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



Etymologically, the term “diagnosis” means “to distinguish,” and “to know thoroughly.” In the DSM all attention goes to the component of distinguishing, where it is assumed that all cases with the same disorder will obey the same natural laws. Taking the epistemological status of mental symptoms into account, this is unjustifiable. In clinical practice one doesn’t meet specimens of diagnostic manuals, but contextualized cases that can never be fully grasped by classifications, hence the reflexive kinds account of psychopathology.

Based on my previous arguments, I conclude that the DSM (from the DSM-III until the DSM-5) uses a naive medical semiotic model: symptoms are signs of underlying conditions that can be studied independently from their context. In this view, context variables only play a moderating role that might alter the shape of mental symptoms, but don’t determine the core characteristics of the symptom. Associated with this point of view, the DSM starts from the assumption that, essentially, men?tal disorders are neurobiological natural kinds. This viewpoint makes up a rhetoric discursive position that feeds the credibility of psychiatric diagnosis, yet this position remains unproven: unambiguous non-overlapping biological validators have never been successfully connected to any of the DSM categories. By concentrating on “biopsychopathology” and “biopsychological” research only, the RDoC project of the NIMH again seems to take such a naturalizing focus, which neglects the self-reference that people have when they experience distress, as well as the contextual embedment of mental health problems.

In contrast with the decontextualizing DSM approach, I believe that mental symptoms should above all be studied within relevant contexts. Obviously, the biology of the body is an important context within which symptoms arise. Yet there are many other contexts that cannot be neglected and should be taken into account in making a diagnosis. Humans should not only be seen as objects that are suitable for naturalistic examination, but also as signifier-using creatures that keep track of their own lives and have memories and experiences in which symptoms are embedded. What is more, human subjects relate to one another, live in social contexts, and thrive on cultural determinants.

Obviously, the project of taking into account context confronts psychiatric diagnosis with new problems that haven’t been addressed in this chapter. A contextualizing approach is especially relevant for studying symptoms, but might be challenging if one solely aims to group symptoms into syndromes (Markova and Berrios 2009). However, this should not necessarily be the case. In line with my discussion of Lacan’s theory of clinical structures, it is justified to presume that a contextualizing approach might cohere with the project of discerning relevant subtypes of psychopathology for which different treatment approaches are needed.

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