Symptom and Context: The Issue of Validity in Diagnosis
Toward a Functional Account of Psychopathology
The question as to how to diagnose a mental condition is as old as the question of how to treat it, and throughout history all kinds of procedures, rituals, and technologies have been explored. Diagnosis is well rooted in knowledge about psychopathology, but at the same time it is often seen as a clinical art, one which requires well-trained clinicians with a good eye for subtle signs of illness. Going against the idea of diagnosis as simply a factual and mechanistic undertaking that is merely concerned with observing and assessing signs of mental disturbance, this chapter addresses the assumptions underlying common ideas about symptoms and disorders. Particular attention is paid to the question of how context plays a role in diagnosis. A main argument I make is that in the DSM, the context of the individual (i.e., the personal life history, social circumstances, cultural background) is thought to play only a minor moderating role in relation to symptom formation and expression. Indeed, the manual mainly follows a sign-based logic, which coheres with the assumption © The Author(s) 2017
S. Vanheule, Psychiatric Diagnosis Revisited,
that biological irregularities are to be found at the basis of mental distress. I argue that by doing so the DSM cultivates a rather naive essentialis- tic view on mental disorders, which not only fuels reification but also obfuscates the fact that the DSM rests on pragmatic grounds. At the same time, I make a plea for a self-reflexive and contextualizing account of psychopathology. Such a viewpoint doesn’t neglect problem-specific or disorder-specific regularities, but assumes that typical configurations never unequivocally apply to single cases, thus necessitating a casuistic approach to diagnosis.
Practically speaking, diagnosis in the DSM is pretty straightforward: using standardized sets of inclusion and exclusion criteria for each disorder, the diagnostician reviews the patient’s complaints and decides which diagnosis is indicated. Indeed, pivotal to DSM-based diagnosis are the brief checklists that are formulated for each disorder. These include key symptoms, specifications on the minimal duration of complaints, and indications of other conditions that might provoke similar symptoms. In total, the DSM-5 discerns 347 mental disorders (spanning 677 pages) grouped into 20 broad categories, such as “depressive disorders,” “neurocognitive disorders,” and “schizophrenia spectrum and other psychotic disorders.”
Next to these checklists, the DSM also contains brief descriptions of each disorder. These descriptions outline the diagnostic features of a given disorder (i.e., its development and course, prevalence, differential diagnosis relative to other conditions, and comorbidity), which provide a slightly broader framework for interpreting the information contained in the checklists. Nonetheless, the DSM focuses on grouping mental symptoms in syndromal disorder clusters, paying less attention to characteristic illness dynamics and typical psychopathological processes.