A few days ago an article on nosological classification appeared in my Twitter timeline. Whenever I read such texts, I keep wondering about things way less complicated. I keep wondering about the translation. As work on ICD-11 is nearing completion (apparently), perhaps it’s time point to some issues.
It all started when I became interested in depression. I bought myself a copy of ICD-10 (the F volume) and read about the diagnostic criteria depression (F32-33). But I was unlucky also to buy the Polish version of the book and consulted it as well. What I found was astonishing.
Let me give you an example. In the original English version, the main temporal criterion of the depressive episode reads:
G1. The depressive episode should last for at least 2 weeks.
And yet, the Polish version reads
G1. The depressive episode lasts for at least 2 weeks (Epizod depresyjny trwa przez co najmniej 2 tygodnie.)
I hope it’s quite clear that the criteria are significantly different. The English version is modalised through should. Instead of a yes-or-no statement (does it last for 2 weeks or not?), we have more of a ‘perhaps’ sentence. Modalisation introduces an aspect of degree. So while the depressive episode, we could say, normally lasts, or is expected to last for two weeks or more, there might be exceptions. Yes, such a formulation also opens the possibility of the question of who gets to decide whether what the patient presents is the depressive episode or not, still the question can be asked, while the ICD10 is not the ultimate decider.
The difference between this and the Polish version is striking. The Polish text removes the modalised sentence, introducing a ‘weakness’ in the auctorial voice. The Polish version is authoritative, introducing a clear rule, with yes-no certainty. The text constructs its author as having the ultimate power to define what the illness is and there is no hint of delegating this responsibility to the diagnostician. In fact, while the English-language version introduces (unquoted here) both hesitation and obligation into the text, the Polish text removes these completely. Indeed, more changes like that happened in the Polish version. All remove any ‘weakness’ or negotiability of the text and I described it more detail in my book on men’s depression.
But there is a story to all that. When I discovered the discrepancy between the two versions, I tried to find out how it happened. And I did. I found out that it had been decided (I’m sorry, but I do not wish to reveal the details of the story) that it was highly unlikely that the author of the volume in English had wanted to dilute the diagnostic criteria. So the Polish edition offered an improvement. Incredible as it sounds, Poles decided to ‘correct’ what they perceived as the badly written ICD10. Why did it happen? Well, there are no clear answers, of course. But I think that it’s at least partly to do with the extremely hierarchical (academic) medicine in Poland that simply cannot countenance an individual ‘nobody of a psychiatrist’ making decisions based on their clinical judgement. The ICD decides.
If I’m right, it’s an interesting insight into psychiatry which is not only social as a practice, but it’s also embedded in the local ideologies and values. In the case at hand, the values and ideologies as espoused and enacted by a groups of psychiatrists’ leaders. But even more interestingly, it also shows the (lack of) faith in the ‘system’ of a group of psychiatrists, some of them major figures certainly in Polish, but also in international psychiatry. They simply decided to ‘correct’ a diagnostic ‘bible’ which was created in the painstaking process of negotiations and field trials. In Poland, however, they simply made it better. If it were not scary, it would be quite funny.
Incidentally, don’t think it’s somehow only Polish thing. Not really. In my view, such decisions are not particularly different from those taken by the American Psychiatric Association when it decided to take a vote on the issue of pathologisation of homosexuality. Yes, the group is larger, but such a crucial and, let’s face it, no-brainier of a decision, is put to a vote! Let’s see how (non-)prejudiced our members are, so we, the leaders, don’t have to cross them.
And then, finally, the International Classification of Diseases is supposed to help doctors from different cultures and countries communicate amongst themselves. Well, it seems Polish shrinks are not so keen on talking, they know better already. Well, at least in the case of depression, which in Poland must last at least two weeks. Elsewhere it doesn’t. It would be interesting to know how different (if they are) are other national translations.
So, as I wait for the green and blue books of ICD11, I am mindful Allen Frances’ words I read a number of times. He was the one who wrote the definitions in the DSM-IV. It’s a monumental task with huge responsibility and I must admit that I admire the person taking it on. I would be scared. But I think, time has come to think about the text of the ICD not only as having some content. I really would like at least some discussion as to how to linguistically render the diagnostic criteria. For example, as I wrote before, perhaps some thought could go into putting more verbs into the text. You know, simple, little verbs. Surely, it wouldn’t hurt. Would it?