I would like to express my deep thanks to CLASSMED project team for giving me the opportunity to attend the meetings that inspired my choice of theme of this article, namely mental health, for the case study of this article on "subject ontogeny". This topic is of course part and parcel of my ongoing PhD research and CLASSMED project offered this insight. In fact, the core of the project deals with the desirability of maintaining the schizophrenia class in the ICD, by considering the epistemological, practical and social impact of classification. The challenge is to analyze the way in which classification systems are designed and updated, in such a way as to induce the inclusion or exclusion of populations, their stigmatization or their recognition by virtue of the categories assigned to them. I would like to particularly thank Professor Laurence Favier University of Lille, who is the main investigator of the projet and psychiatrists Jean-Luc Roelandt and Déborah Sebbane and their research teams.
1Today, information professionals know that the design of encyclopedic and medical classification systems, over a century old, requires constant revision to meet user needs. Indeed, these classification systems, built on the basis of old ideologies, have faced significant societal and technological evolution over recent decades, becoming increasingly rapid especially since the advent of digital technology. The lack of updates, of modifications to these classification systems, consequently leads to harmful effects on part of the population and problems in accessing information for users. That’s why professionals and researchers in Information and Communication Sciences propose new concepts, new theories to allow classification systems to evolve ethically, with the aim to meet the current and future demands of the entire population as best as possible. One of these theories is "… the ontogeny of a subject in a classification scheme…" by Tennis (2012), which provides a very relevant approach to the study of the evolution of a subject within different versions of a classification system. This reflects the idea of a society at a given time but also envisages its evolution through more flexible classification systems. Furthermore, I believe this theory is an ideal complementary approach in the implementation of an ethical evaluation of a classification system because it allows us to detect a subject’s biases.
2The subject studied in this article pertains to mental health and its evolution over space- time within classification systems. "Space" refers to the rate of occupation of the subject within classes, and "time" refers to the effects produced on terminology. Take, for example, the concept and term "schizophrenia" which, today, generates a stigmatizing image with ensuing consequences that incite debate and call for a participative revision involving various stakeholders such as patients, psychiatrists, healthcare facilities, associations, and families. The legitimacy of using the term "schizophrenia" is challenged, and its removal is even requested. Why? What happened during its evolution that it no longer meets the ethical conditions demanded by stakeholders? How has the concept of schizophrenia in mental health evolved to create an ethical problem? Moreover, medical classifications (ICD, DSM) regarding mental disorders have also evolved in view of the emergence of the new paradigm of mental health. Are they moving in the right direction? This evolution, which aims to address old ethical problems, does it not create new ones? These are some of the questions I will attempt to elucidate in this article. This empirical study explores two types of classification, encyclopedic classifications and medical classifications in the analysis of the subject, following a historical recap and the highlighting of causes and outcomes that provoke this revision. The discussion focuses on potential solutions and perspectives.
3From birth, humans must adapt to survive, evolving through various stages of learning. Thus, the development of cognitive abilities allows one to integrate into an environment and assimilate into a community by accepting its norms of thought and behavior. However, a portion of the population is considered deviant due to abnormal behavior. Mental disorders are then articulated in literature, and the term ’madness’ punctuates various eras. Depending on the era, these disorders are diagnosed and treated differently. Indeed, in antiquity, madness was linked to mood disorders generated by physical illness, and the applied treatment was theater, reading, and dialogue. In the Middle Ages, religion considered those afflicted by madness as possessed by evil and categorized them as heretics, with all the ensuing consequences. In the 17th century, the era of the "great confinement" began, where "general hospitals" served to relieve society of the insane, beggars, wandering unemployed, vagabonds, prostitutes, etc. During the French Revolution, madness was treated humanistically, encompassing the entire dimension of the subject; reference was made to a "moral treatment of madness" and recognition of the disease and its symptoms, and the first asylums for the mentally ill were created. These remained the only alternative into the 19th century until the theories of Emil Kraepelin appeared (Ménéchal, 1997). In 1947, a new dogma emerged in the mental health field that transformed asylums into psychiatric hospitals, and then from the 1980s to 2005, new social policies concerning health, especially in psychiatry, appeared. The innovation here was the creation of outpatient psychiatric services as an alternative to hospitalization, later supported by medical- psychological centers (Broutin, 2019).
4If we could see the above evolution of the fate of people suffering from mental handicaps through eras and institutions, we could also observe the evolution of the successive terms that name and classify them. Indeed, "madness", a term used since antiquity, was replaced by "mental alienation", a term suggested by Philippe Pinel in 1800. The term "dementia praecox" was first used by Bénédict Morel in 1852 to designate a specific dementia occurring at the end of puberty (Dollfus, 2019), then it was forgotten until the nosography of Emil Kraepelin, a psychiatrist, popularized it from 1896, even though it had already been proposed in 1891 in its Latin form by Arnold Pick, a neuropsychiatrist known for his work on presenile dementia (Crocq, 2012). Note that during the period between Morel and Kraepelin, other terms were successively used, such as "processes of psychic degeneration" and "dementing processes", and then came the term "schizophrenia" in response to Neumann and Griesinger’s concept of a single psychosis (Bleuler, 2012). Schizophrenia, a term used by Bleuler in 1911 to designate a set of psychiatric disorders, provided a new conceptual framework in mental health, but its evolution also led to misuses (Haouzir, 2010). Within systems of knowledge organization, the ontogeny of the subject allows for the analysis of the development of the subject’s concept, here mental health and, by extension, schizophrenia.
5If the epistemology of a concept refers to a period and culture, social evolution and scientific and technical advances can alter the perception of the concept and impact user information-seeking in the event of a lack of modifications within classification systems. Consider the case of Tennis’s (2012) study on the ontogeny of the subject "eugenics" which shifts from the scientific field of biology focused on improving the human race to a political and social thought related to racism, inherited from World War II, denoting Nazi science in pursuit of a perfect race. The epistemology within our classification systems is characterized by the design of a structural schema that legitimizes knowledge in the eyes of the dominant class of society; ontology complements this concept by defining what exists or is defined in reality through specific criteria. In our classification systems, ontology is expressed by the recognized and validated literary production by publishers and disseminators. Thus, it is not the subject that is classified but the literature referring to it, providing the vision and direction of the concept that should be considered. Hence, epistemology and ontology have a complex relationship that makes them inseparable (Fox, 2016), making the cataloger’s role significant when classifying the subject in good conscience, where the ethical dimension takes on its full meaning.
6In his article on the ontogeny of the subject, Tennis (2012) presents the concept of "collocative integrity" which consists of verifying the subject’s settlement within the architecture of classification systems. If confirmed, this forms the ideal of social constructivism, a principle in which the design of classification systems responds to various uses and understandings by establishing an independent existence to the subject. Nevertheless, Tennis also states that the world’s view on the subject can evolve; therefore, three types of changes can appear in a classification system: structural modification that alters its semantics, modification of its terms and their semantics, and finally, the semantic relationship between the classification’s indexing language and the literary production. Fundamental causes of these changes can be engendered by political context, redefinition of cultural criteria, social evolution, linguistic and semantic evolution, scientific and technological progress, technical evolution, and the imposed ethical model. Thus, the concept of the subject "mental health", studied in this article, including schizophrenia, in various classification systems, is no exception to the rule and calls for the different types of changes previously mentioned given the observed biases.
7Indeed, the school of thought regarding mental illnesses continues to evolve and, over time, reveals a succession of paradigms ranging from "mental alienation" in the 19th century, through a so-called preventive period named "mental hygiene", progressing between the end of World War I in 1918 and 1960, leading to the emergence of "mental health" between 1940 and 1960, which has since then continually developed in its conceptual approach to mental disorders. The graph below, based on the Google Books database via its Ngram Viewer tool, illustrates the ontogeny of the field of mental health over a given period (Fig.1).
Fig.1: Evolution of the terms "mental alienation", "mental hygiene", "mental health" in French literary production between 1810 and 2000 (Ngram Viewer, Google Books)
8Thus, we can observe that the concept of mental health through literary production informs us about its semantic process, constituting the "Literary warrant". The description of this characterizes the ontology referring to what exists and, on an epistemological level, leads professionals in the field of knowledge organization systems (KOS) to find consensus based on their judgements to structure and organize knowledge (Fox, 2016). These judgments originate from the sociological concepts accepted by these professionals concerning the individuals involved in relation to the field. The three-dimensional contribution of ontology, epistemology, and sociology thus allows for the evolution of knowledge within this field (Hjørland, 2017).
9Determining the causes that necessitate a revision and modifications within knowledge organization systems (KOS) regarding mental health proves to be more complicated than it appears and constitutes a significant task. That is why, to begin with, I considered it essential to start by defining the general context by outlining the ideological contour through the new paradigm of mental health, the political and socio-economic influence, as well as three sociological phenomena such as work, sustainable development, and the perception of mental illness by our society.
10As previously stated, the causes that necessitate a change in KOS stem from multiple evolutions and can act on three levels. In the case of mental health, a new paradigm emerged between the 1940s and 1960s, succeeding the mental hygiene movement of 1908, whose objective was to preventively treat mental disorders through collaboration between different stakeholders such as courts, schools, and social structures. This new mental health paradigm gained momentum with the creation of new institutions worldwide, up to the Mental Health Unit created by the WHO in 1949 (Doron, 2015). Since then, this new concept has continually evolved until compelling a revision of classification systems.
11If mental health was previously linked to the absence or presence of mental disorders, today it is defined in a globalist approach where the patient is at the center of concerns. Indeed, we are moving from a radical mental health continuum (Fig.2) to a nuanced mental health continuum (Fig.3) taking into account not only mental illness but also the components of an individual’s environment throughout their existence and the impact on their affect. Various philosophical theories, such as hedonism, which relates to emotional well-being at every moment of life and is conceptualized by a certain number of items, or eudaimonia, which refers to the autonomy and capacity of the individual to achieve social fulfillment, are taken as references in the evaluation of mental health (Doré, Caron, 2017).
Fig.2: Continnum radical
Fig.3: Continuum nuancé
12We see through these schemas that we have transitioned from one paradigm to another in the field of mental health, from the schema (Fig.2) representing poor mental health with a diagnosis that proposes a singular, "biological" and irreversible cause via theoretical assumptions, to the schema (Fig.3) which proposes to evaluate mental health on two axes: mental illness and individual well-being, as measured by specific items related to quality of life and personal autonomy, two distinct dimensions that are generally not correlated according to the study by Leguay et al. (Vidon, 2000). While the paradigm shift regarding mental disorders is due to medical progress, other causes of political, economic, social, technological, and ethical nature necessitate considerations for further adjustments to be made.
13The influence and development of mental health policy have been the prerogative of the World Health Organization (WHO) for several decades, which in its "global action plan for mental health" outlines the political contours of the subject, aiming to promote, protect, prevent mental disorders, and provide access to care for those suffering, allowing them to work towards the best possible recovery and contribute to society without being victims of stigmatization (WHO, 2022). According to the WHO, health in its totality does not only concern physical health but also mental health, as without the latter, it argues, we cannot speak of health. Good mental health is thus the well-being of a person manifested in their ability to adapt to their environment, cope with daily situations, interact with others, fulfill themselves, and contribute to the enrichment of the community (Inserm, 2021). The contemporary concept of mental health embodies two approaches concerning human life: a "treasure" and a "capital" (Champion, Garnoussi, 2017). The "treasure" is characterized by the fight against suicide, with prevention emanating from the WHO since 1969 and becoming a public health policy issue in France during the 1990s. Special attention has been given to certain population categories prone to suicide, such as the elderly, whose mood disorders and suicide risks are correlated with loneliness, inactivity, and loss of autonomy. People suffering from depression, experiencing severe psychological distress related to their poor living conditions, are also considered. The "treasure" aspect thus reflects the fight against social suffering and the granting of a right to well-being, free from psychological disorders, irrespective of any vested interest. As for the "capital" approach, it highlights the benefit of good mental health in the ability to adapt and cope with demanded economic and social evolution, aiming to optimize and increase work performance and thus contribute better to the company’s profitability. Indeed, as Champion and Garnoussi (2017) propose, public policies consider good mental health as an essential criterion for performance and profitability in the economic sphere and equate it with human capital that can be shaped from an early age by psychoeducation or re-education for incumbent professionals who would adjust behaviors considered non-compliant with the standards of adaptability and flexibility. Therefore, the well-being of individuals sought by public authorities in terms of mental health is not altruistic and foreshadows the birth of an innovative economy, that of the psychic economy. Furthermore, the authors highlight a predicted drift in the psychological impact on individuals aimed at standardizing them from an early age and annihilating any counter-productive behavior. Bellahsen (2014) also supports the fact that this new progressive approach, that is mental health, is a means of control and normalization intended to classify, manage, and evaluate every citizen concerning their profitability within society.
14In our society, the concept of work indeed occupies a central place, even a paramount one according to Coupechoux (2014), not only from an economic standpoint but also in the social development of the individual through their identity formation. Work, therefore, constitutes an alienating social and economic device that tirelessly forces the individual to acquire skills and meet the demands of assimilation, autonomy, integration, flexibility, and profitability, regardless of the harshness, in order to be accepted as a full-fledged citizen. This utilitarian approach in defining the citizen only has the effect of producing social alienation which can lead to marginalization and exclusion if affected. Indeed, the individual is considered solely responsible for their success as well as their setback, the latter of which would highlight their inability to cope. Thus, in our modern society, the modeling of a citizen is characterized by their economic performance. Citizens constitute "human resources", a capital that must be preserved and made profitable through the prism of mental health. Coupechoux also notes in the 2010 report by psychiatrist Viviane Kovess-Masféty titled "Mental Health, Everyone’s Business" that good mental health ultimately resides in the individual’s ability to adapt and continually increase their performance in the environment assigned to them. Work is thus considered today not as the dogmatic thought derived from the Age of Enlightenment which signified that work was the necessary psychic basis in the development of a social life and considered as a therapeutic method, but as a suffering generated by psychosocial risks (Calais, 2016). With the new paradigm of mental health, Calais (2016) discusses this new concept as a preventive regime based on the principle of not only social and professional but also mental safety. The psychological state that was once part of an individual’s private life is now a matter for the community and, consequently, classification systems like the DSM are being modified to include all everyday life disorders, raising ethical questions such as the right to privacy.
15Sustainable development, a new policy adopted in 2015 by the United Nations in response to the environmental crisis, underscores the desire to reshape our mass-production- based society into a sustainable organization aimed at better resource management (Guernut, Baleige, 2020). To achieve this end, several objectives are set, including the consideration of mental health in sustainable development and its new approaches in social innovation required by organizations. For Gernut and Baleige (2020), this change can affect discourse modeling by setting new ideological schemes corresponding to the advocated new socio-cultural environment. By presenting the three ideological frameworks in mental health that mark our contemporary society, the authors reveal how a concept can evolve and lead several ideologies to coexist successively such as Psychiatry, Recovery, and the Mad Pride Paradigm. In this evolution, firstly, the conceptual framework of psychiatry defines mental illnesses of biological origin, which are treated by therapeutic substances; the only actor in this approach is the psychiatrist who determines who is sick or normal by the presence or absence of disorders. However, the authors clarify that this ideological framework, due to refractory manifestations against established psychiatry, has questioned itself and is now open to criticism. Secondly, the Recovery concept emerges, launched by the "survivors of psychiatry" movement, it covers all actors including patients, and not only the psychiatrist in the interpretive approach. This ideological framework highlights the wealth of information reported by the patient who occupies a central place in considering their experience and feelings. The authors inform us that this innovative endeavor based on "experiential knowledge" contributes to ecological construction through its social equity and coherence with the World Health Organization’s policy highlighting health as a complete state of well-being, not only physical but also mental and social. Furthermore, the central place occupied by the patient values and redefines health as a fundamental human right, the application of which allows people with mental health problems to be recognized as suffering from a "psycho-social disability". Thirdly, the Mad Pride Paradigm movement promotes the right to institutional recognition of difference, where diversity and pride replace disease and stigma, placing the person concerned in a central role, who participates in social organization, thus responding to an approach consistent with social justice (Guernut, Baleige, 2020). Nevertheless, the authors wonder whether these three ideological frameworks, even if they have managed to adapt to the context of current society, will be able to maintain themselves in a sustainable development society, given the three specific challenges they will have to meet: to assure the outlines of mental health where problems would involve more in the treatment of potentially traumatic situations by respecting individual rights than pathological treatment and to move away from the psychiatric ideological framework by renouncing the scheme of mental illness. The second challenge would be to foster social equity by accepting mental difference and providing necessary support to people suffering from socio-economic trauma and to people in recovery. The third challenge lies in the production of discourse and interpretation derived not from a single actor such as the psychiatrist in the ideological framework of psychiatry but by all stakeholders found in the Recovery ideological framework or by the "survivors" of the Mad Pride Paradigm ideological framework, putting other actors at a subordinate level. The authors particularly draw attention to the fact that sustainable development requires a more collaborative and fairer society that breaks away from the exclusive power of experts and psychiatrists. However, if mental health professionals are required to evolve in their approach, it would also be detrimental not to benefit from their expertise. In fact, Bonal (1996) mentions in his article the need to evolve the professions in mental health and that the first condition to be in line with developing society is openness to all city stakeholders and action in training in new approaches. For Douillet (2012), integrating mental health into organizational management is already a path for sustainable development. Indeed, after having overlooked psychosocial risks, today, their assessment results from strong mobilization within companies. However, according to the author, companies often find themselves ill-equipped regarding the methods to implement sustainably in connection with situations that employees endure daily; consequently, he highlights a method that involves developing a diagnosis to reveal not only constraint factors but also resource factors at work; constraint factors are those perceived as harmful to the smooth progression of the assigned task, and resource factors are those that allow the work to be accomplished in peace and maintain good relationships. This approach is, I believe, preventive because the author shows that it mainly focuses on work and its difficulties and less on psychosocial risks. To implement this method, the main approach, as the author tells us, is to develop a dialogue between the various actors to take into account the claims of employees as well as the requirements of the organization to arrive at a common action plan where solutions to everyone’s problems result in "good work". This participatory perspective of all the organization’s actors, including the employees, allows for valuing them by granting them the recognition they deserve and preserving their mental health by preventing psychosocial risks caused by working conditions. For Douillet (2012), considering mental health issues in work organization is an advance in sustainable development within organizations, where men and women are the main vectors.
16While today the new paradigm of mental health forms an integral part of each individual’s health, stereotypes still persist. Could it be the weight of history on mental illnesses that perpetuates them? It is true that, in collective belief, individuals with mental illnesses are regarded as mad and need to be isolated, even confined, as was the case during the era of asylums. As Durand (2017) suggests, the general population is very adept at assigning pejorative terms to those affected, not to mention the negative image it has of psychiatry. Indeed, the author cites Salbreux, who argues that madness cannot be assimilated by our society, which represents the order that the "madman" disrupts. Durand (2017) also demonstrates the appropriation of terms by the population, originally belonging to the scientific domain of psychiatry, that are now used in everyday language in a derogatory way, such as "idiocy" or the term "degenerate" derived from the theory of degeneration.
17The study by Lampropoulos et al. (2018) reveals that a person with a mental disorder is subject to stigmatization, which can be of three kinds: social stigmatization in relation to the general public, structural stigmatization relative to institutions, and self-stigmatization generated by the patient themselves, reflecting the negative image they have of their condition. Despite campaigns and actions carried out by psychiatry professionals, the authors note that it is difficult to counteract popular belief systems and socio-symbolic aspects, and that schizophrenia is the most stigmatized disorder. The media’s excessive use of the term to report violent acts and crimes leads the population to associate the term schizophrenia with danger. The burden is so great for those affected that in recent years, psychiatric professionals have joined with all stakeholders—families, users, caregivers, researchers, and associations—to reach a consensus to replace the term schizophrenia with another that no longer presents the problem of stigmatization (Roelandt, 2011).
18This article aims to conduct an empirical study centered on the new paradigm of mental health. The research is both historical and descriptive, using the case study of mental health, and by extension, schizophrenia. The key question raised in this study is: how have the relevant classifications evolved ethically in the field of mental health? I retain two ethical criteria: just recognition, i.e., the terminology utilized in the classes of encyclopedic and medical classifications whose quality of determinants can establish a personalized diagnosis, and the criterion that I term "action", which refers to how the classification is formulated and what terminology can define benevolence or discrimination. After gathering my corpus, which includes medical classification systems ICD6, ICD7, ICD9, ICD10, and ICD11 and DSMIII, DSMIV-R, and DSM5, as well as the encyclopedic classification system DDC, I describe the ontogenesis of the medical classifications ICD and DSM and ethically evaluate them in terms of mental health and schizophrenia. Then, I compare the latest edition of the medical classification with the latest edition of the encyclopedic classification.
19After examining the ICD6, ICD7, ICD9, ICD10, and ICD11 medical classifications, significant changes are evident. The first notable change is the integration of the class "V. Mental disorders, psychoneuroses, and personality disorders" into the ICD6 in 1949. It contains seven forms of schizophrenia in its first classes and subclasses under 300 (Fig.4), reflecting the primary importance of schizophrenic disorder at the time. I also observe the use of discriminating terms that could marginalize, such as in the subclasses of "Pathological Personality" under 320, which include "maladjusted", "antisocial", "asocial" personalities, and "Sexual perversion", including homosexuality (Fig.5). Other terms in the subclasses "Mental deficiency" under 325 carry stigmatizing effects such as "Idiocy", "Imbecility", "Mental retardation", "Limited intelligence" and "Mongolism" (Fig.6). In the subclasses of "Mental Debility", I also observed the use of the terms "Cretinism" and "Stupidity". At that time, the use of these terms was more acceptable, as the classification was only available to a select circle of psychiatrists, who themselves were the designers. Mental health did not have the same meaning of "well-being" as it does today, but rather it denoted the stark continuum of the presence or absence of the aforementioned mental disorders (see Fig. 2).
Fig.4
Fig.5
Fig.6
20For ICD7 1955, while no significant structural or terminological changes occur in the main classes, terminological changes appear in the subclasses. Indeed, the degree of "Idiocy", "Imbecility" and "Mental deficiency" is no longer expressed as such but rather under "Mental deficiency" and the term "Cretinism" disappears, though the term “Stupidity” persists. There are no changes to the class of schizophrenic disorders.
21The ICD9 of 1977 replaced the class "Schizophrenic Disorders" with the class "Schizophrenic Psychoses", within which we find the same types of schizophrenia. However, a new form named "Residual Schizophrenia" is added in 295.6, leading to eight forms of schizophrenia. Each type is given an intensity degree in six subclasses: "Unspecified", "Subchronic", "Chronic", "Subchronic with Acute Exacerbation", "Chronic with Acute Exacerbation" and "In Remission". Moreover, the "schizophrenia" class is no longer in the pole position but is after the organic psychotic states. The class "Mental Retardation" in 317, with different levels in 318: Mild, Severe, and Profound, replaces the "Mental Deficiency" class of the ICD6 and 7. In terms of ethics, the terminology gradually evolves and becomes less discriminatory. Regarding the new paradigm of mental health, although it emerged between 1940 and 1960, it was not really felt in terms of "well-being". It is noteworthy that the French public authorities began to take this into account in the 1990s. However, the Neurotic Disorders class develops and opens interesting pathways like the subclasses "Acute Reactionary States to a Stressful Situation" and "Adjustment Disorders", without, however, providing precise cultural criteria.
22The ICD10 came into effect in 1993, in which seven types of schizophrenia are present, including a new one, "Undifferentiated Schizophrenia". The schizoaffective form leaves the schizophrenia class to have its own class and develop its subclasses. The acute schizophrenic episode and latent schizophrenia forms no longer appear in the schizophrenia class. In each form of schizophrenia, subclasses determine frequency and duration: "continuous", "episodic with progressive deficit", "episodic with stable deficit", "episodic remitting", "incomplete remission", "complete remission", "other evolution", "unpredictable evolution, observation period too short". The "Mental Retardation" class expands with the subclass "Mild Mental Retardation" added to Mild, Severe, and Profound. Additionally, its subclasses are also enriched with the degree of deficiency: "behavioral deficiency absent or minimal", "significant behavioral deficiency requiring monitoring or treatment", "other behavioral deficiencies", "without mention of a behavioral deficiency". Neurotic disorders appear with a structural change at the subclass level, which groups, among others, "Adjustment Disorders" and "Acute Reaction to a Stress Factor", previously called "Acute Reactionary States to a Stressful Situation" in the ICD9. There is also a change regarding sexual orientation, which is no longer affected in the "Deviation and Sexual Disorders" class but is affected in two other classes: "Disorders of Sexual Identity" and "Disorders of Sexual Preference", a significant advancement in terms of ethics where the problem is no longer the person’s sexual orientation but the identity or preference disorders that they may experience. Also note that the "Homosexuality" class disappears from the disorders. A significant advancement in mental health appears with the class "Subjects whose health may be threatened by socio-economic and psycho-social conditions" in Z55-Z65 in the category "Factors influencing health status and reasons for health services contact", which is divided into subclasses with difficulties related to unemployment, education, occupational exposure, physical and social environment, economic conditions, entourage, family situation, etc. A significant difference appears compared to the ICD9 in terms of the number of codes, the increase of which provides additional diagnostic assistance.
23The ICD11 replaces the ICD10 class "Mental and Behavioral Disorders" with the class "Mental, Behavioral or Neurodevelopmental Disorders", eliminating the separate classes of neuroses and psychosis. However, the change is not limited to the nomenclature. Indeed, we can observe a proliferation of subclasses providing greater precision regarding disorders and considering the psychopathological causes of these conditions. In the schizophrenia class, we no longer see the various forms of schizophrenia such as paranoid, hebephrenic, catatonic, undifferentiated, post-schizophrenic, residual, and simple, but the diagnosis of schizophrenia now focuses on temporality criteria (first episode, multiple episodes, continuous) and on criteria suggesting that schizophrenia is curable (currently symptomatic, partial remission, complete remission), a concept not previously conceivable when it was assumed that schizophrenia was a lifelong condition. In the ICD11, the neurotic disorders class is replaced by the "Anxiety or Fear-related Disorders" class. There are also changes in sexual disorders; they are no longer part of personality and behavioral disorders but fall under "Paraphilic Disorders", with references to transsexualism, dual-role transvestism, and sexual identity disorders no longer coded in the classification. The "mental retardation" class is replaced by the "Neurodevelopmental Disorders" class and a subclass "Intellectual Development Disorder" with intensity criteria (mild, moderate, severe, profound, and provisional). In mental health, the class "Factors influencing health status" is enriched with terms, but most notably, a new class "Additional section for functional evaluation" equipped with the WHODAS 2.0 tool (Ustun, Kostanjsek, Chatterji, et al., 2010), includes 36 items that measure cognition, mobility, self- care ability, interaction with others, response to various life activities, and participation in community life. With this latest edition, the ICD11 adapts well to the new paradigm of mental health and societal evolution.
24The DSMIII, published in 1980, contrasts with the nosologies of the ICD9. Indeed, through its detailed classification of neurotic personality disorders, we can observe a philosophical approach that is purely empirical and based on behavior. For the schizophrenia class, the DSMIII incorporates the same forms as the ICD9. The ICD9’s "mental retardation" class is adopted by the DSMIII. The DSMIII-R is structurally unchanged compared to the DSMIII but presents progress from a practical point of view. I will not delve further into the description of the DSMs because the ethical dimension is substantially the same as the ICDs given that these two classification systems evolve successively and parallelly in the same eras, so we find the same structural and terminological transformations over time. Note that the DSMIV particularly focuses on ethics by considering the culture and ethnic group of the individual in the diagnosis, an action that is accentuated in the DSM5, where, among other things, the neurodevelopmental and neurocognitive disorders are adopted by the ICD11.
25After having explored medical classifications, I contrast the most recent development in these classifications with the latest edition of the encyclopedic Dewey Decimal Classification, DDC23. In the DDC, we find the term schizophrenia in 300 Social Sciences under the subclass 362.26 Psychoses, and in 600 Technology under the subclasses 618.858 1 Personality Disorders and 618.898 Schizophrenia. "Mental health" also appears in 300 under the subclasses 323.49 Suspension and restriction of rights, 344.044 Regulation of mental health services, 353.64 Mental health services, 362.21 Mental health institutions, 362.22 Community mental health services, 371.71 Student mental health, and 371.713 Mental health services in schools. Neurosis is classified in 600 under the subclass 616.852 Neuroses and related disorders, including traumatic and post-traumatic neuroses, war neuroses, and anxiety neuroses, with a notable inclusion of the subclass for occupational therapy and mental therapies for anxiety neuroses. We also see the existence of the subclass intellectual deficiency (mental retardation) in 616.858 8 and sexual psychology in 155.3, encompassing sex and personality, sexual differences, sexual relationships, and bisexuality. Within the DDC, there is also a significant section on psychology across all personalities, ethnic differences in 155.82, psychological influence of housing in 155.945, interpersonal relationships in 158.2, work psychology in 158.7, as well as a plethora of classes and subclasses in 100, 200, and 300 dedicated to various ethical aspects, from the class on cultural contacts in 303.482, to the class on work psychology in 158.7. We also find numerous classes concerning the internet, including an observed bias, as we find "internet and women" in 004.678 082, but no corresponding entry for men. This overview demonstrates an extremely significant growth of themes and determinants that could form part of the mental health domain. These determinants enrich and multiply the classes and subclasses in great numbers within the DDC. A detailed exploration and analysis of all these themes and determinants would require a Herculean effort that cannot be accomplished within the scope of a single article. Thus, in the table below, I highlight the determinants in the latest editions of the ICD11, DSM5, and DDC23 that could influence mental health, and also indicate the presence and location of the terms "mental health" and "schizophrenia" (Fig.7). We can thus observe in the latest medical classifications, ICD11 and DSM5, the presence of these determinants as well as in the encyclopedic classification DDC23. We can see that schizophrenia in the latest medical classifications is no longer categorized in different forms but rather as a single form with varying evolutionary and remission criteria. In DDC23, schizophrenia is categorized as a psychosis and mental disorder. The term "mental health" appears significantly more frequently in the DSM5 than in the ICD11, while in the DDC23, the term refers to services and institutions as well as the well-being of students in 371.71. As for the determinants, even though we find them all in the classifications below, the choice of terms and their placement are quite heterogeneous among them, causing different meanings and content. Furthermore, I believe that the internet section is not sufficiently developed in mental health, as well as sustainable development and its ideological impact on the individual.
Fig.7: presence and location of the terms "mental health" and "schizophrenia"
Determinants/Terms
|
ICD-11
|
DSM-5
|
DDC-23
|
Schizophrenia categorized into different forms
|
|
|
|
Schizophrenia with evolutionary and remission criteria
|
X
|
X
|
|
Categorized schizophrenia (mental disorders, psychosis)
|
|
|
X
|
Mental Health
|
In evaluation section only
|
In section abuse and neglect (child and adult)
|
Present in 300 and 600
|
Accommodation
|
X
|
X
|
X
|
Purchasing power, finance, precariousness, poverty
|
X
|
X
|
X
|
Feed
|
X
|
X
|
X
|
Family
|
X
|
X
|
X
|
Place of life (urban, rural, sensitive
|
X
|
X
|
X
|
Migration, acculturation
|
X
|
X
|
X
|
Work, conditions
|
X
|
X
|
X
|
Unemployment
|
X
|
X
|
X
|
Environment
|
X
|
X
|
X
|
Relational
|
X
|
X
|
|
Substance use (alcohol, cannabis, cocaine, etc.)
|
X
|
X
|
X
|
Internet
|
In game disorder only
|
In game disorder only
|
X
|
26We can observe that medical classifications ICD and DSM have significantly developed in the redefinition of classes and the multiplication of subclasses, particularly in the etiology of mental health pathologies which now take into account contextual and environmental factors in diagnosis. A number of determinants are thus selected but are they sufficient or judiciously orchestrated? Indeed, it is not easy to discern the determinants that make up an individual’s environment and cultural, socio-economic, psychological, familial, professional, and relational context, let alone establish the links between them that allow for the definition of the cause of a mental disorder. In mental health, we have seen above that there are two aspects, that of emotional well-being which is present at every moment of life and that of autonomy and the capacity to realize oneself socially which is concretized over time by a life project. Quality of life items (Fig.8) and autonomy (Fig.9) can then be determined such as those listed by Vidon (2000) and subsequently declined:
Fig.8: Quality of life
Fig.9: Social Autonomy
27Other proposals, like the guide published by the Ministry of Health and Social Services of Canada (Jobin, et al., 2012) resulted from a reflection on the determinants to take into account in health which, for them, is not limited to physical health but also mental and psychosocial health, thus echoing the concept of WHO and adhering to the new paradigm of mental health. Their concept is very interesting because it is designed from four fields that succeed each other, thereby showing the influence they have on each other with the central element being the overall health status of the population. These fields successively group individual characteristics, living environments, systems, and the overall context (Fig.10). If the Ministry’s objective is to compare differences in health gaps across the entire population to decide the implementation of actions, this concept gathers all individual data for this purpose. This scheme can therefore be applied to each individual.
Fig.10: Determinants from the health map of the communications directorate of the Ministry of Health and Social Services of Canada (Jobin, et al., 2012).
State of health of the population
|
Individual characteristics
|
Living environments
|
Systems
|
Overall context
|
Overall health
Physical health Mental and psychosocial health
|
Biological and genetic characteristics
|
Family environment
|
Early Childhood Education and Care Systems
|
Political and legislative context
|
Personal and social skills
|
Daycare and school environment
|
Health and social service systems
|
Economic context
|
Lifestyle habits and behaviors
|
Workplace
|
Territory Development
|
Demographic background
|
Socio-economic characteristics
|
Lodging environments
|
Support for employment and social solidarity
|
Social and cultural context
|
|
Local community and neighborhood
|
Other systems and programs
|
Scientific and
technological background
|
|
|
|
Natural environment and ecosystems
|
28These determinants constitute interesting leads that could enrich our medical and encyclopedic classification systems, and why not in a specific class dedicated to mental health.
29I also believe that it would be desirable to include and develop the "sustainable development" and "Internet" determinants more significantly in our classification systems for mental health. Indeed, these two phenomena are showing growing interest and are occupying an increasingly important place in the daily life of the individual, and as with all new technologies and ideologies, there is always an impact on health, as the graph below demonstrates by paralleling "Internet" and "sustainable development" with the progression of "mental health" and "schizophrenia" in the documentary corpus (France) of Google Ngram Viewer (Fig.11).
Fig.11: Google Ngram Viewer
30Take the case of the internet, which appears in both medical classifications, but in the category "gaming disorder" (ICD11), "pathological use of internet games" (DSM5), it also appears in DDC23 as a tool for information search, communication, and application but not in the "mental health" dimension. The internet is not a pathology in itself, it can bring a lot to the person who uses it but can also cause or exacerbate addiction problems, dependence, and mental disorders. One thing is certain, the internet is part of our daily lives and changes our behavior, Dollfus (2019) discusses this profound change and its social impact, accentuated by relational dematerialization. The author mentions the negative effects of internet use that impact the school and professional environment, relationships, mental and physical health, and also the use of communication media, online games that can provoke an addiction where the players’ practice is motivated by success factors, the creation of social links, and extricating themselves from their own living conditions. Pornographic content, which through use leads to an excessive dopamine rate in the individual, also leads to addiction, reveals the study by Park et al. (2016). Dollfus (2019) also highlights various disorders (anxiety, mood, etc.) and delusional ideas of influence that internet use can provoke through abusive use, such as those of persecution, thought control, as well as the risks of psychotic symptoms that may appear, she specifically mentions Hikikomori syndrome, which affects adolescents and young adults who end up withdrawing from real social life, even within their family, by using the internet extensively for more than twelve hours a day, and causing symptoms of depression or similar to simple schizophrenia. Wirion (2004) also concludes that excessive internet use can cause not only psychological but also psychiatric disorders and proposes to study a model developed by Weiser that takes into account two impact criteria, social integration based on social involvement and social support, and the second concerns psychological well-being based on loneliness, depression, and life satisfaction. Addiction is also part of the author’s findings, who proposes three determinants to evaluate it: compulsion, tolerance, and withdrawal. There are also new possibilities that the internet offers, like video conferencing, which has suddenly shifted work methods during the Covid19 lockdown period, what are the mental health impacts? In addition, a large amount of information can cause behavior disorders according to Guimon et al. (2004), the difficulty in filtering information can be conducive to schizophrenia, indeed, too much information pushes the person to isolate themselves, so we can question the consequences of this mass of information circulating on the internet. Schizophrenia can be caused by biological and physical factors, but it can also have a psychosocial character due to the various environmental criteria that surround us and that we must face, assimilating new technologies and new ideologies is part of this. According to the study by Alexandre et al. (2021), if the individual finds themselves powerless in the face of social adversity, traumatic socio-economic situations, identity issues, which prevent them from achieving their fundamental goals, this results in a social devaluation of the latter called "social defeat", producing acute and primarily chronic stress. The authors (Alexandre et al., 2021) draw attention, among other things, to situations of social adversity such as discrimination affecting ethnic minority groups, sexual orientations, and people with disabilities. They therefore demonstrate the importance of the concept of "social defeat" in the diagnostic process of schizophrenia, even though the risk factors it covers cannot characterize schizophrenia alone but can form an etiopathogenic basis. The authors also specify that while studies on social stress are limited, the importance of the concept of "social defeat" and social adversity is gradually being taken into account in the study of mental disorders related to schizophrenia. Thus, we can see that new subjects must necessarily be addressed in mental health and included in medical and encyclopedic classifications.
31Barthélémy (2003) states, "Psychiatry is inherently a heterogeneous discipline: the most human of sciences and the most scientific of human sciences. In this sense, the debate about the place of psychiatry in society is doubled by another debate, internal to the discipline, constitutive of psychiatry itself and rooted in its original major currents, sometimes conjugated, often opposed." As we can observe, the medical classifications ICD and DSM have favorably evolved over seventy years in their diagnostic approach to mental disorders, taking into account the context and environment of the patient which allows for unique case consideration. The treatment towards the patient is now inherently benevolent and no longer authoritarian leading to the confinement of the individual labeled as irretrievable, uncontrollable, and potentially dangerous, but instead to more personalized follow-up and appropriate autonomy in line with the individual’s capacity with the ambition of recovery. Schizophrenia has also evolved in the ICD and DSM classifications; it is no longer categorized into several forms but is now the subject of an approach based on progression, symptomatic presence, and remission. The terms have also changed, for example, the terms “idiocy”, “imbecility”, and “debility” have been replaced by “intellectual developmental disorder”, Determinants are well present in medical classifications like the ICD11 which lists them in Class 24 "Factors influencing health", a class which I am sure, will only enrich further. From an ethical perspective, medical classifications have made significant strides as they fulfill the criteria of fair recognition since the quality of determinants can diagnose each patient equitably, and at the ’action’ level the approach is no longer in categorization or in stigmatizing terminological choices. Regarding the encyclopedic classification CDD23, I hope that it will develop a class dedicated to mental health, including socio-economic determinants and include and develop societal phenomena such as the internet and sustainable development. Furthermore, this class would make the field accessible to the entire population and would raise awareness about the causes of stigmatization. In addition, I believe it would be wise for all classifications to move towards structural and terminological standardization. And to conclude, I would say that while the new paradigm of mental health is a benevolent medical advance that has made considerable ethical efforts towards humans, I fear that this concept may be diverted and used as a tool for performance and economic production, thereby creating new ethical problems.