Table Of ContentShanghai Archives of Psychiatry, 2013, Vol.25, No.1 ·3·
• Editorial •
Complaints, symptoms and the cross-cultural
relevance of diagnoses
John E. COOPER
Expensive, high-technology research currently rates than psychiatrists; and, despite reporting a similar
dominates the content of most psychiatric journals, prevalence of schizophrenia (0.5% for lay interviewers
but there is still a continuing need for detailed clinical and 0.7% for psychiatrists), the agreement about which
studies and for studies that address fundamental individuals met the diagnostic criteria for schizophrenia
conceptual issues. These studies, which are primarily was very poor (of 33 individuals given the diagnosis only
based on the interviewing and follow-up of patients and 3 were assigned the diagnosis by both interviewers).[4,5]
other community members, do not require expensive Some years later, a similar comparison was made in the
technology and laboratory equipment but they do need United Kingdom, in which subjects were interviewed with
trained professional staff over significant periods of time, the successors to the DIS and the PSE -- the Composite
so they are not necessarily much cheaper than high- International Diagnostic Interview (CIDI)[6] administered
technology studies. This editorial will discuss a few of by trained lay interviewers and the Schedule for Clinical
these types of studies. Assessment in Neuropsychiatry (SCAN)[7] administered
by psychiatrists. Again, lay interviewers using the CIDI
First, a problem of wide international interest is
reported higher rates of disorders than psychiatrists using
an as yet unanswered question: ‘When a person is
the SCAN; this difference was greatest for depressive
interviewed about their emotional state, what is the
disorders and anxiety disorders.[8]
relationship between what that person complains about
and the symptoms that a psychiatrist might conclude are It is clear that complaints and symptoms are not the
present?’ This question first became prominent during same, but nobody has yet done a follow-up study to
the Epidemiological Catchment Areas (ECA) studies in the examine which is most useful in predicting, at an individual
United States[1] which involved the interview of a large level, such things as need for treatment, demand for
sample of community members using the Diagnostic treatment, response to treatment, or levels of persistent
Interview Schedule (DIS).[2] This schedule was designed disability. Both the CIDI and the SCAN have now been
to be administered by specially trained lay interviewers – used widely in different languages and cultures, so the
rather than by more expensive psychiatrists – who strictly necessary translations and modifications for a variety of
follow the questions in the schedule about the possible languages are available. Moreover, the CIDI is the main
presence of psychiatric symptoms and record the replies diagnostic instrument employed in the WHO-supported
of subjects without asking follow-up questions about World Mental Health Survey Initiative [9] that has already
the frequency or severity of the reported conditions. In been conducted in 28 countries. Before basing major
other words, the complaints of the subject are recorded. policy decisions on the results of these epidemiological
To compare the results of the DIS interview with a studies, it would be important to determine the relative
psychiatrist interested in eliciting symptoms, a sub-sample predictive power of complaints versus symptoms – a
of the same subjects was re-interviewed by a psychiatrist difference that may vary in different cultural settings.
who did not know the results of the DIS interview. The
A second unsolved clinical problem is to do with the
psychiatrist covered the same topics but followed the
diagnosis of neurasthenia. This diagnosis is not present
style of the Present State Examination (PSE),[3] which
in the DSM-IV, but it is included in ICD-10 because there
allows psychiatrists to ask additional questions about
are psychiatrists from several countries who regard it
frequency, severity and other aspects of the subject’s
as a useful category. An opportunity to examine the
state. Comparisons of the two interviews found broad
symptomatic basis of neurasthenia arose during the 1982
similarities but some interesting differences. For many
Chinese National Epidemiological Survey, conducted in 12
disorders, lay interviewers using the DIS obtained higher
doi: 10.3969/j.issn.1002-0829.2013.01.002
University of Nottingham, Nottingham, UK
correspondence: [email protected]
·4· Shanghai Archives of Psychiatry, 2013, Vol.25, No.1
regions of the country.[10] The PSE-9 was used in this study, investigated. But there are few published reports about
and diagnoses were made using the then current Chinese these disorders, possibly because most of them are acute
modification of ICD-9. The criteria for the diagnosis of transient conditions that are difficult to study.
Neurasthenia were:
The use of the word ‘dominant’ to describe the two
A neurosis manifest principally as an unusual internationally recognized diagnostic systems is inten-
susceptibility to fatigue, irritability, difficulty in tional. Although internationally recognised classifications
concentration, insomnia and a variety of unpleasant are necessary as a common language for communication
physical symptoms and feelings of weakness (asthenic purposes, it is easy to forget that they come accompanied
feelings). Anxiety is not a prominent feature of by certain dangers. The formulistic and often arbitrary
neurasthenia (particularly anxiety symptoms related definition and differentiation of diagnoses promoted by
to feelings of unreality); if anxiety is prominent then a these diagnostic systems inhibit creative thinking about
diagnosis of anxiety neurosis should be considered. In diagnoses and limit the examination of conditions that do
the same way, prominent depressive symptoms should not fit into the internationally accepted categories. The
usually lead to a diagnosis of depressive neurosis. same can be said of structured or standardised diagnostic
(reference 10, page 32) research interviews such as the CIDI and the SCAN. They
are necessary, but what do they leave out?
A detailed comparison of the symptoms of the 88 subjects
given a diagnosis of neurasthenia in the national survey
with subjects who had other neurotic disorders found that Conflict of interest
it was not possible to identify a unique symptom cluster
The author reports no conflict of interest.
that could distinguish neurasthenic patients from patients
with other neurotic disorders. Despite the difficulty of
distinguishing the clinical characteristics of the disorder, References
the diagnosis remained popular. Ten years later a large
1. Robins LN, Regier DA (eds). Psychiatric Disorders in America: The
14-country study of patients in general and primary
Epidemiological Catchment Areas Study. New York: Free Press,
health care settings reported the following prevalence 1990.
of ICD-10 disorders in 5000 consecutive attendees:
2. Robins LN, Helzer JE, Croughland J, Ratcliff KS. National Institute
mild to moderate depression, 10.4%; neurasthenia, of Mental Health Diagnostic Interview Schedule: its history,
5.4%; somatoform disorder, 2.7%; dysthymia, 2.1%; and characteristics and validity. Arch Gen Psychiatry 1981; 38(4): 281-
hypochondriasis, 0.8%.[11,12] 289.
3. Wing JK, Cooper JE, Sartorius N. The Measurement and
Perhaps it is now time to regard neurasthenia as a
Classification of Psychiatric Symptoms. Cambridge: Cambridge
historical curiosity, but it would be wise to have good University Press, 1974.
reasons to justify this. When writing about the history of
4. Helzer JE, Stolzman R, Farmer A, Brockington IF, Plesons D,
similarly problematic but popular terms such as ‘hysteria’ Singerman B, et al. Comparing the DIS with a DIS/DSM III–
and ‘psychosomatic’, Aubrey Lewis[13] warned that based physician re-evaluation. In: Eaton WW, Kessler LG
favourite terms such as these have a tendency to outlive (eds). Epidemiologic Field Methods in Psychiatry: the NIMH
Epidemiologic Catchment Area Program. Orlando FL: Academic
their obituarists. Two aspects of this problem still need
Press, 1985: 285-308.
investigating. First, in any particular country or culture,
5. Anthony JC, Folstein M, Romanoski AJ, Von Korff MR, Nestadt GR,
what proportion of psychiatrists still regard neurasthenia
Chahal R, et al. Comparison of lay Diagnostic Interview Schedule
as a useful diagnosis, and why? (This requires a study of the and a standardized physician diagnosis. Arch Gen Psychiatry
psychiatrists.) Second, what are the features of patients 1985; 42(7): 667-675.
receiving a diagnosis of neurasthenia that distinguish them
6. Robins LN, Wing J, Wittchen HU, Helzer JE, Babor TF, Burke J,
from other patients in terms of symptoms and response et al. The Composite International Diagnostic Interview. An
to treatment? (This requires a study of patients.) Anybody epidemiologic instrument suitable for use in conjunction with
contemplating an investigation of this problem would do different diagnostic systems and in different cultures. Arch Gen
Psychiatry 1988; 45(12): 1069–1077.
well to start by consulting the reviews on neurasthenia in
Problems of Psychiatry in General Practice by Gastpar and 7. Wing JK, Babor T, Brugha T, Burke D, Cooper JE, Giel R, et al. SCAN:
Schedule for Clinical Assessment in Neuropsychiatry. Arch Gen
Kielholz.[14]
Psychiatry 1990; 47: 499-515.
The study of neurasthenia is closely related to the 8. Brugha TS, Jenkins R, Taub N, Meltzer H, Bebbington PE. A general
wider topic of culture-specific disorders. Do they exist or population comparison of the Composite International Diagnostic
are the clinical states covered by this term better regarded Interview (CIDI) and the Schedules for Clinical Assessment in
Neuropsychiatry (SCAN). Psychological Medicine 2001; 31: 1001-
as local variants of the more generally recognised
1013.
disorders such as anxiety, depression and acute stress
9. The World Mental Health Survey Initiative. Available at: http://
reactions? The currently dominant classification systems
www.hcp.med.harvard.edu/wmh/ (accessed 27 December 2012)
such as ICD-10 and DSM-IV both contain appendices
10. Cooper JE, Sartorius N. Mental Disorders in China: Results of the
listing and describing possible culture-specific disorders,
National Epidemiological Survey in 12 Areas. London: Gaskell,
together with the suggestion that these should be 1996.
Shanghai Archives of Psychiatry, 2013, Vol.25, No.1 ·5·
11. Ustun TB, Sartorius N (eds). Mental Illness in General Health Care: 13. Lewis AJ. The Survival of Hysteria. Psychological Medicine 1975;
an International Study. Chichester: John Wiley and Sons, 1995. 5(1): 9-12.
12. Sartorius N, Ustun TB, Costa e Silva JA, Goldberg D, Lecrubier Y, 14. Gaspar M, Kielholtz P (eds). Problems of Psychiatry in General
Ormel J, et al. An international study of psychological problems Practice. Toronto: Hogrefe and Huber, 1991.
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Dr. John Cooper graduated from Oxford University and then received his DPM and
psychiatric post-graduate training at the Royal Bethlem and Maudsley Hospital and
the Institute of Psychiatry in London. While in London, Dr. Cooper led the UK team
involved in the US/UK Diagnostic Project, worked as a consulting psychiatrist at the
Royal Bethlem and Maudsley Hospitals, and was the vice-dean at the Institute of
Psychiatry. From 1972-1991 Dr. Cooper served as a professor and founding chair of
the Department of Psychiatry at the University of Nottingham, where he is currently
an emeritus professor. Dr. Cooper was a consultant to WHO in the development of
the ICD-8, ICD-9, and ICD-10; he participated in the WHO Collaborative Studies on
Schizophrenia; and he has been a WHO consultant to the United Arab Emirates
and Saudi Arabia. Dr. Cooper’s areas of research interest include diagnostic
classification, the promotion of psychiatric services in general health settings, and
the measurement of disability.
