Commentaire du texte de Spitzer et Endicott 1978 : « Troubles médicaux et mentaux : proposition d’une définition et de critères », un article clé du débat sur la nosographie psychiatrique

Abstract

The article of Spitzer and Endicott (1978) is part of the preparatory work for the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III). This article highlights the need to define the concept of mental disorder to better identify guiding principles for determining which conditions should be included in the classification, which conditions should be excluded, and how these conditions should be delineated. The article describes a proposed definition and criteria for delineating a medical condition. The first originality of this article is to propose a reversal: the mental disorder will be delimited from a general definition of disorder in medicine. The second originality is to propose a hybrid position: the medical disorder is defined at the intersection of a physiological perspective (based on facts) and a social perspective related to the notion of disability (based on values). Despite the originality of the positions of Spitzer and Endicott and the interests to clarify the current debate in psychiatry, the major issue of the proposed definition is the absence of an attempt to link together the level of physiological dysfunction inside the human organism with the level of disability. This absence could be related to the fact that the authors do not propose a reference theory of cerebral and mental functioning. We will therefore analyze how the recent Research Domain Criteria (RDoC) project can highlight the limit of the original Spitzer and Endicott project. It will be emphasized, however, that explanatory models in medicine are not entirely guided by physiological knowledge but remain fundamentally a pragmatic choice. Thus an intermediate level of physiological explanation will be proposed between the level of explanation of brain function (such as the neurosciences constitute it), and the practice level of psychiatric medical action.