Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
From Mental Suffering to Mental Disorder and Back Again
What Do We Diagnose?
When exactly is a thought, feeling, or behavior disturbed, and does it bear witness to psychopathology, or to a mental disorder? The question is simple, but the answer is far less so. Evidently, upon making diagnoses, we make decisions about specific actions and interactions. For example, this is most clear in the DSM, with its checklists of disorder criteria that need to be evaluated. Take the diagnosis of ADHD; the first criterion listed for the aspect of inattention is the following: “Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate),” and the last one in the list is: “Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments)” (DSM-5, p. 59). What is remarkable about these criteria is that they are worded in ambiguous language, which implies that they leave much space for interpretation and appreciation. For example, when are mistakes in class- work “careless” in nature? Or at what point is “forgetfulness” in daily life abnormal?
© The Author(s) 2017
S. Vanheule, Psychiatric Diagnosis Revisited,
The following clinical situation can illustrate the difficulty. One day a mother consulted me about her son. His primary school teacher is very unhappy with how he functions at school, and suggests to the mother that medication for ADHD might solve the problem. The mother is also concerned about her son. The boy is often careless while completing assignments, and forgetfulness is another problem. On several occasions he has forgotten his lunch box at school; his sports bag has also gone missing. Yet, are these behaviors a reason for major concern and do they make up a legitimate cause for medical intervention? According to the teacher, who is displeased with the boy’s functioning, they are. However, the mother is hesitant. The boy, in his turn, experiences unease at school, yet his concerns particularly concern the teacher’s brutal style of interaction in the classroom, which the mother recognizes. The child has difficulty with reading and spelling, which irritates the teacher. Personally, I conclude that the boy’s apparent carelessness actually reflects his difficulty with spelling and reading, as well as a certain clash between the teacher’s approach and the boy’s spontaneous style of interaction. The boy’s forgetfulness seems to be related to the overall unease he experiences in the school, where the teacher holds fast to a psychiatrizing focus.
This example illustrates major issues in diagnostic decision-making: which criteria really matter in evaluating a situation of distress? Whose opinions are the most important in evaluating specific mental states or behaviors? And based on which norms can one legitimately judge whether an individual’s functioning makes up a source for major concern or not?
In the DSM these questions are not raised, nor does the handbook encourage clinicians to dwell on such issues, ethically reflect on how diagnostic judgments are best made, or how such judgments should be substantiated in terms of what is morally at stake when an individual’s behavior is evaluated. Yet these questions matter. As Eric Parens and Josephine Johnston (2011) indicate in a Hastings Center special report, diagnoses are rooted in evaluations, which are always value-laden. Indeed, when both formulating and implementing diagnostic criteria and guidelines, value judgments and subjective opinions about what is normal or not determine our actions: “The exact boundaries between, for example, healthy and unhealthy anxiety or healthy and unhealthy aggression are not written in nature; they are articulated by human beings living and working in particular places and times” (Parens and Johnston 2011, p. 4). Given the central impact of ethical values, great care needs to be taken with respect to whose opinions predominate in diagnostic judgment about what is acceptable and what is normal.
From a Lacanian point of view it might be argued that diagnostic situations should above all start from emptiness at the level of moral expectations, or from an “ethics of the lack.” This does not mean that ethical stakes should be ignored, but that diagnosticians should by no means take any morally based criterion for granted in judging an individual’s functioning. The main task for the diagnostician consists of noting and addressing the suffering or distress the patient expresses, without taking for granted what signs of distress actually mean, or judging whether behaviors are acceptable or not. The “good” that the diagnostician should above all engage in is good listening, and considering what the patient is expressing.
In his seminar on ethics Lacan (1959-1960) discusses the necessity of an ethics of the lack via the provocative example of Saint Martin of Tours. As a young man Saint Martin, who lived in the fourth century AD, was a soldier of the Roman army in Gaul. According to the legend, Martin of Tours, the soldier, met a naked beggar at one of the gates of the city of Amiens and gave him half of his cloak. Since he was a Roman soldier half of the cloak was owned by the Roman Empire, meaning that he gave away the part he owned himself. The following night Martin of Tours dreamt that Christ was wearing the half-cloak he had given away, and that their interaction in fact actualized one of the seven Works of Mercy from Christian religion: to clothe the naked. This story might be read as an exploit: the wealthy Martin of Tours pitifully shares with a poor beggar, thus exemplifying what a good man should do. Lacan’s reading is somewhat different, and stresses that above all Martin of Tours made a major supposition that what the naked beggar needed was clothing. According to Lacan nothing guarantees that this supposition was correct. Indeed, “We are no doubt touching a primitive requirement in the need to be satisfied there, for the beggar is naked. But perhaps over and above that need to be clothed, he was begging for something else, namely, that Saint Martin either kill him or fuck him”
(Lacan 1959-1960, p. 186). The presumption that Martin of Tours made covers the beggar’s perspective, hiding it way under the cloak of charity, thus precluding that the otherness of the other can be expressed. Martin of Tours fails to get hold of the element that doesn’t fit within the framework he takes for granted. Without explicitly addressing the other’s disarray, he assumes that he knows what is good for the beggar. Thus, the benefactor not only imposes normative interpretations and values onto the other, but also receives narcissistic gratification: his cloak is ruined, but the good is at his side. This installs a power relation, which grants a superior position to the benefactor. Yet, the beggar might refuse to comply with the evolving scenario. No doubt such an attitude would provoke outrage in the benefactor, which is exactly why the diagnostician does better when engaging in good listening instead of offering the good he possesses.
Indeed, when making diagnoses, an individual’s mental and social functioning is evaluated. Careful diagnosis requires that the diagnostician act thoughtfully when judging specific behaviors and mental states. Usually, diagnosis evaluates whether someone’s functioning bears witness to psychopathology, abnormality, or mental disorder. Psychopathology, abnormality, and mental disorder are the attributes that a diagnosis maps. These three concepts should not be thought of a synonymous. In the next sections I discuss the dissimilarity between these concepts, arguing that someone’s experience of pathos should guide clinical diagnostic decisionmaking. Indeed, clinical diagnosis should not be so much concerned with detecting abnormalities or catching mental disorders, but above all with getting hold of psychopathology.
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