 Transient Situational Personality Disturbance as the major symptom in impairment of brain 54.0 Gross stress reaction tissue function. 54.1 Adult situational reaction 62 Mental Deficiency (x4) 54.2 Adjustment reaction of infancy 62.0 Severe 54.3 Adjustment reaction of childhood 62.1 Moderate 54.4 Adjustment reaction of adolescence 62.2 Mild 54.5 Adjustment reaction of late life 62.3 Severity not specified

3. DIAGNOSTIC CLASSIFICATION OF THE DOMINION BUREAU OF STATISTICS, CANADA *

Psychoses Somatization reaction Syphilis of central nervous system Other and unspecified psychoneurotic reactions Schizophrenia Disorders of character, behaviour and intelligence Manic depressive Involutional melancholia Pathological personality Paranoia and paranoid states Alcoholism Senile and cerebral arteriosclerosis Drug addiction Presenile Mental deficiency Alcoholic Epilepsy Other and unspecified psychoses Primary behaviour disorders Psychoneuroses Other and unspecified disorders of character, behaviour and intelligence Anxiety reaction Hysterical reaction Non-psychiatric conditions Obsessive-compulsive reaction Syphilis without psychosis Neurotic-depressive reaction Mental observation without need for further medical care * Canada, Dominion Bureau of Statistics (1957) Mental health statistics 1956, Ottawa Other non-psychiatric conditions CLASSIFICATION OF MENTAL DISORDERS 631

4. FRENCH STANDARD CLASSIFICATION States of mental backwardness Acute confusional states (simple confusion, acute idiocy delirium, encephalitic psychoses, symptomatic imbecility psychoses, etc.) debility Intoxication cretinism alcoholic (acute, chronic, with dementia) States of constitutional imbalance others disorders of personality and behaviour Syphilitic mental diseases disorders of emotionality sexual perversions general paralysis, cerebral syphilis mental disorders in diabetics Psychoneuroses (neurasthenia, psychasthenia, hysteria, etc.) Organic dementias with arteriosclerosis Manic-depressive psychoses with circumscribed brain lesions manic state senile dementia melancholic state periodic psychosis Presenile or involutional psychoses Delusional states Secondary dementias acute Epilepsy chronic Mental disorders in epidemic encephalitis Dementia praecox (schizophrenias, chronic mental Atypical mental disorders deterioration) simulation

5. GERMAN CLASSIFICATION (WURZBURG SCHEME), AS RECOMMENDED BY THE DEUTSCHER VEREIN FOR PSYCHIATRIE * 1. Congenital and early-acquired mental deficiency (b) presenile forms (depressive and paranoid (idiocy and imbecility): pictures) (a) without manifest cause (c) senile forms (b) subsequent to brain damage (d) other forms (Alzheimer's disease, Pick's (c) cretinism disease, etc.) 2. Mental disorders due to brain injury (cerebral 7. Huntigton's chorea concussion or contusion): (a) acute traumatic psychosis (commotional 8. Mental disorders due to other diseases of the psychosis) brain (tumour, disseminated sclerosis, etc.) (b) traumatic sequelae (epileptic personality changes, etc.) 9. Mental disorders associated with: 3. General paralysis of the insane (a) infectious diseases (including chorea minor) 4. Mental disorders accompanying Lues cerebri (b) diseases of internal organs, general diseases and Tabes and cachexia (disorders of organs of the circulatory system, intestinal disorders, 5. Epidemic encephalitis diabetes, uraemia and eclampsia, 6. Mental disorders of later life: anaemia, carcinosis, pellagra, etc.) (a) arteriosclerotic forms (including essential (c) Graves-Basedow's disease, myxoedema, hypertension) tetany and other endocrine disorders (d) symptomatic psychoses during puerperium * Nitsche, P. (1934) Allg. Z. Psychiat., 102, 377 and lactation 632 E. STENGEL

10. Alcoholism: 17. Abnormal reactions: (a) drunkenness (a) paranoid reactions and developments (para- (b) chronic alcoholism (jealousy delusions, noia querulans, etc.) etc.) (b) depressive reactions which do not come (c) delirium tremens and hallucinoses under 15. (d) Korsakow's psychosis (polioencephalitis (c) imprisonment reactions haemorrhagica) (d) compensation neuroses 11. Addictions (morphinism, cocainism, etc.) (e) other psychogenic reactions 12. Mental disorders due to other intoxications (f) induced reactions (folie 'a deux) (narcotics, lead, mercury, arsenic, carbon 18. Psychopathic disulfide, carbon monoxide, etc.) children and juveniles 13. Epilepsy: 19. Undiagnosed cases (a) without manifest cause 20. Nervous, i.e., neurological diseases: (b) symptomatic epilepsy (a) without mental disorders 14. Schizophrenic group (b) with mental disorders 15. Manic-depressive group (cyclothymia) 21. Free from nervous disease and mental abnor- 16. Psychopathic personalities malities.

6. CLASSIFICATION OF THE DUTCH ASSOCIATION FOR PSYCHIATRY AND NEUROLOGY

1. Neuroses and psychopathies (c) psychoses associated with brain diseases, (a) neurasthenic reactions Huntington's chorea, etc. (b) constitutional nervousness 6. Encephalitic and post-encephalitic states (c) psychogenic reactions 7. General paralysis of the insane and syphilitic (d) hysterical reactions psychoses (e) psychopathic personalities 8. Psychoses due to alcoholic abuse 2. Manic-depressive psychoses and other endo- 9. Climacteric and involutional psychoses genous and reactive mood disorders 10. Arteriosclerotic psychoses 3. Paranoia and paranoid states 11. Senile and presenile psychoses 4. Schizophrenia and paraphrenic states 12. Epilepsy and epileptic psychoses 5. Exogenous reaction types and organic psychoses (a) symptomatic psychoses and psychoses 13. Oligophrenias associated with childbirth 14. Myxoedema and cretinism (b) psychoses due to intoxication 15. Unclear cases

7. CLASSIFICATION OF THE DANISH PSYCHIATRIC SOCIETY, 1952

A. Psychoses 0114 Alcoholic psychosis 01 Intoxications 0115 Alcohol-antabuse reaction 0119 Alcohol abuse of psychotic origin 01 1 Alcohol 012 Opium 0111 Acute intoxication 013 Other addictions 0112 Pathological drunkenness (mania a potu) 02 Psychotic states in general physical diseases, 01 13 Chronic alcoholism fever and exhaustion CLASSIFICATION OF MENTAL DISORDERS 633

03 Infectious diseases of the brain and meninges 04 Hysterical neuroses 031 Dementia paralytica 05 Psychosomatic neuroses 032 Other syphilitic diseases affecting the Other neuroses CNS 06 Sexual neuroses 033 Encephalitis epidemica 07 Asthenic reactions neurotic, psychopathic, 08 Mixed or unspecified oligophrenic, unclassifiable C. disorders 04 Traumatic brain lesions with mental symptoms Non-psychotic personality 041 Acute trauma 1 Predominantly endogenous (psychopathic) 042 Post-traumatic cerebral syndrome (with 2 Predominantly exogenous (pseudo- neurotic, psychopathic, unclassifiable psychopathic) picture) 21 predominantly physiogenic 043 Post-leucotomy states in psychosis, neu- 22 predominantly psychogenic (character rosis, psychopathy, unclassifiable neurosis) 044 Other traumatic brain lesions (hanging, 3 Of uncertain origin etc.) 4 Habitual non-psychotic personality variations 05 Brain tumours with mental symptoms 01-21 06 Psychosis with vascular lesions in the CNS (schizoid, cycloid, ixiod, hyperthymic, 07 Senile and presenile psychoses depressive, sensitive, fanatic, self-assertive, 071 Senile moody, explosive, callous, unstable, infan- 072 Presenile psychoses tile, erethic, emotional, dysphoric, emo- 0721 Alzheimer's disease tionally labile, insecure, homosexual, other 0722 Pick's disease perversions) 0723 Presbyophrenia D. Oligophrenia 0724 Involutional depression 0725 Others 1 Idiocy 08 Manic-depressive psychoses 2 Imbecility 09 Schizophrenia 3 Intellectual debility 10 Epilepsy 4 Subnormal intelligence 101 hereditary 5 Unspecified 102 without known heredity E. Other disabilities 103 acute epileptic mental disorder Dyslexia, etc. 104 chronic epileptic mental disorder 11 Psychosis in hereditary organic brain disease, F. Isolated abnormal reactions malformations, etc. 1 Affective reactions 12 Psychogenic mental disorder 2 Reactions to shock 121 psychogenic affective syndrome 3 Hysterical reactions 122 psychogenic psychoses with disturbance of 4 Paranoid reactions consciousness (including twilight states) 123 psychogenic paranoid psychoses G. Without certain mental abnormality; mentai 13 Other mental diseases. Diseases of uncertain abnormality of uncertain type diagnosis H. Without mental abnormality B. Neuroses I. Under 15 years Neuroses without predominant somatic symp- toms J. Suicidal attempt or suicide 01 Anxiety neurosis 1 Suicidal attempt or suicide 02 Anankastic neurosis 2 Pseudo-attempt 021 predominantly phobic 3 Recent attempt 022 predominantly obsessive compulsive K. Criminals 03 Depressive neurosis Neuroses with predominant somatic symptoms L. Termination ofpregnancy 634 E. STENGEL

8. INTERNATIONAL CLASSIFICATION PROPOSED BY H. BERSOT *

Oligophrenias Organic psychoses Psychopathies Luetic Manic-depressive psychoses Presenile and senile Simple psychoses (schizophrenias, paranoid psy- Other choses and psychoses not falling into any other Intoxications category) Endogenous-symptomatic psychoses Epilepsy Exogenous Alcoholic * Bersot, H. (1937) In: Comptes Rendus du Deuxieme Other Congres International d'Hygiene Mentale, Paris, vol. 2, p. 313 Psychoneuroses

9. USSR CLASSIFICATION BY KERBIKOV ET AL.*

A. Mental diseases due to infections E. Mental diseases due to cerebral vascular disease in the brain (a) acute general infections (typhus, dysentery, influenza, etc.) (a) cerebral arteriosclerosis (b) chronic general infections (b) hypertension (tuberculosis, rheumatism, malaria, etc.) (c) thrombosis of cerebral blood vessels 1. Cerebral syphilis F. Mental diseases due to other brain lesions 2. General paralysis of the insane (c) encephalitis, meningitis (a) brain tumours (b) Huntington's chorea, Pick's disease, amaur- B. Mental diseases due to non-infectious physical otic idiocy, tuberculosis, etc. illness G. Psychogenic mental diseases (a) diseases of the liver, kidneys, tumours, etc. (a) (b) avitaminoses reactive psychoses (b) neurasthenia (c) endocrine disorders (c) neuroses with obsessional states C. Mental diseases due to intoxications (d) hysterical reactions (a) drug addiction H. Mental diseases of unknown etiology (b) industrial poisoning (a) schizophrenia (c) food poisoning (b) manic-depressive psychoses (d) other intoxications (c) epilepsy (d) presenile psychoses D. Mental diseases due to brain trauma (e) senile psychoses (Open or closed wounds, blast injury, electric shock, etc.) I. Mental diseases associated with pathological mental development * Kerbikov, 0. V., Ozeretzkij, N. I., Popov, A. & Snezh- (a) psychopathies nevskij, A. V. (1958) Uchebnik psikhiatrii (Textbook of psychiatry), Moscow (b) oligophrenias CLASSIFICATION OF MENTAL DISORDERS 635

10. USSR CLASSIFICATION ACCORDING TO GILJAROVSKIJ *

1. Psychoses due to infections 7. Presenile and senile mental disorders (a) acute infections (a) presenile psychoses, involutional melan- (b) encephalitis and meningitis due to acute cholia, etc. infections (b) senile psychoses (simple dementia, other (c) encephalitis due to subacute infections senile psychoses, etc.) (including malaria, disseminated sclero- sis, etc.) 8. Schizophrenia (d) chronic infections 9. Manic-depressive psychoses (e) neurosyphilis (lues cerebri, general para- lysis) 10. Epilepsy (genuine, symptomatic, pyknolepsy) 11. Psychogenic disorders 2. Psychoses due to intoxications (a) neuroses (neurasthenia, hysteria, psych- (a) morphine asthenia, obsessional neuroses) (b) food poisoning (b) reactive psychoses (traumatic mental reac- (c) industrial poisoning tions including psychogenic stupor; (d) intoxicants (alcohol, morphine, etc.) fugues, including psychogenic twilight states; reactive depression: psychogenic 3. Psychoses following cerebral injury paranoid state ; atrogenic reactions; (delirium, twilight state, Korsakow's syndrome, paranoia) encephalitis, dementia, epilepsy, personality disorders, etc.) 12. Psychopathic personalities (excitable, labile, impulsive, sexually perverse, 4. Mental disorders due to brain tumours hysterical, psychasthenic, asthenic, asocial, querulant types) 5. Mental disorders in somatic diseases 13. Mental states due to under-development (oligo- 6. Mental disorders in cerebral vascular disease phrenias) (a) hypertension microcephaly and other developmental cere- (b) cerebral arteriosclerosis bral disorders early traumatic brain lesions * Giljarovskij, V. A. (1954) Uchebnik psikhiatrii (Text- sequelae of meningitis and encephalitis book of psychiatry), Moscow syphilis acquired in utero or in infancy

11. CLASSIFICATION IN USE IN JAPAN*

A. Exogenous (or Symptomatic) Mental Disorders 8. due to syphilis of central nervous system 1. due to or associated with infectious diseases 9. due to cerebral arteriosclerosis 2. due to endocrine dysfunctions 10. involutional psychoses 3. due to diseases of inner organs 11. senile psychoses 4. due to disturbances of metabolism B. Endogenous Psychoses 5. due to brain diseases 6. due to brain injuries 12. schizophrenia 7. due to intoxications (i) hebephrenia (ii) catatonia * Compiled by Professor T. Muramatsu, Department (iii) dementia paranoides of Neuropsychiatry, Nagoya National University, Japan, on the basis of the classifications in the five Japanese text- (Some authors add others type, such as dementia books most widely used in Japan. simplex, paraphrenia) 636 E. STENGEL

13. manic-depressive psychoses D. Psychopathic Personalities (Kurt Schneider's 14. epilepsy typology seems to be most popular) C. Neurosis or Psychoneurosis D. Behaviour Disorders (in children) of different (i) neurasthenia types (ii) hysteria E. Mental Deficiency (iii) compulsive-obsessive neurosis (Some authors classify this group into more (i) idiocy types adding those such as anxiety neurosis, (ii) imbecility traumatic neurosis, etc.) (iii) moronity C. Psychogenic Psychoses (paranoid reaction and (Special types such as mongolism, etc., are paranoia are included in this group) also mentioned) CLASSIFICATION OF MENTAL DISORDERS 637

Annex 2

OTHER CLASSIFICATIONS DISCUSSED IN THE TEXT

Page 1. Classification of Bosch and Ciampi ...... 637

2. Henry Ey's Simplified Scheme of Classification ...... 637

3. Kleist's Classification of Neuropsychiatric Diseases ...... 638

4. Kraepelin-Lange's Classification ...... 640

5. Krapf's Classification ...... 640

6. Adolf Meyer's Classification ...... 641

7. Classification Proposed for Official Use in Norway ...... 642

8. Rado's Classification ...... 646

9. Rumke's Classification ...... 646

10. Schneider's Classification ...... 647

1. CLASSIFICATION OF GONZALO BOSCH AND LANFRANCO CIAMPI

(a) Premorbid mental syndromes (d) Mental syndromes with defects in development (b) Mental syndromes with temporary lowering of of mental autonomy mental autonomy (e) Mental syndromes with complete permanent (c) Mental syndromes with complete and temporary loss of mental autonomy loss of mental autonomy

2. HENRY EY'S SIMPLIFIED SCHEME OF CLASSIFICATION *

Disturbance of Awareness Disturbance of Personality (? Consciousness) (Acute psychoses) (Chronic psychoses and neuroses)

Manic-depressive attacks Mental imbalance. Neuroses

Paranoid and hallucinatory Chronic deliria and schizophrenia episodes. Oneiric states

Confusional-oneiric psychoses Dementias

' Ey, H. (1954) Etudes psychiatriques, Paris, p. 22 638 E. STENGEL

3. KLEIST'S CLASSIFICATION OF NEUROPSYCHIATRIC DISEASES *

ALLOGENIC DISEASES (with and without mental A. Metabolic (Continued) disturbance) 4. Gout with depressions A. Physical Damage 5. Porphyria 6. Paramyloidosis with dementia 1. Mechanical 7. Disturbance of calcium metabolism 2. Abnormal atmospheric pressure 3. Thermic B. Dysglandular 4. Electrical 1. Thyroid 5. Radiation 2. Parathyroid B. Chemical Damage-Poisoning 3. Pancreas 1. Intoxicants 4. Adrenal 2. Food 5. Pituitary 3. Sedatives and narcotics 6. Testicular and ovarian, including menstrual 4. Other drugs and climacteric disorders 5. Industrial poisons C. Procreational and Involutional 6. Gases 1. Eclamptic toxaemia C. Infections, Virus and Parasitic Diseases 2. Puerperal toxaemia 3. Agitated 1. Neuritis and polyneuritis; herpes involutional depression 2. Myelitis 4. Involutional paranoia 3. Chorea D. Blood Diseases 4. Demyelinating diseases 1. Anaemia 5. Encephalitis epidemica 2. Polycythaemia 6. Encephalitis rabies, etc. 3. Leukaemias 7. Symptomatic psychoses in infectious disease 8. Syphilitic diseases (general paralysis of the E. Diseases of the Heart insane, etc.) Anxiety states, disturbance of consciousness, 9. Tuberculosis of the nervous system focal symptoms 10. Abscess of the central nervous system, puru- lent meningitis F. Vascular and Circulatory Disorders 11. Epidemic meningitis 1. Arteriosclerosis, hypertension (dementia, 12. Echinococcus, aktinomykosis etc.) D. Deficiency Diseases 2. Venous and sinus thrombosis 3. Air and fat embolism 1. Lesions of the nervous system due to hunger 4. Carotid lesions with cerebral damage and thirst: cachectic psychoses 5. Strangulation with cerebral damage 2. Anoxaemia and high-altitude syndrome 3. Avitaminoses G. Postoperative Psychosis 4. Acquired nervous exhaustion H. Skeletal Diseases II. SOMATOGENIC DISEASES 1. Cervical rib, spina bifida, Paget's disease, etc. 2. Hyperostosis frontalis interna, turricephaly A. Metabolic with cerebral involvement 1. Liver and gall-bladder diseases; cholaemia- comatose, akinetic and related syndromes J. Diseases of the Meninges, Choroid Plexus and 2. Wilson's disease Ventricles 3. Kidney disease with anaemia 1. Subdural and subarachnoid haematomas 2. Arachnoiditis, ependymitis * Kleist, K. (1953) Mschr. Psychiat. Neurol., 125, 539 3. Liquorrhoea CLASSIFICATION OF MENTAL DISORDERS 639

K. Neoplasms C. Transient Disorders with Autogenic Fluctuations 1. Meningioma, adenoma 1. Attacks and episodic diseases (genuine 2. Neurinoma epilepsy, pyknolepsy, narcolepsy, episo- dic mood disorders (dipsomania, pario- 3. Spinal tumours mania, etc.) episodic twilight states and 4. Brain tumours sleep) 5. Pituitary and epiphyseal tumours Related: epileptoid psychopathy L. Neoplastic Dysplasias 2. Pasophrenias (a) simple (unipolar) forms: 1. Syringomylia melancholia, anxiety psychosis, psy- 2. Tuberous sclerosis chosis of reference with anxiety, 3. Neurofibromatosis hypochondriacal depression, depres- sive stupor, mania, manic ecstasy, hypochondriacal excitement 1IT. NEUROGENIC DISEASES (b) multiform (bipolar) types manic-depressive mood disorder, hyper- A. Progressive Degenerative Diseases kinetic-akinetic mobility psychosis, 1. Systematic degenerations, including Fried- agitated-stuporous confusional psy- reich's disease, Pick's disease, Hunting- chosis, anxious-ecstatic delusional ton's chorea, etc. psychosis 2. Metabolic degenerations (Tay-Sachs, Schil- Related : cycloid and similar psycho- der's, Alzheimer's disease, senile demen- pathy tia) D. Abnormal Dispositions with Psychogenic and 3. Schizophrenias Autogenic Fluctuations (a) systematic forms: hebephrenias (fatuous, depressive, apathetic, 1. Paranoid psychopathy with fluctuations autistic) and developments based on overvalued katatonias (lacking in speech impulses, talk- ideas (querulent and sensitive forms) ative, akinetic, parakinetic, negativistic, 2. Obsessive-compulsive psychopathies with proskinetic, stereotyped) fluctuations paranoid (phantasiophrenia, progressive con- E. fabulosis, progressive hallucinosis, pro- Abnormal Dispositions with Psychogenic Reac- gressive somatopsychosis, progressive in- tions fluence psychosis, inspiration psychosis) 1. Emotional psychopathies with reactive de- confused (incoherent, paralogical, schizo- pression and excitation phasia) 2. Hysterical psychopathy and corresponding combined forms reactions (hysterosomatic disturbances, hysterical twilight states) (b) unsystematic forms (iterative-stuporous, 3. catatonic attacks, confused schizophrenic Psychopathy with pseudologia phantastica attacks, paraphrenias) and similar reactions Related: schizoid psychopaths 4. Characteropathy and imprisonment psy- chosis; instability and addiction B. Transient Disturbances due to Abnormal Vegeta- 5. Sexopathy and sexual neuroses tive-nervous Disposition 6. Neuroses related to accidents, war, con- flicts and 1. Vegetative dystonia and organ neuroses occupation 2. Raynaud's disease, aeroparaesthesiae, etc. F. Abnormal Dispositions with Exogenic Exhaustion 3. Migraine and migraine psychoses, habitual States headache Constitutional neurasthenia and psycha- 4. Periodic ophthalmoplegia sthenia 640 E. STENGEL

IV. DEFECT STATES B. Somatogenic Defect States A. Allogenic Defect States of Prenatal, Natal and 1. Phenylketonuric mental deficiency 2. Cretinism and other glandular deficiencies Postnatal Origin 3. Disorders of vascular origin: bilateral 1. Mongolism athetosis with status marmoratus 2. Defect states due to congenital syphilis, toxoplasmosis and other infections, with C. Defect States of Neurogenic (Hereditary) and infantile paralysis, hydrocephalus and Obscure Origin convulsions 1. General and circumscribed mental 3. Brain lesions due to birth injury and deficiency deficiency states 2. Hereditary tremor, tic, stammering and 4. Deficiencies with kern icterus other motor disorders

4. KRAEPELIN-LANGE'S CLASSIFICATION *

1. Psychoses due to brain injuries 11. Epilepsy 2. Psychoses due to diseases of the brain 12. Manic-depressive psychoses 3. Psychoses due to intoxications 13. Psychogenic disorders (neurasthenia; neurosis of 4. Psychoses due to infectious diseases anticipation; fright neurosis; psychogenic 5. Psychoses due to syphilis depression; induced psychosis (folie 'a deux); 6. Dementia praecox imprisonment psychosis; paranoid reaction; 7. Endocrine psychoses traumatic neurosis; war neurosis 8. Arteriosclerotic psychoses 14. Hysteria 9. Presenile and senile psychoses 15. Paranoia 10. Endogenous dementing processes 16. Obsessional neurosis; compulsive psychosis sexual perversions * Kraepelin, E. & Lange, J. (1926)Lehrbuch derPsychiatrie, 17. General paralysis of the insane Leipzig, Barth, Bd 2 18. Mental deficiency

5. EDUARDO KRAPF'S CLASSIFICATION * * 1. Primary Psychopathic' Deficiencies (c) Infantile group 1.1 Oligophrenias (i) Hyperemotivity (a) Idiocy (ii) Histrionism (b) Imbecility 2. Psychopathic Reactions (c) Mental deficiency (moronism) 2.1 Situational reactions 1.2 Dysphrenias (a) Emotional shock (a) Primary group (b) Reactive depression (i) Explosivity (c) Anxiety neurosis (ii) Instability (d) Neurotic depression (b) Antinomic group (e) Neurasthenia (i) Psychasthenia 2.2 Historical reactions (ii) Sensitivity (a) Hysteria (conversion) (b) Phobic neurosis (anxiety hysteria) (c) Obsessional neurosis 'In the Spanish language, " psychopathic is a generic term for all types of mental disorder. (d) Hypochondria * * This classification is at present undergoing revision. (e) Paranoia CLASSIFICATION OF MENTAL DISORDERS 641

2. Psychopathic Reactions (continued) 3. Psychopathic Disorders (continued) 2.3 Psychosomatic disturbances (iii) Infectiousandtoxic-infectiouspsy- 2.4 Sexual deviations (perversions) choses (iv) Vascular and anoxic psychoses 2.5 Abnormal reactions of the deficient (v) Metabolic deficiency psychoses (a) Typical reactions of the deficient 3.2 Processes (i) Impulsive reaction (a) Autochthonous (ii) Evasive reaction (iii) Irritable reaction (i) Infantile processes (infantile de- mentia, etc.) (iv) Resentment reaction (v) Passion reaction (ii) Processes of maturity (vi) Ostentatious reaction (A) Schizophrenia a. Simple dementia (b) Reactive psychoses of the deficient b. Hebephrenia (" psychoses of the degenerate ") c. Catatonia (i) Impulsive confusion d. Paranoid dementia (ii) Pseudodementia (Ganser's syn- e. Paraphrenia drome) (B) Huntington's disease (iii) Anxiety confusion (iii) Processes of the elderly (iv) Hyperemotive twilight state (A) Presenile psychoses (v) Histrionic twilight state ("delu- (B) Presenile dementias sional imagination of the de- generate ") a. Alzheimer's disease b. Pick's disease 3. Psychopathic Disorders (C) Senile dementia 3.1 Episodes (b) Symptomatic (a) Autochthonous (i) By physical agents (tumours etc.) (i) Dysbiotonias (ii) Bu chemical agents (A) Dysthymic (manic-depressive (iii) By infections disease) (A) Neurosyphilis (B) Dyskinesia (hyper- and akine- a. General progressive paralysis tic psychosis) b. Cerebral syphilis (C) Dyseidetic (amentia) (B) Other infections (ii) Dysrhythmias (iv) By vascular diseases (A) Epilepsy (v) By metabolic deficiencies (B) Episodic twilight state (b) Symptomatic 4. Terminal Psychopathic Deficiencies (i) Traumatic psychoses 4.1 Dementias (ii) Exo- and endotoxic psychoses 4.2 Character disorders

6. ADOLF MEYER'S CLASSIFICATION *

Merergasia - the psychoneuroses Parergasia - the fantastic, incongruous schizo- phrenic states Thymergasia - the primary affective disorders, divided into hyperergastic or Dysergasia - the toxic delirious states other active manic states and Anergasia - with defect traits characteristic of hypoergastic or depressive re- the tarded states organic group Oligergasia - the group of constitutionally defec- * Meyer, A. (1957) Psychobiology, Springfield, Ill., Thomas tive states 642 E. STENGEL

7. CLASSIFICATION PROPOSED FOR OFFICIAL USE IN NORWAY *

1. PSYCHOSES (P 01 - P 13) P 03.2 Melancholia manico-depressiva (301.1, 301.2) Melancholia: P 01 Psychoses schizophrenicae (300) NUD (301.1) P 01.1 Schizophrenia sensu strictorii (300.0 - Manico depressiva (301.1) 300.5, 300.7) Psychosis: Dementia praecox (300.7) depressiva (301.1) Schizophrenia manico depressiva (301.1) NUD (300.7) Reactio manico-depressiva catatonia (300.2) NUD (301.2) hebephrenica (300.1) Stuporosa (301.2) latens (300.5) P 04 Melancholiae involutivae (302) paranoides (300.3) Melancholia: paraphrenica (300.1) climacterica (302) primaria (300.0) involutiva (302) reactiva acuta (300.4) residuae (300.5) P 05 Psychoses seniles aut praeseniles (304, 305) sequelae (300.5) P 05.1 Psychosis senilis (304) simplex (300.0) Atrophia cerebri cum psychosi (304) P 01.2 Psychosis schizo-affectiva (300. 6) Degeneratio cerebri cum psychosi (304) Psychosis senilis (304) P 02 Psychoses reactivae, constitutionales et psychogenicae (301.1, 303, 309p, 314p) P 05.2 Psychosis praesenilis (305) Atrophia cerebri praesenilis cum psychosi P 02.1 Paranoia et psychosis paranoides (303) (305) paranoia (303) Degeneratio cerebri praesenilis cum psychosi Psychosis paranoides (303) (305) Status paranoicus (303) Morbus Alzheimer (305) P 02.2 Psychosis reactiva depressiva (301.1, 314p) Morbus Pick (305) Psychosis praesenilis (305) P 02.3 Excitatio reactiva (309p) P 06 Psychoses e morbis vasorum cerebri (306, Reactio excitativa (309p) 308.2 p) Excitatio reactiva (hysteriformis) (309p) P 06.1 Psychosis ex arteriosclerose cerebri (306) P 02.4 Confusio reactiva (309 p) Confusio reactiva (hysteriformis) (309 p) P 06.2 Psychosis e morbo alio vasorum cerebri (308.2 p) P 03 Psychoses manico-depressivae (301) Psychosis: P 03.1 Psychosis manica et circularis (301.0) ex embolia cerebri (308.2 p) Cyclothymia (301.0) e haemorrhagia cerebri (308.2 p) Hypomania (301.0) e thrombose cerebri (308.2 p) Mania (NUD) (301.0) P 07 Psychoses alcoholicae aut euphomanicae aliae Psychosis: (307, 308.2 p) circularis (301.0) manica (301.0) P 07.1 Psychosis alcoholica (307) Delirium tremens (307) Dementia alcoholica (307) * Only the terms in small capitals or italics form part of the official classification; the others are examples only. Hallucinosis alcoholica (307) The numbers in brackets in Roman type refer to the Paranoia alcoholica (307) ICD. The letter p after a number indicates that the heading corresponding to this number covers only part of the cases. Psychosis polyneurotica alcoholica (307) The letters NUD signify Non ultro descriptus. Syndroma Korsakoff (307) CLASSIFICATION OF MENTAL DISORDERS 64r3

P 07.2 Psychosis euphomanica alia (308.2 p) P 15 Neuroses hystericae (311) Addictio veneni auphorici cum psychosi Hysteria (308.2 p) NUD Euphomania cum psychosi (308.2 p) cum amaurosi P 08 Psychosis ex oligophrenis (325) amblyopia amnesia P 09 Psychoses epileptica (308.1) anaesthesia P 10 Psychoses syphiliticae (02-.1, 025, 026 p) anoreia anorsmia P 10.1 Paralysis generalis (020.1, 025) aphasia Dementia paralytica (adultorum) (juvenilis) catalepsia (020.1 p) conversione Paralysis generalis (tabetica) (025) convulsione P 10.2 Psychosis syphilitica alia (026 p) dyskinesia Syphilis cerebrospinalis cum psychosi (026 p) cum fuga P 11 Psychoses e morbis organicis allis cerebri ingresu abnormi (083.2, 308.0, 308.2 p) mutismo paralysi P 11.1 Psychosis e neoplasmate s. tumore cerebri paresi (308.0) postura abnormi P 11.2 Psychosis ex encephalitide (083.2) reactione dissociativa somnambulismo P 11.3 Psychosis e morbo hereditario cerebri (308.2p) tic P 11.4 Psychosis e traumate cerebri (308.2 p) tremore P 11.5 Psychosis e morbo organico alio cerebri postraumatica compensativa (308.2 p) Reactio hysterica posttraumatica compensatione causa P 12 Psychoses symptomaticae causis aliis definitis P 16 Neuroses ananoasticae (312, 313) (642.1 p, 648.3 p, 688.1, 308.2 p) P 16.1 Phobia (312) P 12.1 Psychosis in graviditate et puerperio (642.1 p, Phobia (obsessiva) (312) 648.3 p, 688.1) Reactio phobica (312) P 12.2 Psychosis causa alia definita (308.2 p) P 16.2 Neurosis obsessiva-compulsiva (313) P 13 Psychoses aliae aut non definitae (309) Neurosis: Delirium acutum NUD (309) compulsiva (313) Dementia NUD (309) impulsiva (313) Insania NUD (309) obsessiva (313) Psychosis: Reactio: NUD (309) compulsiva (313) e lassitudine (309) impulsiva (313) causa ignota, alibi non indicabilis (309) obsessiva (313) P 17 Neuroses depressivae (314 p) II. NEUROSES (P 14-P 20) Depressio reactiva s. psychogenes (314 p) Neurosis depressiva (314 p) P 14 Neuroses angoris sine symptomatibus soma- Reactio neurotico-depressiva p) ticis (310) (314 Neurosis angoris (NUD) (sine symptoma- P 18 Neuroses cum symptomatibus somaticis (315- tibus somaticis) (310) 318) Reactio angoris (NUD) (sine symptomatibus P 18.1 Neurosis cardiovascularis (315) somaticis) (310) Angioneurosis (315.2) Status angoris (NUD) (sine symptomatibus Arrhythmia nervosa (315.1) somaticis) (310) Asthenia neuro-circulatoria (315.0)

17 644 E. STENGEL

P. 18.1 Neurosis cardiovascularis (315) (continued) P 19 Neuroses asthenicae (318.3) (contiuued) Dystonia neuro-circulatoria (315.1) Lassitudo nervosa (318.3) Cor militis s. militum (soldier's heart) Prostratio nervosa (318.3) Effort syndrome (315.0) Neurasthenia (318.3) Morbus cordis militis (315.0) Neurosis cordis (315.1) P 20 Neuroses aliae et non definitae (318.0, 318.1, Tachycardia nervosa (315.1) 318.5) Syndroma Da Costa s. lassitudinis (315.0) P 20.1 Hypochondria (318.0) P 18.2 Neurosis respiratorica (317.0) P 20.2 Neuroses alia et non definita (318.1, 318.5) Asthma nervosum s. psychogenes (317.0) Depersonalisatio (318.5) Neurosis respiratorica s. cardio-respiratorica Collapsus nervosus s. psychogenes (318.5) (317.0) Neurosis NUD (318.5) P 18.3 Neurosis gastro-intestinalis (316) Psychasthenia (318.5) Aerophagia (316.3) Psychoneurosis NUD s. alibi non indicabilis Diarrhoea nervosa s. psychogenes (316.1) (318.5) Dyspepsia nervosa s. psychogenes (316.2) Colitis mucosa s. spastica nervosa aut psy- chogenes (316.0) III. ANOMALIAE CHARACTERIS ET PERSONALITATIS Globus (316.3) (P 21 - P 24) Neurosis: P 21 Anomalia e characteris s. personalitatis gastrica s. gastro-intestinalis (316.2) constitutionalis aut habituales (Neuroses intestinalis (316.2) characteris s. psychopathiae) (320, 321, P 18.4 Neurosis uro-genitalis (317.1) 326.4) Frigiditas nervosa s. psychogenes (317.1) Impotentia.nervosa s. psychogenes (317.1) P 21.1 Anomalia sexualis s. psychopathia sexualis Micturito nervosa s. psychogenes (317.1) (320.6) Exhibitionismus (320.6) P 18.5 Neurosis systematis locomotorici (317.4) Fetischismus (320.6) Arthralgia nervosa s. psychogenes (317.4) Homosexualismus (320.6) Dorsalgia nervosa s. psychogenes (317.4) Lesbianismus (320.6) Myalgia nervosa s. psychogenes (317.4) Masoschismus (320.6) Neuralgia s. neuromyalgia psychogenes Sadismus (320.6) (317.4) Sexualitas pathologica (320.6) P 18.6 Neurosis professionalis (318.2) Transvestitismus (320.6) Graphospasmus professionalis (318.2) Neuromyalgia professionalis (318.2) P 21.2 Anomalia alia habitus characteris s. person- Nystagmus e tenebris (Miners' nystagmus) alitatis (Neurosis characteris s. psycho- (318.2) pathia) (320.0 - 320.5, 320.7, 321, 326.4) P 18.7 Neurosis cum symptomatibus somaticis aliis Anomalia characteris s. personalitatis, se aut non definitis (317.2, 317.3, 317.5) neurosis characteris Morbus psychosomaticus NUD (317.5) Aggresivitas abnormis (321.2) Neurosis cutanea (317.3) Constitutio psychopathica NUD (320.7) Neurosis somatisata s. vegetativa NUD Enuresis psychoinfantilica (321.3) (317.5) Dependentia passiva s. psychoinfantilica Pruritus neuroticus s. psychogenes (317.2) (321.1) Reactio psychosomatica NUD (317.5) Inferioritas constitutionalis (320.3) Somato-neurosis NUD (317.5) Instabilitas emotionalis (excessiva) (psycho- P 19 Neuroses asthenicae (318.3) infantilica) (321.0) Debilitas nervosa (318.3) Insanita moralis (320.5) Exhaustio nervosa (318.3) Maladaptatio socialis adultorum (326.4) Defatigatio nervosa (318.3) Mendacitas pathologica (320.3) CLASSIFICATION OF MENTAL DISORDERS 645

P 21.2 Anomalia alia habitus characteris s. person- P 23.2 Euphomania alia. Addictio veneni euphorici alitatis (continued) alius (323) Neurosis characteris: Abusus medicamenti, se euphomania NUD (320.7) Addictio medicamenti s. veneni euphorici, asocialis (320.5) se euphomania antisocialis (320.4) cyclothymica (320.2) excentrica (320.7) P 24 Habitus abnormis infantum (324) parancides (320.6) Delinquentia juvenilis (324) schizoides (320.0) Enuresis (diurna) (nocturna) (324) Personae s. personalitas abnormis: Excitabilitas excessiva (324) constitutionalis, se neurosis characteris habitualis, se neurosis characteris IV. ANOMALIA INTELLIGENTIA ET LOCUTIONIS Psychoinfantilitas: (P25- P26) NUD (321.4) cum aggressivitate (321.4) P 25 Oligophreniae (325) dependentia passivae (321.1) P 25.1 Idiotia (I.Q. 0-35) (325.0) enuresi (321.3) instabilitate emotionali (excessivi) (321.0) P 25.2 Imbecilitas (I.Q. 36-55) (325.1) Psychopathia NUD, se neurosis characteris P 25.3 Debilitas mentis (I.Q. 56-75) (325.2) (320.7) P 25.4 Inferioritas intellectualis (I.Q. 76-90) (325.3) P 22 Reactiones maladaptoricae transitoriae P 25.5 Mongolismus (325.3) (326.1) P 25.6 Defectus alius mentalis (325.5) Maladaptatio situationalis acuta (326.3) Idiotia amaurotica (325.5) Excitatio abnormis (326.3) Defectus mentalis NUD (325.5) Exhaustio s. lassitudo abnormis (326.3) Deficientia mentalis NUD (325.5) Reactio maladaptorica transitoria Oligophrenia NUD (325.5) proeliatoris (326.3) Oligophrenia phenylpyruvica (325.5) situationalis (326.3) Retardatio mentalis NUD (325.5) P 23 Euphomaniae. Addictiones venenorumn Syndroma Tay-Sachs (325.5) euphoricum (322, 323) P 26 Anomaliae aliae intelligentiae aut locutionis P 23.1 Alcoholismus (322) (326.0 - 326.2) P 23.11 Alcoholismus acutus (322.0) P 26.1 Dysarrythmia et dyslexia primaria (326.0) Alcoholismus Agraphia (NUD) (primaria) (326.0) Ebrietas (acutus,a reactio normals Alexia (NUD) (primaria) (326.0) Ethylismus Dysarrythmia (NUD) (primaria) (326.0) Dyslexia (NUD) (primaria) (326.0) P 23.12 Alcoholismus, reactio pathologica (322.0) Strephosymbolia (326.0) P 23.13 Alcoholismus, reactio ex antabu (322.1) P 26.2 Balbutio primaria (326.1) Balbutio (NUD) (primaria) (326.1) P 23.14 Alcoholismus chronicus (322.1, 322.2) Battarismus (NUD) (primaria) (326.1) Alcoholismus: P 26.3 Impedimentum aliud loquendi primerium NUD (322.2) (326.2) chronicus (322.1) Aphasia (NUD) (primaria) (326.2) periodicus (322.1) Dysarthria (NUD) (primaria) (326.2) recurrens (322.1) Dysphasia (primaria) (326.2) Dipsomania (322.1) Impedimentum loquendi (primarium) (326.2) Ethylismus. se alcoholismus Vitium loquendi (primarium) (326.2) 646 E. STENGEL

8. RADO'S CLASSIFICATION *

Class I. Over-reactive disorders. (1) Emergency precursors of the obsessive pattern. (8) The paranoid dyscontrol: the emotional outflow, the riddance pattern. Paranoid elaboration of common mal- through dreams, the phobic, the inhibitory, the adaptation: the non-disintegrative version of the repressive, and the hypochondriacal patterns. (2) Magnan sequence. Descending dyscontrol. (3) Sexual disorders: Class II. Moodeyclic disorders. Cycles of depres- disorders of the standard pattern. Dependence on sion; cycles of reparative elation: the pattern of reparative patterns: the patterns ofpain-dependence; alternate cycles; cycles of minor elation; cycles of the male-female pattern modified by replacements; depression masked by elation; cycles of preventive the eidolic and reductive patterns. Fire-setting and elation. shoplifting as sexual equivalents. (4) Social over- dependence. (5) Common maladaptation: a combi- Class III. Schizotypal disorders. (1) Compensated nation of sexual disorder with social over- schizo-adaptation. (2) Decompensated schizo- dependence. (6) The expressive pattern: expressive adaptation. (3) Schizotypal disintegration marked by elaboration of common maladaptation: ostentatious adaptive incomptence. self-presentation; dream-like interludes; rudimentary Class IV. Extractive disorders. The ingratiating pantomimes; disease-copies and the expressive com- (" smile and suck ") and exertive (" hit and grab ") plication of incidental disease. (7) The obsessive conduct. pattern: obsessive elaboration of common mal- patterns of transgressive adaptation: broodings, rituals and overt temptations. Class. V. Lesional disorders. Tic and stammering as obsessive equivalents; bed- Class VI. Narcotic disorders. Patterns of drug- wetting, nail-biting, grinding of teeth in sleep, as dependence. * Rado, S. (1953) Amer. J. Psychiat., 110, 406 Class VII. Disorders of war adaptation.

9. ROMKE'S CLASSIFICATION * *

I. Mental disorders in patients with a previously Most frequent forms of expression: encephalopathic undisturbed development and without signs of an syndrome with variations: frontal, brain stem and abnormal constitution diencephalic syndromes, temporal and parietal (a) Mental disorders on the basis of apparent organic syndromes, Korsakow's syndrome, syndromes of diseases ofthe brain: dementia. 1. vascular diseases (b) Mental disorders on the basis of extra-cerebral 2. tumours noxious influences 3. atrophy 1. intoxications from outside, auto-intoxica- 4. inflammations tions 5. trauma capitis 2. infectious diseases 6. anaemia permiciosa 3. psychotraumata (?) 7. heredo-degenerations, Huntington's Forms of expression: the exogenous reaction types disease (Bonhoeffer) 8. Pick's and Alzheimer's diseases II. Mental disorders mainly on the basis of disturb- 9. part of the epilepsies ances in the constitution 10. hydrocephalus (a) Constitutional disorders with phasic course: ** Riimke, H. C. (1959) Nosology, classification, nomen- 1. manic-depressive psychosis clature. In: American Psychopathological Association. Report of work conference on problems of field studies in 2. degeneration psychoses mental disorders, New York (in press) 3. part of the epileptic psychoses CLASSIFICATION OF MENTAL DISORDERS 647

(b) Constitutional mental disorders with progressive (b) Mental disorders on the basis of disturbances in course: the processes of growth of the personality 1. schizophrenia (mainly hereditary) 2. paraphrenia 3. unclear chronic paranoid states, paranoia 1. part of the psychopathies 4. chronic hypochondria 2. infantilism 5. malignant chronic compulsive syndrome 3. part of the perversions 6. part of the epileptic psychoses 4. disturbances in the course of the phases of (c) Constitutional mental disorders noticeable during life the whole life: 5. part of the oligophrenic diseases 1. nervositas 2. neurasthenia (c) Mental disorders on the basis of mainly psycho- 3. psychasthenia genetically determined disturbances in the 4. part of the psychopathies processes ofgrowth of the personality 5. degeneres superieurs III. Mental disorders on the basis of a disturbed 1. neuroses in the strict sense course of development 2. character neuroses (a) Mental disorders on the basis of a defective 3. part of the perversions natural disposition 4. part of the psychopathies and abnormal 1. part of the psychopathies reactions of the personality 2. part of the oligophrenic diseases 5. developmental schizophrenia (type 3. part of the perversions Sechehaye) ?

10. SCHNEIDER'S CLASSIFICATION *

1. Abnormal varieties of sane mental life Abnormal intellectual capacity (Anlagen) Abnormal (psychopathic) personalities Abnormal reactions to emotional impressions 2. Results of illness and developmental defects Somatological (etiological) grouping Psychological (symptomatological) grouping Intoxications Paresis | Acute: Clouding of consciousness Other infections I Other somatic ilinessess Chronic: Personality deterioration Abnormal brain development | (congenital: arrested personality Brain injuries development) and dementia. Cerebral arteriosclerosis Senile brain diseases X Other brain diseases Cyclothyma Genuine epilepsy I ? } Schizophrenia

* Schneider, K. (1950) Amer. J. Psychiat., 107, 334 648 E. STENGEL

Annex 3

CLASSIFICATIONS NOT INCLUDED IN ANNEX 1 OR ANNEX 2

1. Conrad's Scheme of Psychiatric Diagnosis ...... 648

2. Essen-Moller's and Wohlfahrt's Classification ...... 649

3. Classification suggested by Henderson and Gillespie ...... 650

4. Van der Horst's Classification ...... 650

5. Jung's Classification ...... 653

6. Classification proposed by L6pez Ibor ...... 654

7. Kloos' Classification ...... 655

8. Langfeldt's Classification ...... 655

9. Classification of Lecomte et al...... 657

10. Leonhard's Classification of Endogenous Psychoses ...... 658

11. Mira Lopez' Classification ...... 658

12. J. E. Meyer's Proposed Diagnostic Scheme ...... 659

13. Selbach's Classification ...... 659

14. Pacheco e Silva's Classification ...... 661

15. Sjogren's Classification ...... 661

16. Skottowe's Classification ...... 662 17. Psychiatric Nomenclature and Classification of the United States War Depart- ment ...... 662

1. CONRAD'S SCHEME OF PSYCHIATRIC DIAGNOSIS *

Abnormal personalities, including addicts Phobias 312 Abnormal personalities 3201 Obsessional neurosis and obsessional illness 313 Disturbances of maturation 321 Psychogenic disturbances of the circulatory Addictions I: to drugs and intoxicants 323 system 315 Addictions II: alcoholism (except complica- Psychogenic disturbances of the digestive tions) 322 system 316 Neuropathies and personality disorders of Psychogenic disturbances of the other systems 317 uncertain origin 326 Other psychogenic disorders and disabilities in childhood (including sexual neuroses) 314 Reactions to inner conflict and other mental stress Impulsive and primitive reactions 319 Anxiety neurosis 310 Neurasthenic states 790 reactions 311 Hysterical Paranoid states 303 * Conrad, K. (1956) Fortschr. Neurol., 24, 231 Endogenous psychoses 1 The numbers refer to the corresponding categories of the ICD. Schizophrenias 300 CLASSIFICATION OF MENTAL DISORDERS 649

Endogenous psychoses (continued) Psychoses due to alcoholism 307 Cyclothymia 301 Involutional depressions 302 Symptomatic psychoses (acute syndrome) 308 Atypical endogenous psychoses 309 Maldevelopments and isolated disabilities in Presenile and senile psychoses childhood 324-326 Senile psychoses 304 Psychoses related to pregnancy 688 Presenile psychoses 305 Cerebral arteriosclerosis, with dementia 306 General paralysis of the insane 025

2. ESSEN-MOLLER'S AND WOHLFAHRT'S CLASSIFICATION *

Reactions Alzheimer's disease, Pick's disease, Huntington's chorea Schizophrenia, schizophreniform reactions, schi- zoidia Amaurotic idiocy, diffuse sclerosis Manic-depressive reactions, dysphoria, hyperthymia Dementia paralytica, cerebral syphilis Epilepsy, ixophrenia, ixoidia Encephalitis of different kinds Oligophrenia Asthenia, hydrophrenia, hypochondria Multiple sclerosis Obsessive-compulsive states, apprehensive or hyper- Cerebral trauma sensitive reactions Haemorrhage, malacia Asphyxia, strangulation Hysteria, mythomania Primitive reaction Tumour, abcess, swelling of the brain Delirium amentia, twilight state Chidhood, puberty Motor disturbances, catatonia Climacterium, presinility, senility Paranoiac reaction, fixed idea, querulousness Hallucinosis Pregnancy, abortion, puerperium, lactation Dementia, impaired judgement, amnesia, aphasia Myxoedema, Basedow's disease, diabetes Emotional instability Weakness of will, intantilism Cachexia, uraemia Emotional frigity, amorality Undernourishment, deficiency disease Asociality Suicidal attempt Systemic infection Sexual abnormality Blood disease Narcomania, abuse of intoxicants Cardiac disease, hypertension Anorexia Agrypnia, rhythm disorder Alcoholic intoxication, acute or chronic Cephalalgia, hemicrania Vegetative lability Alkaloid intoxication Normal personality variant Barbiturate intoxication Carbon monoxide intoxication Etiology Mental trauma Cerebral arteriosclerosis Mental stress Senile atrophy of the brain Induction, faulty ubpringing Strain Hereditary * Essen-Moller, E. & Wohlfahrt, S. (1947) Acta psychiat. (Kbh.) Suppl. 47, p. 551 Cryptogenic 650 E. STENGEL

3. CLASSIFICATION SUGGESTED BY HENDERSON AND GILLESPIE *

1. Affective reaction types: 5. Organic reaction types (toxic-infectious; meta- (a) manic-depressive bolic diseases of internal organs; cerebral (b) involutional melancholia degenerative, traumatic, etc.) 2. Schizophrenic reaction types (a) acute (delirium) (b) chronic 3. Paranoiac and paranoid reaction types: (a) paranoia 6. Epilepsy (b) paraphrenia (c) paranoid states, with or without hallucina- 7. Mental deficiency tions 8. Psychoneuroses: 4. Psychopathic states in: (a) neurasthenia (a) aggressive psychopathic personality (b) inadequate personality (b) anxiety states (c) creative personality (c) hysteria (d) obsessive-compulsive states * Henderson, D. K. & Gillespie, R. D. (1956) A textbook ofpsychiatry, 8th ed., London, Oxford University Press 9. Unclassified, e.g., some cases of folie a deux

4. VAN DER HORST'S CLASSIFICATION * *

1. Paranoia A. IT. Hypothymic or athymic psychopaths (continued) 2. (c) indolent 3. Manic-depressive constitution 111. Poikilothymic psychopaths (a) constitutional mood disorder (a) constitutional emotional lability (b) constitutional exaltation (b) reactive emotional lability 4. Manic-depressive psychosis IV. Dysthymic psychopath (a) melancholia (a) moody (b) mania (b) depressive (c) mixed states (c) timid (d) atypical states B. (a) unstable (e) circular states (b) schizoid (c) cold autistic 5. Psychopathic constitution (d) anankastic A. I. Hyperthymic psychopaths (e) sensitive (a) explosive (f) hysterical (b) irritable (g) hypochondriacal (c) expansive (h) quarrelsome (d) tachythymic (i) eccentric II. Hypothymic or athymic psychopaths (j) asthenic (a) phlegmatic (k) paranoid (b) dull (1) inadequate (m) aboulic * * Personal communication from Professor L. van der C. Psychopathic reaction types Horst, Psychiatric and Neurological Clinic, University of Amsterdam I. Criminality (habitual delinquents) CLASSIFICATION OF MENTAL DISORDERS 651

C. Psychopathic reaction types (continued) 13. Symptomatic psychoses II. Perversions A. (a) in infectious diseases (a) excessive masturbation (b) in exhaustion and chronic diseases (b) homosexuality (c) heart disease (c) exhibitionism (d) uraemia (d) fetishism (e) lues and tabes (e) sadism (f) *intoxications (f) masochism (g) rheumatism (g) transvestitism B. (a) confusional psychosis (h) paedophilia (b) neurasthenic state III. Kleptomania (c) hallucinatory state IV. Poriomania (d) Korsakow's syndrome V. Pseudologia phantastica (e) amentia VI. Addictions 14. Psychoses associated with the reproductive D. Psychopathic states functionis (a) excitement (a) postpuerperal psychosis (b) periodic twilight states (b) pregnancy psychosis (c) epileptoid psychopathy (c) menstrual mood disorders (d) diencephalic psychopathy 15. Endocrine psychoses 6. Innate mental deficiency (a) thyreogenic (Graves' disease: myxoedema) (a) debility (b) others (b) imbecility (c) idiocy 16. Auto-intoxications 7. Neuropathy 17. General paralysis of the insane (a) vegetative (b) psychic 18. Presenile psychoses 8. Asthenia (a) melancholia (a) confusional psychosis (b) anxiety states (b) asthenic psychosis (c) depressive delusions (d) depressive states followed by dementia (c) psychasthenic psychosis (e) presenile paranoid psychosis 9. Intoxication (f) others, including presenile dementia of A. I. Alcoholism unknown origin (a) pathological drunkenness 19. Arteriosclerotic psychosis (b) acute hallucinosis (c) delirium tremens (a) neurasthenic state (d) paranoia (b) general debility (e) Korsakow's syndrome (c) dementia (f) chronic alcoholism (d) depressive (g)- dipsomania (e) delirious (h) alcoholic dementia (f) apoplectic dementia B. Morphinism, cocainism 20. Senile dementia C. I. Other drugs (narcotics, etc.) I. (a) dementia II. Other intoxications (b) presbyophrenia 10. (c) senile paranoia 11. (d) senile delirium 12. II. Alzheimer's disease

18 652" E. STENGEL

21. Heredodegenerative psychoses 27. Involutional psychoses (a) Pick's disease 28. Degeneration psychoses (b) Huntington's disease (c) Wilson's disease A. Psychoses (d) amaurotic idiocy (a) autochthonous delusion (e) atypical (e.g., Jacob-Creutzfeldt's disease) (b) acute hallucinosis (c) mobility psychosis 22. Organic psychoses A. Infections (encephalitis, disseminated B. Degenerative states sclerosis, chorea) 29. Psychogenic psychoses B. Neoplasms (a) psychogenic disorders of affect C. Trauma (b) psychogenic psychosis in the strict sense (a) acute (c) existential neurosis (b) post-traumatic (d) sensitive delusions of reference (i) dementia (e) paranoid states in deaf people (ii) psychopathy (f) folie a deux 23. "Dementia praecox" (schizophrenia) 30. Organ psychoses A. I. (a) hebephrenia (a) essential hypochondria (b) catatonia 31. Psychoses in mental defectives (c) dementia paranoides (a) pseudo-schizophrenic syndrome (d) dementia simplex (b) autochthonous lability of affect II. Defect states (c) simple delusion (a) hypochondriacal hallucinosis 32. Reactive states (b) verbal hallucinosis (c) hebephrenic flattening of affect I. Fright psychosis B. Paraphrenias (a) stupor (a) systematica (b) twilight state (b) expansiva II. Reactive disturbance of affect (c) confabulatoria (a) depression (d) phantastica (b) mania C. Dementia praecocissima 33. Nervous state 24. Epileptic psychoses (a) dementia 34. Neurasthenia (b) twilight states and fugues 35. Psychasthenia (c) violent rages (a) obsessional neurosis delirium (d) 36. Hysteria 25. I. Hysterical psychoses (a) conversion hysteria 11. (a) imprisonment psychoses (b) hysterical character (b) situational psychoses (c) hysterical depression 26. Disturbances of development 37. Unclassifiable neurosis (e.g., in children) (a) behaviour disorders in puberty 38. Traumatic neurosis (b) psychoses in puberty and prepuberty (c) psychoses and other disorders of integra- 39. Vegetative neurosis (anorexia nervosa) tion 40. Other disturbances of the vegetative nervous (d) infantile psychoses system (Raynaud's disease, sclerodermia, etc.) CLASSIFICATION OF MENTAL DISORDERS 653

41. Vasomotor-trophic disturbances 45. Epilepsy 42. Allergic states This system also includes further categories 43. Migraine covering endocrine disease and organic neurological 44. MWnie're's syndrome diseases.

5. JUNG'S CLASSIFICATION *

1. Innate or early acquired mental deficiency 7. Alcoholism (a) of unknown origin (a) intoxications (b) due to brain lesion 1. simple (c) cretinism 2. pathological (epileptoid) (d) mongolism (b) chronic alcoholism (e) specific disability (delusions of jealousy) (c) delirium (f) phenylketonuria mental deficiency tremens and hallucinosis (d) Korsakow's psychosis and polioencepha- 2. Mental disorders due to brain injuries litis haemorrhagica (a) acute traumatic (contusional) psychoses 8. Addictions (morphinism, cocainism, etc.) (b) traumatic dementia and personality 9. Mental disorders due to poisoning (drugs, other disorders chemicals, gas, etc.) 3. General paralysis of the insane 10. Neurasthenic-depressive states of somatic origin 4. Mental disorders of later life with brain atrophy (a) neurasthenic states due to starvation, ex- (a) presenile haustion and infections 1 premature deficiency (b) chronic pseudo-neurasthenic pictures in 2. Pick's disease metabolic diseases (porphyria, anaemias) 3. Alzheimer's disease 11. Mental disorders in endocrine diseases (endocrine 4. other dementias psycho-syndrome) (b) senile 12. Symptomatic epilepsy (c) arteriosclerotic (including hypertension) (a) residual (including pyknolepsy) (d) confusional states (b) traumatic 5. Mental disorders due to other cerebral diseases (c) others (tumour, encephalitis, disseminated sclerosis, 13. (a) Epilepsy without ascertainable origin cerebral syphilis, Huntington's chorea and (b) Epilepsy with established heredity other heredodegenerative syndromes) 14. Group of the schizophrenias 6. Symptomatic psychoses (a) simple (a) in infectious diseases (b) predominantly hebephrenic (b) in diseases of the inner organs, cachexia, (c) predominantly catatonic systemic diseases (including carcinoma, (d) predominantly paranoid-hallucinatory uraemia, eclampsia, pellagra, etc.) (e) pseudo-neurotic (c) psychoses of pregnancy, puerperium, lacta- (f) paraphrenia tion, and menstruation (g) simple defect state (d) postoperative psychoses 15. Manic-depressive group * This is a modification of the Wurzburg Scheme (see (a) genuine cyclothymia, i.e., with depressive page 631). and manic phase 654 E. STENGEL

15. Manic-depressive group (continued) 17. Obsessive-compulsive disease (including anati- (b) manic phase kastic personalities) (c) depressive phase (d) cyclothymic disorders during involution 18. Abnormal reactions and developments; neuroses and old age (without cerebral change) (a) primitive reactions (e) depressive-paranoid disorders during the (b) paranoid reactions and developments climacteric and involution (c) depressive reactions (not included in group (f) endo-reactive forms (dysthymia, basic and 15) background depressions) (d) actual crises (" actual neuroses ") (e) neurotic developments 16. Psychopathic personalities (f) phobic symptoms (a) hyperthymic (g) sexual neuroses and perversions (b) depressive (h) hysterical syndrome (c) insecure (i) induced psychosis (folie 'a deux) (d) fanatic (k) compensation neurosis (e) self-assertive (1) imprisonment reaction (f) emotionally labile (m) suicidal attempt (to be added) (g) explosive (h) callous 19. Developmental and behaviour disorders of (i) weak-willed children and adolescents (k) asthenic (1) others 20. Unclear cases

6. CLASSIFICATION PROPOSED BY LOPEZ IBOR *

1. Congenital and acquired oligophrenias 6. Mental disorders with diseases of the rest of the (a) without known cause organism (state the disease or disorder of (b) due to cerebral lesions, or of other known origin) etiology 7. Alcoholism (c) cretinism (a) pathological drunkenness 2. Mental disorders from cerebral traumatisms (b) chronic alcoholism (c) delirium tremens and hallucinosis 3. Syphilitic psychosis (d) Korsakow's psychosis (a) general paralysis of the insane (b) mental changes in cerebral lues and tabes 8. Drug addiction 9. Epilepsies 4. Mental changes in old age (a) true or essential (a) vascular forms (b) symptomatic (b) senile forms (c) special forms (Alzheimer's, Pick's disease, 10. Schizophrenias etc.) 11. Manic-depressive psychosis 5. Mental disorders with other diseases of the 12. Psychopathic personalities and development nervous system (tumours, multiple sclerosis, Huntington's chorea, etc.) 13. Abnormal mental reactions (neurosis) 14. Obscure cases * Personal communication from Professor J. J. L6pez Ibor, Madrid. 15. Cases under observation CLASSIFICATION OF MENTAL DISORDERS 655

7. KLOOS' CLASSIFICATION *

PSYCHOSES ABNORMAL REACTIONS I. Endogenous (i.e., of unknown, constitutional I. Reactions to external events organic origin) A. Qualitatively abnormal (a) schizophrenia (a) reactive depression (b) manic-depressive psychosis (b) hypochondriacal reaction (c) psychotic episodes in genuine epilepsy (c) anxiety reaction (d) terror reaction It. Exogenous (i.e., caused by known constitutional (e) reactive states of excitement (joyful or or acquired physical disease) irascible) (a) of cerebral origin B. Qualitatively abnormal (b) symptomatic psychoses, i.e., of non- (a) purposeful reactions cerebral origin (i) hysterical (c) toxic psychoses (ii) simulation (b) delusional reactions (i) paranoid (sensitive, expansive) ABNORMAL PERSONALITIES (ii) induced psychosis (folie 'a deux) C. Mixed I. Oligophrenia (a) to accidents (a) general deficiency (b) to war (b) special disability (c) to imprisonment 1I. Abnormal reactions to inner events (i.e., to IJ. Psychopathy internal conflicts), the neuroses (a) conflicts of the instinct of self-preservation III. Neuropathy (organ neurosis, neurasthenia) (b) conflicts of the instinct of power (c) conflicts of the social, including the sexual, * Kloos, G. (1951) Med. Klin., 46, 1 instinct

8. LANGFELDT'S CLASSIFICATION * *

I Main diagnoses with subdiagnoses Group c: Mental disorders following organic brain diseases Group a: Schizophrenic disorders 1. Hebephrenic form 17. Presenile psychoses (in Pick's and Alzheimer's 2. Catatonic form atrophies) 3. Paranoid form 18. Senile psychoses 4. Simple demential form 19. Arteriosclerotic psychoses 5. Other forms 20. General paralysis 6. Schizophreniform forms 21. Other luetic forms (schizophrenia-like) 22. Epileptic psychoses and epileptic disturbances Group b : Manic-depressive disorders of conscience 10. Depressive form 23. Psychoses e tumoral cerebri and cerebral 11. Manic form tumour 12. Circular form 24. Psychoses e sclerose multiplicae and multiple 13. Involutional melancholia sclerosis 14. Atypical forms 25. Psychoses e chorea Huntington and Hunting- ton's chorea * * Langfeldt, G. (1956) The prognosis in schizophrenia. 26. Psychoses in chronic encephalitis and chronic Acta psychiat. scand., Suppl. 110 encephalitis 656 E. STENGEL

Group c : Mental disorders following organic brain Group m : Psychoneuroses diseases (continued) 79. Depressive reactions 27. Psychoses in other brain disorders of non- 80. Anxiety reaction traumatic nature 81. Anancastic reaction 28. Other disorders in organic brain diseases. 82. Hysterical reaction (conversion) Group d: Traumatic and post-traumatic disorders 83. Neurastheniform and hypochondriacal reac- 31. Traumatic neuroses acute reactions tions 32. Traumatic psychoses a 84. Psychosomatic reactions 33. Post-traumatic neuroses 85. Other forms 34. Post-traumatic psychoses late 35. Post-traumatic dementia reactions Group n: Neurasthenias 36. Post-traumatic encephalopathy 87. Constitutional forms 37. Post-traumatic disorders, others 88. Post-infectious forms secondary Group e : States of intoxication 89. Post-intoxicational forms S forms 40. Alcoholic psychoses - 90. Due to exhaustion 41. Chronic alcoholism 91. Other secondary forms 42. Other states of exogenic intoxication Group o: Observation Group f: Psychoses in infections andgeneral diseases 93. Judicial observation 45. Psychoses in infectious diseases 94. R.T.V. (medical insurance observations) 46. Psychoses in endocrine disorders 95. Other observations 47. Psychoses in other general diseases Group g: Constitutional psychoses Group p : Temporary diagnoses and incompletely 50. Affective reactions investigated patients 51. Amential reactions II. Diagnoses of personality 52. Paranoiac and paranoid reactions 53. Ideas of reference This heading is intended for recording of more 54. Other dominant traits in the individual, as manifested prior to illness. Group h: Psychogenic psychoses 57. Emotional states The concept of personality is here used less in 58. Amential states the meaning of the unique and individual and more 59. Paranoid states in the meaning of personality type. 60. Other states 0. Non-abnormal person Group i : Other mental disorders 1. Intellectual and socially positive individual 63. Psychoses of uncertain origin 2. Hypophrenic person 64. Symptomatic psychoses 3. Infantile person 4. Ambitious person Group k: Oligophrenia 5. Hypersensitive person 66. Slight moronism (I.Q. 90-75) 67. Pseudodebility (pseudo-moronism) 6. Repressed person 68. Moronism 7. Person of weak character 69. Imbecility (I.Q. 50-25) 8. Schizoid person 70. Psychotic reaction in oligophrenia 9. Constitutional emotional abnormalities: Group 1: Psychopathias (a) Depressive (b) Hypomanic 71. Cycloid form HereditarY 72. Schizoid form H (c) Cyclothymic 73. Constitutional forms 10. Paranoid person 74. Post-encephalitic form 11. Paranoiac person 75. Post-traumatic form 12. Anancastic person 76. Other forms 13. Impulsive person CLASSIFICATION OF MENTAL DISORDERS 657

14. Sexually abnormal person III. Diagnoses of situation and milieu 15. Person having previous brain damage This heading is intended for the recording of 16. Other forms situations in the environment of the individual 17. Combinations having a stated or supposed relation to the actual state. This relation may be supposed to be of three 18. Hysteroid person different types: 19. Affective, unstable person 1. Predisposing factors 20. Incompletely investigated person 2. Pathoplastic factors 21. Asthenic: (a) neurasthenic 3. Factors directly causing the disease. 36 types (b) psychasthenic of situational factors are listed.

9. CLASSIFICATION OF LECOMTE ET AL. *

Oligophrenic syndromes 2 o 2 4 ) *0 0 S. . 0 00 ______Mental U - U' 0~~~~~SOCC

Idiocy Imbecility Deficiency 20 420 0 0 . 2 0 O s0 C 4

No. of cases

So-called degenerative stigmata Syphilis Hereditary syphilis Alcoholism Hereditary alcoholism Personal tuberculosis Family tuberculosis Epidemic encephalitis Various infectious diseases Parasitic diseases Cerebral tumours Cancers Endocrine disturbances Puerperium Cranial traumatism Senility Arteriosclerosis Hypertension Somato-sensory disorders Emotional and affective factors Social factors

* Lecomte, M., Donney, A., Delage, E. & Marty, F. (1947) Techn. hosp., 2, 5 658 E. STENGEL

10. LEONHARD'S CLASSIFICATION OF ENDOGENOUS PSYCHOSES *

A. Phasic psychoses D. The systemic schizophrenias 1. Manic-depressive group 1. Schizophrenia with 1X. (a) pure melancholia (b) pure mania (a) simple systemic catatonia III. (a) pure depression 1. parakinetic 1. agitated 2. manneristic 2. hypochondriacal 3. proskinetic (i.e., with liability to 3. self-torturing automatic movements) 4. suspicious 4. negativistic 5. apathetic 5. talkative 6. untalkative (b) pure euphorias 1. unproductive (b) simple systemic hebephrenia 2. hypochondriacal 1. fatuous 3. exalted 2. odd 4. confabulatory 3. emotionally flat 5. indifferent 4. autistic B. Cycloid psychoses (c) simple systemic paraphrenia I. Anxiety-bliss psychosis 1. hypochondriacal II. Excitation-retardation psychosis with 2. phonemic (i.e., with verbal halilu- confusion cinations) III. Hyperkinetic-akinetic psychosis 3. incoherent 4. phantastic C. The unsystemic schizophrenias 5. confusional I. Affective paraphrenia 6. expansive 11. Schizophasia II. Combined systemic schizophrenias III. Periodic catatonia (a) combined systemic catatonia (b) combined systemic hebephrenia * Leonhard, K. (1957) Aufteilung der endogenen Psy- chosen, Berlin, Akademie-Verlag, p. 480 (c) combined systemic paraphrenia

11. MIRA LOPEZ' CLASSIFICATION**

A. Deficiency disorders B. Disorders ofpersonality integration, constitution (a) Congenital, early (oligophrenia) andpsychopathic reactions 1. Idiocy (a) Asthenic 2. Imbecility (b) Paranoid 3. Mental deficiency (c) Hysterical (b) Acquired and incurable (dementia) (d) Irritable 1. Vascular (e) 2. Infectious Compulsive 3. Degenerative (f) Explosive (g) Cycloid (h) Schizoid * * Bustamante, J. A. (1948) Las enfermedades mentales en Cuba, La Habana, Tamayo, p. 87 (i) Perverse CLASSIFICATION OF MENTAL DISORDERS 659

C. Mental disorders 2. Traumatic (a) Psychoneuroses and organic neuroses 3. Infectious and post-infectious 1. Hysterical 4. Exotoxic 2. Neurasthenic 5. Endotoxic 3. Anancastic 6. Epileptic 4. Anxiety 7. Manic-depressive (b) Psychoses 8. Schizophrenic 1. Situational or reactive 9. Paranoiac and paraphrenic

12. J. E. MEYER'S PROPOSED DIAGNOSTIC SCHEME * 1. Psychoneuroses, psychoneurotic reactions special forms 1 2. Psychopathic personalities (c) climacteric depression (a) antisocial and criminal psychopaths (d) affective disorders of the aged (b) all other types 3. Atypical psychotic disorders Some well-defined forms of 1 and 2: if not under 1 (b) or 1 (c). (a) neurotic and maladjusted children (b) psychoneuroses with predominant somatic III. manifestations (c) sexual deviations 1. Sequelae of brain trauma (d) obsessional and phobic states 2. Convulsive disorders (e) alcoholism (a) idiopathic epilepsy (f) drug addiction (b) symptomatic forms of epilepsy (g) depressive reactions 3. Syphilis of the central nervous system 4. Presenile, senile and vascular brain disease II. 5. Mental disorders associated with other brain 1. The schizophrenic disorders lesionis (a) schizophrenia (b) schizophrenic episodes 6. Mental disorders in toxic, infectious and other (c) paranoid states diseases, as far as not included in No. 7 2. Affective disorders 7. Mental disorders associated with metabolic and (a) mania endocrine disturbances and avitaminoses (b) depression 8. Mental deficiency (a) with proved somatic cause * Meyer, J. E. (1959) An internationally acceptable diagnostic scheme suitable for comparative psychiatric studies. (b) of unknown cause In: American Psychopathological Association. Report of work conference onproblems offield studies in mental disorders, 1 If there was no attack previous to climacterium or New York (in press) aging.

13. SELBACH'S (BERLIN) CLASSIFICATION** I. Mental deficiency II. Mental disorders in heredo-degenerative diseases 1. hereditary 2. of unknown etiology 1. Pick's disease 3. acquired in utero 2. Huntington's chorea 4. due to birth trauma 5. acquired in early childhood 3. spino-cerebellar ataxia * * Personal communication from Professor H. Selbach, 4. amyotrophic lateral sclerosis Psychiatric and Neurological Clinic, Free University of Berlin 5. paralysis agitans 660 E. STENGEL

I1I. Mental disorder in and subsequent to systemic IX. Special psychotic forms (" mixed psychoses ") diseases 1 1. with mainly schizophrenic symptoms 1. heart and circulation diseases 2. with mainly manic-depressive symptoms 2. gastro-intestinal diseases 3. unclear types 3. liver diseases 4. kidney diseases X. Abnormal psychic reactions 5. metabolic diseases 1. primitive reactions 6. deficiency diseases and dystrophies 2. reactive excitements 7. blood diseases 3. depressive reactions 8. endocrine diseases 4. conversion reactions 9. infectious diseases 5. hysterical reactions 10. pregnancy and puerperium 6. hypochondriacal reactions 11. cachexias due to neoplasm 7. paranoid reactions IV. Mental disorders in and subsequent to brain 8. imprisonment reactions diseases XI. Abnormal psychic developments and neuroses 1. traumatic psychoses 1. simple developments 2. post-traumatic personality change 2. paranoid developments 3. acute meningo-encephalitis, etc. 3. conversion neuroses V. Mental disorders due to syphilis 4. anxiety neuroses 1. general paralysis 5. obsessional neuroses 2. juvenile paralysis 6. depressive neuroses 3. taboparalysis 7. character neuroses VI. Mental disorders associated with involution 8. neuropathy and aging 9. neurasthenia 1. climacteric psychosis with depression XII. Psychopathies and perversions 2. climacteric psychosis with paranoid ideas and hallucinations XIII. Addictions 3. involutional depression XIV. Alcoholism 4. involutional paranoid psychosis with 1. states of intoxication hallucinations 2. chronic alcoholism 5. senile dementia 3. delusional jealousy 6. Alzheimer's disease 4. hallucinosis 7. senile depression 5. delirium tremens 8. senile mania 6. Korsakow's psychosis 9. senile paranoia 10. cerebral atrophies XV. Intoxications VII. Manic-depressive group (cyclophrenia) XVI. Mental disorders in children and adolescents 1. cyclical type Mental deficiency 2. mania 3. depression 1. simple inherited 4. constitutional dysthymia Acquired defects 5. 2. partial disabilities 6. 3. other forms of acquired deficiency 7. reactive depression Special forms of mental deficiency VIII. Schizophrenic group 4. in hereditary organic nervous diseases 1. catatonia 5. in endocrine diseases 2. paranoid-hallucinatory schizophrenia 6. mongolism 3. hebephrenia Developmental and sensory defects 4. dementia simplex 7. general disorders of development Addition to No. 1-7 ps = psychoses, delirious states Addition to No. 1-7 de = organic dementia 8. speech disorders Addition to any category = suicidal attempt 9. sensory defects CLASSIFICATION OF MENTAL DISORDERS 661

XVI. Mental disorders in children and adolescents (continued) Psychopathies, abnormal reactions (neuroses) Neuroses 10. irritable psychopath 20. neuropathics 11. overanxious psychopath 21. stammerers 12. oversensitive psychopath 22. enuretics 13. overexcitable psychopath 23. wanderers 14. affectless psychopath Childhood psychoses 15. unstable psychopath 24. schizophrenia 16. self-assertive psychopath 25. manic-depressive illness 17. depressive psychopath 26. symptomatic psychoses 18. obsessional psychopath Asociality 19. others 27. asocial, delinquent

14. PACHECO E SILVA'S CLASSIFICATION * 1. Infectious psychoses minantly manic forms; predominantly melan- 2. Autotoxic psychoses cholic; mixed 3. Heterotoxic psychoses 8. Involutional psychosis 4. Dementia praecox 9. Psychosis through cerebral lesion and terminal 5. Systematic hallucinatory chronic delirium; dementia (arteriosclerosis, syphilis, etc) paraphrenia 10. General paralysis 6. Paranoia 11. Epileptic psychosis 7. Manic-depressive (periodic) psychosis; predo- 12. Psychoses called neurotic (hysteria, chorea, neurasthenia, psychasthenia) 13. psychopathies (atypical * Bustamante, J. A. (1948) Las enfermedades mentales Other constitutional ent Cuba, La Habana, Tamayo, p. 87 degeneratives states)

15. SJOGREN'S CLASSIFICATION * *

A. SYMPTOMATOLOGICAL ETIOLOGICAL GROUP II. Infectious diseases and diseases of the internal organs 1. Intoxications (a) Alcohol 1. hallucinosis syndrome 1II. Disorders of the nervous systen 2. paranoid syndrome 1. encephalitis 3. delirium syndrome 2. brain tumour 4. dipsomania syndrome 3. traumatic encephalopathy 5. amnesia syndrome 4. syphilitic brain disease 6. chronic alcoholism syndrome 5. cerebrovascular disease 7. others 6. Alzheimer's and Pick's diseases (b) Other chemical substances 7. senile dementia 1. morphine 8. others 2. barbiturates 3. amphetamine 4. coal gas IV. Epilepsy 5. metallic poisons 1. grand mal syndrome 6. others 2. petit mal syndrome ** Personal communication from Professor H. Sjogren, 3. psychomotor syndrome University of Gothenburg 4. others 662 E. STENGEL

B. PSYCHOLOGICAL-SYMPTOMATIC GROUP VI. Schizophrenic reactions or syndronmes (continued) V. Psychoneurosis or situational (psychogenic) reactions or syndromes 3. catatonic syndrome 4. paranoid syndrome 1. neurasthenic syndrome 5. other forms 2. anankastic syndrome 3. hysterical syndrome VII. Manic-depressive reactions or syndronmes 4. reactive-depressive syndrome 1. manic syndrome 5. paranoid syndrome 2. depressive syndrome 6. others 3. manic-depressive syndrome 4. melancholic syndrome C. OTHER GROUPS 5. other forms VI. Schizophrenic reactions or syndromes VIII. Psychopathic reactions or syndromes 1. dementia simplex syndrome 2. hebephrenic syndrome IX. Oligophrenic reactions or syndromes

16. SKOTTOWE'S CLASSIFICATION *

1. Affective disorders (the manic-depressive psy- exogenous poisons with psychosis [alcohol, etc.]; choses; minor depressive syndromes; anxiety organic brain disease with psychosis). states; involutional depressive syndromes). 5. Obsessive disorders (essential obsessional illness; 2. Schizophrenic disorders (essential schizophrenia; other obsessional syndromes). schizophrenoid states). 6. Hysterical disorders (the hysterical personality; 3. Paranoid disorders (paranoia; paraphrenia; general hysterical syndromes [fugues; amnesia; reactive and incidental paranoid syndromes). mimicry; grande hysterie]; conversion hysteria 4. Organic mental disorders (toxic-exhaustive states [paralysis; anaesthesia; aphonia; blindness]). [symptomatic psychoses]; minor toxic-exhaustive 7. Disorders of development (oligophrenia; special syndromes [including so-called " neurasthenia "]; disabilities; backwardness). malnutrition with psychosis [pellagra, etc.]; 8. Psychopathic personalities. 9. Mental disorders in children (the foregoing formal disorders; disorders of behaviour, per- * Skottowe, 1. (1953) Clinical psychiatry for practitioners and students, London, The Practitioner sonality and habits; the maladjusted child).

17. PSYCHIATRIC NOMENCLATURE AND CLASSIFICATION OF THE UNITED STATES WAR DEPARTMENT (1945) * *

1. Transient personality reactions to acute or special 2. Psychoneurotic disorders stress (a) General (a) General (b) Anxiety reaction (b) Combat exhaustion (c) Dissociative reaction (c) Acute situational maladjustment (d) Phobic reaction (e) Conversion reaction ** The Standard Veterans Administration Nomenclature (1951) is a modification of this scheme. The most important (f) Somatization reactions change is the introduction of a separate main category of (i) General disorders headed " Alcoholic intoxication and drug ad- diction ". In the 1945 classification these were included (ii) Psychogenic gastro-intestinal reaction under " Character and behaviour disorders ". (iii) Psychogenic cardiovascular reaction CLASSIFICATION OF MENTAL DISORDERS 663

2. Psychoneurotic disorders (continued) 5. Psychotic disorders (iv) Psychogenic genito-urinary reaction (a) Psychoses without known organic etiology (v) Psychogenic allergic reaction (i) General (vi) Psychogenic skin reaction (ii) Schizophrenic disorders (vii) Psychogenic asthenic reaction (ii.i) General (g) Obsessive-compulsive reaction (ii.ii) Schizophrenic reaction, latent (h) Hypochondriacal reaction (ii.iii) Schizophrenic reaction, simple (i) Neurotic and depressive reaction type (ii.iv) Schizophrenic reaction, hebe- 3. Character and behaviour disorders phrenic type (a) General (ii.v) Schizophrenic reaction, cata- (b) Pathological personality types tonic type (i) General (ii.vi) Schizophrenic reaction, para- (ii) Schizoid personality noid type (iii) Paranoid personality (ii.vii) Schizophrenic reaction, un- (iv) Cyclothymic personality classified (v) Inadequate personality (iii) Paranoid disorders (vi) Antisocial personality (iii.i) Paranoia (vii) Asocial personality (viii) Sexual deviate (iii.ii) Paranoid state (iv) Affective disorders (c) Addiction (iv.i) Manic-depressive reaction (d) Immaturity reactions (iv.ii) Psychotic depressive reaction (i) General (iv.iii) Involution melancholia (ii) Emotional instability reaction (iii) Passive-dependency reaction (b) Psychoses with demonstrable etiology or (iv) Passive-aggressive reaction associated structural changes in the brain, (v) Aggressive reaction or both (vi) Immaturity with symptomatic "habit" reaction Manner of recording 4. Disorders of intelligence Only the lowest sub-classification of the disorder (a) Mental deficiency is to be specified. Multiple diagnoses should be (i) General recorded, showing where relevant the primary (ii) Mental deficiency, primary diagnosis. Apart from type of reaction, its severity (iii) Mental deficiency, secondary should be noted, as also type, degree and duration of (b) Specific learning defects external stress; predisposition; degree of incapacity.