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Putting into play summary prototypes,

exemplars, clusters, and dimensions

Segunda Jornada Internacional de Clasificación y


Diagnóstico Psiquiátricos

Lima, 23-25 September 2010

Claudio E. M. Banzato, M.D., Ph.D.


University of Campinas (Unicamp), Brazil
PITFALL OF OBJECTIVITY

Objectivity is a method of understanding,


which does not imply that all phenomena
are better understood the more objectively
they are viewed.
Nagel, 1986

Problems arise when we treat what is


vague as if it were precise.
Adapted from Ramsey, 1929
A CAUTIONARY TALE BY
HEMPEL

 The fictitious concept of ‘Hage’: product of Height


(mm) and Age (years): fully objective, operationally
defined, but with no systematic (theoretical) import
whatsoever (Carl Hempel, 1952)

 Psychiatrists are often allured by promises of


objectivity, but meaningfulness should not be a
casualty in the legitimate process of setting standards
FORMAL DEFINITION OF
CLASSIFICATION

A classification is a spatial, temporal, or


spatio-temporal segmentation of the world

Properties an ideal classification is expected to


exhibit:

o There are consistent, unique classificatory


principles in operation

o The categories are mutually exclusive

o The system is complete

Bowker and Star, 1999


An influential scientific icon
An influential scientific icon
DSM-III (1980)

Polythetic diagnostic criteria sets (predominantly)


 Internal variability within diagnostic categories
 Heterogeneous clinical presentations among patients
that receive the same diagnostic label

Brought psychiatric diagnosis closer to the prototype view


However, it backfired somehow...

As its rule-based format and explicit diagnostic criteria drew


most of the attention, this classification ended up being
received as if it were a neat and precise nosological map

Pigeonholing practice got even worse


‘Symptom recognition’ and
‘disease (disorder) recognition’

 Independentcognitive events
(two-stage model)

 Interdependent cognitive events


(back-and-forth interactions)

Berrios & Chen, 1993


Classical versus Prototypical Approach to
Categorization

Classical approach: membership defined by:


Singly necessary and jointly sufficient features
 Distinct boundaries
 Certain homogeneity
 Perfect nesting
Classical versus Prototypical Approach to
Categorization

Prototypical approach: membership defined by:


Similarity-matching procedure
 Features correlate with category membership
 They need not to be necessary and sufficient
 Family resemblance and natural categorization:
games, birds, furniture
The prototype view

Summary prototype model


 Similarity-matching procedure
 The features of a prototype are by no means criterial
 Category membership is determined by the degree of
similarity between a particular instance and the standard of
comparison, the prototype

Exemplar prototype model (multiple-examples)


 Many ways to be a good example of a category
 Multiple concrete examples work as standards of comparison
 Category membership depends on the existence of a sufficient
match to at least one exemplar

Cantor and Genero, 1986


Working with prototypes

 The widespread poor case-category fit seen in everyday clinical


practice should not need to be treated as errors provoked by flawed
classifications, but instead as an indication of great variability of cases
found in real world

 Prototypical categorization may lend itself readily to concomitant


dimensional description (in terms of closeness to prototype or goodness
of fit) and so generate hybrid models

 Diagnostic training should emphasize the process of operating with


fuzzy categories, where membership is really a matter of degree and
members are arrayed along a continuum of fit
Working with prototypes

 The interest raised by diagnostic categories lately and the


emphasis on counting symptoms for sake of diagnostic algorithms
obscured the fact that the assessment of psychopathology involves
a great deal of interpretation

 Psychiatric symptoms, the features that constitute diagnostic


criteria, are far from being elementary in any sense (they are by no
means self-evident building blocks)

 A prototypical approach to diagnosis makes it more explicit the


centrality of clinical judgement
Suggestion
 To use of prototypes along with diagnostic criteria. Typical
clinical vignettes or series of them (not necessarily fully developed
clinical cases) could be added as illustrations for the main
diagnostic classes

Rationale
 The relevant cultural aspects, related for instance to particular idioms of
distress, would be already built-in

 Arguably, the adoption of a prototype view could offer a more realistic


and useful framework for sake of conceptualization of psychopathology and
psychiatric diagnosis, as it helps to emphasize, rather than obscure, the
probabilistic nature of diagnostic categorizations
Symptom Domains in Schizophrenia and other related
Psychoses
Thought Positive
insertion,
Re
withdrawal or du
c ed
ke so
-li broadcasting dr
iv cia
am oid) Al e l
re ir og
D Ab ia
one e
( at ce Influence or Av ul
st ren t ol
iti
ia Negative
e
oh en passivity Bl on
c l m un
In rai te
D
e ed Hallucination d
n iz af or
a Delusion fe fla
rg t ct t
Disorganization is o
u gh
D o
th

,
dd
,o te
St w ia
H up l lo r Mood
yp a op
er
ki
or Sh apr d
ne in
n oo
Au si Attention, m
ob t s on
ed om Processing s si
au ie at re ty
to nce ic speed ep ie
m D x
M
an at an An
ne ism d Verbal fluency
ris s
m
s
Executive
Motor functions Cognitive
Case vignettes as exemplars
Dave, a 46 year old S.W.M. male, has a long history of psychiatric and social problems. He enlisted in
the army at age 20, after dropping out of college. He scored very well on military intelligence tests but
was unable to complete basic training because of apparent confusion under stress and difficulty
concentrating on training tasks. After an early discharge, Dave tried to return to school and was
referred to the mental health center after he was found wandering around campus in a heavy trench
coat on a hot day. He reported that his radio was telling him what to wear.

A few weeks later Dave was committed to a state mental hospital after starting a fire in his dormitory
room “to help me stay warm so I can study.” He was found to have delusions that he was unable to
control his body temperature and would freeze to death if he was not careful. He responded to
treatment with neuroleptic medication, but he discontinued taking it after discharge from the hospital.
Over the next 25 years Dave was hospitalized on many occasions, each time with delusions of body
deterioration of some sort, or of persecution by voices from outer space. He did not adapt well socially,
never married, has not been able to work, and has never had serious problems with the law.

At this time, Dave is living semi-autonomously in a boarding home, where he spends his days watching
TV or walking about a nearby park. He expresses few emotions and has little motivation. He
scrupulously avoids illicit drugs and alcohol, although he smokes 20-30 hand-rolled cigarettes a day. He
takes anti-psychotic medication daily. He has not been completely free of his symptoms since they first
appeared, although they don’t trouble him very much.

Source: DSM Case Vignettes


http://www.eiu.edu/~csd/files/leitschuh/leitschuhdsmvignettes.pdf
(Accessed on 19 April 2010)
Case vignettes as exemplars
Chris, a 44 year old D.W.F. woman, was arrested after harassing a local
television newscaster with telephone calls and letters asserting that he had
fathered, then absconded with her child. She denied any wish to harm him
but steadfastly pursued him with demands that he give her “visitation rights”
to “their” child. She said she understood that he would be unable to marry
her, or even to outwardly acknowledge his love for her, because of his delicate
public position.

There was no indication that the newscaster had ever had a relationship with
Chris, although evidence from her files and from her apartment indicated that
her fantasized relationship with him had existed for several years. There was
no indication of hallucinations, disturbance of affect, significant Mood
Disorder, or organic illness, and the woman had never been treated for a
psychiatric disorder.

Source: DSM Case Vignettes


http://www.eiu.edu/~csd/files/leitschuh/leitschuhdsmvignettes.pdf
(Accessed on 19 April 2010)
Closeness to prototypes or
goodness of fit

 Full match or perfect fit

 Close match or good fit

 Partial match or moderate fit

 Poor match or minimal fit


Tandon et al., 2009
Dimensions of psychopathological
formulation

1. Closeness to the prototype or goodness of fit

2. Staging of the illness (severity & overall impact)

3. Degree of experienced distress

4. Level of insight

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