Perspective Is "Organic" Obsolete? Z.J.
LIPOWSKI,
M.D., F.R.c.P.(C)
In
Received March 2. 1990; accepted March 5. 1990. Address reprint requests to Dr. Lipowski. Department of Psychiatry•University of Toronto. 250 College Street. Toronto Canada. M5T IR8. Copyright © 1990 The Academy of Psychosomatic Medicine.
342
1707, nearly two centuries ago, Stahl I was the first writer to distinguish explicitly mental conditions that are psychological in cause from those that are organic in basis, such as delirium. In 1989, Psychosomatics published an article by members of the DSM-IV Work Group on Organic Mental Disorders, who proposed that the organic category be eliminated from the classification on the grounds that the term "organic" perpetuated a false dichotomy, obstructed an integrated approach to diagnosis, and implied that the remaining categories included in the diagnostic manual represent nonorganic conditions. 2 Thus, a time-honored and universally applied differentiation was to be abolished for reasons that invite critical scrutiny. Is "organic" obsolete? That is the question I propose to address. A crucial factor is how one chooses to define the term "organic." DSM-III-R 3 addresses this issue indirectly by stating that the essential feature of all the organic mental disorders is a "psychological or behavioral abnormality associated with transient or permanent dysfunction of the brain" (p. 98). This statement implies that the mental disorders not considered to be organic do not feature such a dysfunction-a questionable notion. A much more satisfactory formulation can be found in the 1989 draft of the International Classification of Diseases (ICD- 10):4 "The term 'organic' ... does not imply that the conditions in other sections of this classification are 'non-organic' in the sense of not having a cerebral substrate. In the present context the term 'organic' means no more and no less than that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease" (p. 30). One could hardly state more clearly and succinctly that the term "organic," so defined, neither implies a "false dichotomy" nor negates the generally accepted assumption that all mental disorders involve cerebral processes. I have proposed elsewheres that the organic mental disorders comprise psychopathological manifestations of cerebral disease or disorder, which constitutes a necessary condition for their occurrence. Four main classes of the relevant diseases or disorders may be distinguished: primary cerebral disease; cerebral disease secondary to a systemic one; cerebral disorder resulting from exogenous toxic agents; and a cerebral disorder due to withdrawal from PSYCHOSOMATICS
Perspective
an abused substance. s So defined, organic mental disorders are distinguished on the grounds of their etiology, which needs to be demonstrated, or at least tentatively assumed, in every given case. According to our present knowledge, the disorders not included in this category lack such an etiologic basis. As a result, there is a dichotomy here, but one that is hardly false. Moreover, setting apart the "organic" disorders has a practical advantage and is useful because it implies that the diagnosis and treatment of the underlying brain disease or disorder should have an overriding priority in clinical practice. The classification of the organic mental disorders in DSM-I1I and DSM-I1I-R departed radically from that in DSM-I and DSMII. S.6 One of the basic changes was the liberalization of the concept "organic," which no longer was confined to the presence of global intellectual impairment. The overlap between the organic and at least some of the so-called functional disorders was explicitly acknowledged. As the member of the DSM-I1I task force who was entrusted with the revision of the organic category, I tried to reorganize it to reflect clinical observations, to stimulate research in this area of psychiatry, and to facilitate the diagnostic process. The revised classification brought to the clinician's attention the possibility that an affective, a personality, or a delusional disorder in a given patient could be due to an identifiable somatic disease or to a toxic factor, and it thus encouraged him or her to look for it. That classification was based on the one I formulated in 1975,' and it was accepted, with some modifications, by the task force. The revision has been well received by the international psychiatric community and is reflected in the 1989 draft of ICD-IO. 4 Probably the largest ever international conference on psychiatric diagnosis and classification, one attended by some 150 psychiatrists from about 50 countries, was held in Copenhagen in 1982. One of the workshops at that conference was devoted to "mental disorders associated with organic brain conditions." As the scientific rapporteur for tile workshop. I can state that the DSM-I1I classification of organic mental disorders was, in principle, wellreceived and that nobody at the conference suggested publicly that the organic category be abolished. Organic mental disorders had been largely neglected by American psychiatry prior to the introduction of DSM-I1I. 6 Their classification was grossly inadequate, and their terminology was muddled. Both of these facts were, most likely, at least partly responsible for the neglect of this area of psychiatry by researchers. One could argue that the revision contained in DSM-I1I has stimulated interest in, and research on, the organic disorders and that it has improved communication and teaching. Moreover, the aging of the population, as well as the epidemics of drug abuse and of AIDS, has drawn growing attention to them. There is little doubt that the description, the diagnostic criVOLUME 31· NUMBER 3· SUMMER 1990
343
Perspective
teria. and the guidelines for the establishment of etiologic links of the organic mental syndromes call for some revision and increased precision. This should be reflected in DSM-IV. A classification reflects no more than the state of current knowledge and needs to be revised periodically to keep pace with progress. Yet the proposed changes do not so much indicate progress as idiosyncratic viewpoints. s Major tinkering with the organic category at this time would bring back the semantic muddle that had bedeviled this area of psychiatry for decades. Consequently, it would impede research, communication. and teaching at a time when this would be particularly inopportune. especially since the incidence and prevalence of organic disorders are on the rise.
The proposed changes would conflict with the structure of ICD-l 0 and thus hamper communication with psychiatrists worldwide. Liaison and geriatric psychiatrists particularly would be affected since they see the bulk of the patients with organic disorders and need to communicate intelligibly with the nonpsychiatrists. One may predict that, in the future, a multifactorial etiologic classification of mental disorders will be developed and that, at such time, the term "organic" may become buried. I believe, however. that such a burial would be premature in DSM-IV. To answer my initial question: Is "organic" obsolete? I would say no, not yet.
References I. Alexander FG. Selesnick ST: The History of Psychiatry. New York. Harper and Row. 1966 2. Popkin MK. Tucker G. Caine E. el al: The fate of organic mental disorders in DSM-IV: a progress repon. Psychosomatics 30:438-441. 1989 3. American Psychiatric Association: Diaf(nostic and Statistical Manual of Mental Disorders. 3rd Edition. Rel·ised. Washington. DC. American Psychiatric Association. 1987 4. World Health Organization: World Health Orf(ani:ation /989 Draft ofChapter 5: Mental and Behal'ioral Disorders. Geneva. World Health Organization. 1989
5. Lipowski ZJ: Psychosomatic Medicine and Liaison Psychiatry: Selected Papers. New York. Plenum Medical Book Co. 1985, pp 227-245 6. Lipowski ZJ: A new look at organic brain syndromes. Am } Psychiatry 137:67~78. 1980 7. Lipowski ZJ: Organic brain syndromes: overview and classification. in Psychiatric Aspects ofNeurolof(ical Disease. Edited by Benson DF. Blumer D. New York. Grune and Stratton. 1975. pp 11-35 8. Lipowski ZJ: Organic mental disorders and DSM-IV (letter). Am} Psychiatry (in press)
The International Psychogeriatric Association (IPA) has announced the winners of its 1989 Research Awards First Place, Barry W. Rovner, MD. Paper: The Prevalence and Management of Psychiatric Disorders in Nursing Homes
Second Place, Alistair Burns, M.Phil., M.R.C.P., M.R.C.Psych. Paper: Behal'ioral Abnormalities and Psychiatric Symptoms in Alzheimer's Disease
Second Place, D. Henry Brodaty, MD., B.S., F.R.A.C.P., F.R.A.N.Z.C.P. Paper: Less Institutionalization and Lower Stress After Dementia Carers Programme The IPA announces its second. biennial Research Awards in psychogeriatrics. Cash awards: $7500first place; $5000-second place. in addition to travel and accommodations expenses for presentation of each paper at the Fifth Congress of the International Psychogeriatric Association in Jerusalem, Israel, from August 18-23. 1991. For further details. contact Fern F. Finkel. IPA Secretariat, 3127 Greenleaf Avenue. Wilmette. Illinois 60091. Telephone: (708) 866-7227; FAX: (708) 866-6984.
344
PSYCHOSOMATICS
LIPOWSKI,
M.D., F.R.c.P.(C)
In
Received March 2. 1990; accepted March 5. 1990. Address reprint requests to Dr. Lipowski. Department of Psychiatry•University of Toronto. 250 College Street. Toronto Canada. M5T IR8. Copyright © 1990 The Academy of Psychosomatic Medicine.
342
1707, nearly two centuries ago, Stahl I was the first writer to distinguish explicitly mental conditions that are psychological in cause from those that are organic in basis, such as delirium. In 1989, Psychosomatics published an article by members of the DSM-IV Work Group on Organic Mental Disorders, who proposed that the organic category be eliminated from the classification on the grounds that the term "organic" perpetuated a false dichotomy, obstructed an integrated approach to diagnosis, and implied that the remaining categories included in the diagnostic manual represent nonorganic conditions. 2 Thus, a time-honored and universally applied differentiation was to be abolished for reasons that invite critical scrutiny. Is "organic" obsolete? That is the question I propose to address. A crucial factor is how one chooses to define the term "organic." DSM-III-R 3 addresses this issue indirectly by stating that the essential feature of all the organic mental disorders is a "psychological or behavioral abnormality associated with transient or permanent dysfunction of the brain" (p. 98). This statement implies that the mental disorders not considered to be organic do not feature such a dysfunction-a questionable notion. A much more satisfactory formulation can be found in the 1989 draft of the International Classification of Diseases (ICD- 10):4 "The term 'organic' ... does not imply that the conditions in other sections of this classification are 'non-organic' in the sense of not having a cerebral substrate. In the present context the term 'organic' means no more and no less than that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease" (p. 30). One could hardly state more clearly and succinctly that the term "organic," so defined, neither implies a "false dichotomy" nor negates the generally accepted assumption that all mental disorders involve cerebral processes. I have proposed elsewheres that the organic mental disorders comprise psychopathological manifestations of cerebral disease or disorder, which constitutes a necessary condition for their occurrence. Four main classes of the relevant diseases or disorders may be distinguished: primary cerebral disease; cerebral disease secondary to a systemic one; cerebral disorder resulting from exogenous toxic agents; and a cerebral disorder due to withdrawal from PSYCHOSOMATICS
Perspective
an abused substance. s So defined, organic mental disorders are distinguished on the grounds of their etiology, which needs to be demonstrated, or at least tentatively assumed, in every given case. According to our present knowledge, the disorders not included in this category lack such an etiologic basis. As a result, there is a dichotomy here, but one that is hardly false. Moreover, setting apart the "organic" disorders has a practical advantage and is useful because it implies that the diagnosis and treatment of the underlying brain disease or disorder should have an overriding priority in clinical practice. The classification of the organic mental disorders in DSM-I1I and DSM-I1I-R departed radically from that in DSM-I and DSMII. S.6 One of the basic changes was the liberalization of the concept "organic," which no longer was confined to the presence of global intellectual impairment. The overlap between the organic and at least some of the so-called functional disorders was explicitly acknowledged. As the member of the DSM-I1I task force who was entrusted with the revision of the organic category, I tried to reorganize it to reflect clinical observations, to stimulate research in this area of psychiatry, and to facilitate the diagnostic process. The revised classification brought to the clinician's attention the possibility that an affective, a personality, or a delusional disorder in a given patient could be due to an identifiable somatic disease or to a toxic factor, and it thus encouraged him or her to look for it. That classification was based on the one I formulated in 1975,' and it was accepted, with some modifications, by the task force. The revision has been well received by the international psychiatric community and is reflected in the 1989 draft of ICD-IO. 4 Probably the largest ever international conference on psychiatric diagnosis and classification, one attended by some 150 psychiatrists from about 50 countries, was held in Copenhagen in 1982. One of the workshops at that conference was devoted to "mental disorders associated with organic brain conditions." As the scientific rapporteur for tile workshop. I can state that the DSM-I1I classification of organic mental disorders was, in principle, wellreceived and that nobody at the conference suggested publicly that the organic category be abolished. Organic mental disorders had been largely neglected by American psychiatry prior to the introduction of DSM-I1I. 6 Their classification was grossly inadequate, and their terminology was muddled. Both of these facts were, most likely, at least partly responsible for the neglect of this area of psychiatry by researchers. One could argue that the revision contained in DSM-I1I has stimulated interest in, and research on, the organic disorders and that it has improved communication and teaching. Moreover, the aging of the population, as well as the epidemics of drug abuse and of AIDS, has drawn growing attention to them. There is little doubt that the description, the diagnostic criVOLUME 31· NUMBER 3· SUMMER 1990
343
Perspective
teria. and the guidelines for the establishment of etiologic links of the organic mental syndromes call for some revision and increased precision. This should be reflected in DSM-IV. A classification reflects no more than the state of current knowledge and needs to be revised periodically to keep pace with progress. Yet the proposed changes do not so much indicate progress as idiosyncratic viewpoints. s Major tinkering with the organic category at this time would bring back the semantic muddle that had bedeviled this area of psychiatry for decades. Consequently, it would impede research, communication. and teaching at a time when this would be particularly inopportune. especially since the incidence and prevalence of organic disorders are on the rise.
The proposed changes would conflict with the structure of ICD-l 0 and thus hamper communication with psychiatrists worldwide. Liaison and geriatric psychiatrists particularly would be affected since they see the bulk of the patients with organic disorders and need to communicate intelligibly with the nonpsychiatrists. One may predict that, in the future, a multifactorial etiologic classification of mental disorders will be developed and that, at such time, the term "organic" may become buried. I believe, however. that such a burial would be premature in DSM-IV. To answer my initial question: Is "organic" obsolete? I would say no, not yet.
References I. Alexander FG. Selesnick ST: The History of Psychiatry. New York. Harper and Row. 1966 2. Popkin MK. Tucker G. Caine E. el al: The fate of organic mental disorders in DSM-IV: a progress repon. Psychosomatics 30:438-441. 1989 3. American Psychiatric Association: Diaf(nostic and Statistical Manual of Mental Disorders. 3rd Edition. Rel·ised. Washington. DC. American Psychiatric Association. 1987 4. World Health Organization: World Health Orf(ani:ation /989 Draft ofChapter 5: Mental and Behal'ioral Disorders. Geneva. World Health Organization. 1989
5. Lipowski ZJ: Psychosomatic Medicine and Liaison Psychiatry: Selected Papers. New York. Plenum Medical Book Co. 1985, pp 227-245 6. Lipowski ZJ: A new look at organic brain syndromes. Am } Psychiatry 137:67~78. 1980 7. Lipowski ZJ: Organic brain syndromes: overview and classification. in Psychiatric Aspects ofNeurolof(ical Disease. Edited by Benson DF. Blumer D. New York. Grune and Stratton. 1975. pp 11-35 8. Lipowski ZJ: Organic mental disorders and DSM-IV (letter). Am} Psychiatry (in press)
The International Psychogeriatric Association (IPA) has announced the winners of its 1989 Research Awards First Place, Barry W. Rovner, MD. Paper: The Prevalence and Management of Psychiatric Disorders in Nursing Homes
Second Place, Alistair Burns, M.Phil., M.R.C.P., M.R.C.Psych. Paper: Behal'ioral Abnormalities and Psychiatric Symptoms in Alzheimer's Disease
Second Place, D. Henry Brodaty, MD., B.S., F.R.A.C.P., F.R.A.N.Z.C.P. Paper: Less Institutionalization and Lower Stress After Dementia Carers Programme The IPA announces its second. biennial Research Awards in psychogeriatrics. Cash awards: $7500first place; $5000-second place. in addition to travel and accommodations expenses for presentation of each paper at the Fifth Congress of the International Psychogeriatric Association in Jerusalem, Israel, from August 18-23. 1991. For further details. contact Fern F. Finkel. IPA Secretariat, 3127 Greenleaf Avenue. Wilmette. Illinois 60091. Telephone: (708) 866-7227; FAX: (708) 866-6984.
344
PSYCHOSOMATICS
