Descriptive Psychopathology: The Signs and Symptoms of ...

23 Chapter 2: A history of psychiatric classificationpressed for new categories and subcategories while others sought parsimonyand searched for common denominators and fewer categories. The influence ofthese “splitters” and “lumpers” mingled with theoretical constraints and socialdemands continues in efforts crafting new DSM and ICD iterations. Science hasplayed only a modest role in the formation of classifications.Empirical research, however, is not “theory-free”. Every major shift in classificationrequires consensus, i.e. a best-estimate interpretation of the informationat hand. Agreement is needed on what is to be classified and what factorswill be used in sorting out patients. In psychiatric classification it must firstbe decided what is normal and what is not, what is deviance due to pathology ormaturational variability and what deviance is the result of odd upbringing orother experience. This first step has never been resolved, even in the modern erawhere biology and genetics are so highly valued. 5For the clinician who cares for patients with behavioral disorders, however,a flawed classification system is better than none to avoid practice anarchy. Theflaws in present classification affecting practice are detailed in other chapters.Understanding how the flaws emerged suggests corrective options. Those optionsare presented in the last chapter.Theory drives description and classificationFor millennia, philosophy dominated Western medicine’s ideas about psychiatricillness. 6 In classical Greek literature and in the writings of Herodotus, madnesswas attributed to punishment by a deity, avenging demons, excessive drinking,and physical illness. 7 The Christian “Old Testament” pronounces madness andwhat can be considered neurotic disorders as god-sent. The Christian “NewTestament” attributes these states to evil spirits. 8Despite the mythological views of causality, physicians of these eras describedmany recognizable behavioral disorders. Hippocrates (fourth century BCE)detailed familiar images of epilepsy, mania, melancholia, paranoia, and hysteria.Aretaeus of Cappadocia (first century CE) considered psychiatric disease tooriginate in the head and described melancholia and mania, manic-depression,alcohol-related and toxic states, and dementia. He grouped behavioral conditionsby course and outcome, foreshadowing Karl Kahlbaum and EmilKraepelin. 9Galen (130–200CE), marshalling the knowledge of Western medicine, consideredbehavioral conditions to reflect brain disorder. Classifications of behavioralsyndromes followed his formulations until the mid-nineteenth century,with perturbations in pulse and fever the main guidelines for separatingsyndromes. Epilepsies were well delineated. Melancholia was an established