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Home arrow Psychology arrow Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation


Worldwide an increasing number of people suffer from mental health problems. In 1990 a study on the global burden of disease attributable to mental or substance use disorders estimated that they accounted for more than a quarter of all non-fatal diseases. Between 1990 and 2010 the burden of psychiatric disorders further increased by 37.6% (Whiteford et al. 2013). This observation brought the World Health Organization to formulate a global action plan that aims to fight mental distress and disability, and to promote mental health (World Health Organization 2013).

At the same time numerous scholars have been increasingly warning us against the tendency toward overdiagnosis. More and more, common suffering and the discontents of daily life are being framed as diseases, even in the absence of severe impairment, which undermines the self-reliance of people dealing with such issues (Bolton 2013). A good illustration of this can be found in the work of Allen Frances (2013). Frances chaired the task force that prepared the previous version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association, which is a widely used instrument for diagnosing psychiatric disorders. One key message he now conveys is that under the influence © The Author(s) 2017

S. Vanheule, Psychiatric Diagnosis Revisited,

DOI 10.1007/978-3-319-44669-1_1

of diverse stakeholders, like medical associations and the pharmaceutical industry, the stresses and sorrows of ordinary life are being increasingly medicalized. This wrongly stigmatizes people and inauspiciously encourages medical consumption.

These messages provide us with a paradox: on the one hand the burden of mental distress is serious, yet, on the other hand a substantial amount of diagnoses seem to be trivial. This paradox cannot be neglected, and points to the heart of all mental health-related professional action: diagnoses should accurately grasp the problems people suffer from, and should not be influenced by the whims and fancies of third parties that might profit at the expense of potential patients. Indeed, the diagnoses that professionals give should be valid and reliable, such that adequate action can be taken. Yet, what kind of diagnosis should guide further action? And what criteria should we take into account when assessing the value and impact of our diagnoses? These questions are central to this book. My research has brought me to think critically about classificatory diagnosis and to appreciate clinical case formulations.

In 2013 the American Psychiatric Association published the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM- 5). For many academics and clinicians the DSM has a scientific credibility that it does not deserve. Numerous people believe that the manual provides a common language that enhances straightforward communication about mental health problems, and are convinced that the disorders described in the DSM comprise objective realities. These convictions are naive and mistaken.

In popular press, the DSM is frequently coined as “the bible of psychiatry” and this is precisely how the handbook seems to function: people believe in its accuracy and legitimacy, largely without question. The manual could also be said to function somewhat at the base of the economy of psychiatry. Not only does it facilitate a belief system, but also survives as an important economic device for managing the flow of money invested into mental health care. It is on the basis of this classificatory system that decisions are made on issues such as the reimbursement of treatments, the right to financial aid, and the allocation of means across health care providers.

With this book I argue that the value of the DSM-5, and previous versions of the handbook, should not be taken for granted: the manual should be closely assessed and discussed. End users of the DSM-5 should not assume that the handbook is “good” or “useful,” but become cognizant of its strengths and weaknesses, including its theoretical underpinnings and its position in historical debates on the scientific status of psychiatry and clinical psychology. Two chapters of this book discuss the reliability and validity of the DSM. Starting from a critique of the limitations that are inherent to classificatory diagnosis I subsequently discuss what I consider as a better alternative: clinical case constructions that provide a detailed account of people’s symptoms and functioning, and do not neglect the dimension of the subject. Clinical case construction allows contextualized and personalized diagnosis. On the condition that the quality of such a narrative approach to diagnosis is optimized, working with clinical case constructions enables a more valid and reliable approach to mental health problems.

Chapter 2 focuses on the reliability of the DSM-5 and previous versions of the handbook. In the early days of psychiatry, diagnosis did not begin from checklists of symptoms, but from elaborate prototypical descriptions of a diverse range of psychopathology. Guided by administrative purposes these descriptions gave rise to classification systems such as the DSM. An important impetus for the switch to checklist-based diagnosis can be found in harsh discussions on the fundaments and the practice of psychiatry during the 1960s and 1970s. In these years, psychiatry was in crisis: several academic researchers demonstrated that psychiatric diagnosis was unreliable, critical scholars pointed to weak points in the overall ethos of psychiatry, and societal changes challenged the practice of psychiatry. A group of so-called neo-Kraepelinian psychiatrists responded to the malaise in the discipline by defining psychiatry as a strictly medical discipline and thus replacing the method of diagnosis with a criteria- based system. Checklist-based diagnosis is often believed to be more scientifically sound than narrative-based diagnosis. However, in this chapter I demonstrate that this is not the case: DSM-5 diagnosis is by no means more statistically reliable than it was 40 years ago. The main thing to have changed in the last decades is the standard upon which statistical reliability is based and evaluated. If the fact of the ever-increasing relaxation of these statistical standards of evaluation continues to be ignored, we simply continue to invest in the fantasy that psychiatric diagnosis with the DSM is more reliable than ever before. Moreover, to this day the plethora of problems addressed by critical researchers in the 1970s (such as the issue of hasty decision-making, and the problems of reification, stigma, and power) remain largely unresolved and, thus, continue to pose a fundamental challenge for contemporary psychiatric diagnosis.

Chapter 3 focuses on how the DSM-5 takes context into account and discusses the kind of entity the DSM considers mental disorders to be. The main argument I make is that in the DSM the context of the individual (i.e., the life history, social circumstances, and cultural background) is thought to play only a minor moderating role in relation to symptom formation and expression. Moreover, as the manual follows a sign-based logic it coheres with the assumption that biological irregularities lie at the basis of mental distress. In this way the DSM cultivates a rather naive essentialistic view of mental disorders, which is certainly not supported by relevant evidence. In this chapter, starting from phenomenological psychiatry and Lacanian psychoanalysis, I make a plea for a “reflexive” approach to psychopathology. Such an approach does not neglect problem-specific or disorder-specific regularities, but assumes that typical configurations never (unequivocally) apply to single cases, thus demanding a casuistic approach to diagnosis. Starting from the model of symptom formation that was formulated by German Berrios and Ivana Markova I propose a Triangular Model of Symptom Formation. Within this model, the symptom is a multidimensional product with certain speech-act specific qualities, biological characteristics, and contextual configuration features covering characteristics that are specific to an individual, family, social context, and (sub-)culture.

Chapter 4 starts with the idea that all diagnostic assessment implies value-laden judgment, and as a result great care must be taken with respect to whose opinions predominate in diagnostic judgment about what is acceptable or not, and what is normal or not. Psychopathology, abnormality, and mental disorder are the core concepts reviewed in this chapter. Starting from Canguilhem it is argued that decision-making about normality and abnormality typically builds on external norms: conventional opinions of others, like professionals or relatives who believe that some behaviors are not acceptable, or statistical norms that sanction extreme modes of behavior guide this type of judgment. In the diagnosis of psychopathology, the subjective experience of pathos or suffering is central, which I operationalize via the works of Ricoeur on the topic of suffering, and Lacan’s distinction between the dimensions of the Real, the Symbolic, and the Imaginary. In this context I make a plea for studying the quality of mental suffering in case formulations or case constructions, which focus on core symptoms and key clinical characteristics in a patient’s functioning, and aim to get hold of structural patterns and single incidents that elucidate why an individual functions the way he or she does. Here I indicate that through its focus on mental disorders, and while paying lip service to the idea of taking into account psychopathology, the DSM-5 mainly builds on an assessment of abnormality. To conclude this chapter I contrast two operational ways of dealing with mental suffering in diagnostic contexts. The phenomenological focus of obtaining a genuine understanding of what the patient lives through (Verstehen) is juxtaposed with a psychoanalytic approach that states “beware of understanding” (Gardez-vous de comprendre), and concentrates on the logic in the patient’s functioning.

In Chap. 5 I concentrate on the methodological strengths and pitfalls of clinical case construction, and discuss how the reliability and validity of case formulations can be assured. Chapters 2 and 3 focus on the poor reliability and validity of the DSM. In Chap. 5 I discuss how both methodological dimensions apply to, and can be optimized in, the practice of clinical case construction. Along this way I aim to counter the idea that clinical case construction is less rigorous than psychiatric classification. Starting from clear similarities between the materials used in clinical case formulation, and the data collected by qualitative researchers, I review literature on quality control in qualitative research, and indicate how aspects of it can be used to enhance the quality of clinical case formulation. Three dimensions are discussed: reflexivity, reliability, and validity. I indicate how specific clinical formats that professionals often use (e.g., systematic note taking, case discussions with colleagues, personal therapy, supervision) might function as practices that develop the credibility and confirmability of clinical case formulations.

Shorter versions of the first two chapters of this book were already published in 2014 (Diagnosis and the DSM—A Critical Review). Since that time I have further elaborated the lines of reasoning in these chapters, and supplemented them with two further chapters that concentrate on what I consider as an alternative: clinical case formulation. It is my hope that the future of psychiatric and clinical psychological diagnosis is to the personalized and contextualizing approach of clinical case construction.

Other References

Bolton, D. (2013). Overdiagnosis problems in the DSM-IV and the new DSM- 5: Can they be resolved by the distress — Impairment criterion? Canadian Journal of Psychiatry, 58, 612—617.

Frances, A. (2013). Saving normal — An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: William Morrow & Harper Collins Publishers.

Whiteford, H. A., Degenhardt, L., Rehm, J., et al. (2013). Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. The Lancet, 382, 1575—1586.

World Health Organization. (2013). Mental health action plan 2013—2020. Geneva: World Health Organization. Retrieved June 21, 2016, from http://

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