My interest in mental illness and diagnosis stems from the fact that my brother is autistic, low functioning and nonverbal. In my attempt to discover more about the process of diagnosis, I have written several posts on the subject: Diagnosis, the Beginning; Diagnosis (dx) Basics; Diagnosis and Mental Health; Stamp Collecting (about taxonomy); Autism Diagnosis – Early History. Today, I had an extremely interesting conversation about diagnosis with a physician colleague and friend of mine, Dr. Andrew Lautin who is a psychiatrist. He is the author of The Limbic Brain,[1] and primary author of the forthcoming A Beginners Guide to the Study of Neuroanatomy.[2] I am a co-author of the latter volume. Below is a summary of what we discussed.

Freudian Theory

Freud was looking for universal laws of mental life, which could be applied to any person[3]; pathological conditions could be explained on the basis of these laws and therefore abnormal conditions were psychogenic in origin. That is, behaviors originate from psychological, not physical causes.

1960s

Freudian psychoanalysis held sway until the late 1960s. A very compelling account of this era can be found in the engrossing book, Madness on the Couch¸ by Edward Dolnick.[4] There was no categorization of patients’ mental issues: each patient was continually queried until the secrets of his or her unconscious were revealed. These, according to Freudian theory were the roots of a person’s behavior.

J. K. Wing, J. E. Cooper and N. Sartorius developed the Present State Examination at the Maudsley Hospital in Britain in the 1960s. “The aim was to facilitate the standardized identification of psychiatric cases and to improve psychiatric classifications, both for research and clinical purposes.”[5] Dr. Wing subscribed to the view that “mental malfunctioning” is best understood via the disease model.[6]

The long and short of it

Classification of disease states has been evolving for more than a century. Kendler gives a fascinating account of the history of psychiatric taxonomy and compares it to the history of classification in the biological sciences.[7] Physicians such as Bleuler, Kraepelin, Wernicke and Krafft-Ebing developed classification systems based on their own clinical experience and assumptions.

Complexities

As I’ve said before, clear-cut biological determinants for behavior is lacking for most psychiatric conditions. There is little doubt that biological conditions may be responsible for many behaviors. A man with a brain tumor committed the Austin Clock Tower massacre in 1966; the investigating commission concluded that the tumor could have contributed to the man’s commission of the crime.

Why do doctors diagnose?

The idea that there are universal laws of mental life has been debunked. There must be an alternative to perpetual psychoanalysis in determining the cause of psychiatric problems. Diagnosis is about knowing the cause of something; classification is a methodical way to go about finding causes. This is why it is so important to have a gold standard classification system based on scientific principles.

[Note: The recollections of my conversation with Dr. Lautin are my own. If I have erred, I will make corrections in a future post.]