Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
Psychopathology Versus Abnormality
In his writings on the topic of diagnosis, the French philosopher and physician Georges Canguilhem (1966) makes an interesting distinction between psychopathology and abnormality, thus paving the way for the studies of Michel Foucault on the themes of psychiatric power and biopolitics. In Canguilhem’s view, decision-making about normality and abnormality is generally based on two factors. First, one starts from the observation of variability in the way human beings function: individuals present with a range of behaviors just as their mental life is characterized by a diversity of beliefs and experiences, of which some are more prevalent than others. Then, a judgment is made about normality versus abnormality, which is based on a norm or standard against which behaviors are evaluated and considered as deviant or not. At this level, two possibilities open up: a judgment is made based on psychosocial criteria or statistical norms.
If the judgment is based on psychosocial criteria, it is the extent to which the individual’s functioning fits his environment that is assessed. Following this logic, behavior is “normal” if nobody is particularly concerned about it, or if it doesn’t cause others inconvenience. Such a line of reasoning might seem plausible, but it is based on the idea that individuals must adapt to their context: “To define abnormality in terms of social maladaptation is more or less to accept the idea that the individual must subscribe to the fact of such a society, hence must accommodate himself to it as to a reality which is at the same time a good” (Canguilhem 1966, p. 283). As social conventions change over time, identical modes of human functioning will be judged differently. The case of homosexuality illustrates this well: in the early twentieth century homosexuality was mainly seen as a moral aberration; and in the works of early sexologists homosexuality was classified as a perversion. This gave rise to the medi- calized idea of homosexuality as a mental disorder. However, following societal protest in the 1970s, homosexuality was gradually accepted as a sexual orientation, alongside heterosexuality.
Applied to the DSM-5 it can be concluded that some disorders, especially those diagnosed in children, are strongly based on judgment in lieu of norms that are imposed onto the individual. For example, the criteria for diagnosing ADHD exclusively build on third-party opinions about a child, and use common sense ideas about desired behaviors in specific contexts (e.g., school) as the standard against which behaviors are evaluated. ADHD diagnostic criteria include characteristics like “Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction),” or “Often has difficulty waiting his or her turn (e.g., while waiting in line)” (DSM-5, pp. 59-60). In the DSM-5, and other relevant literature, these diagnostic criteria are rarely discussed, leaving all interpretation as to (a) what is meant by the term “often,” and (b) why specific behaviors are deemed problematic, down to the judging diagnostician. Thus, it is the professional’s personal opinions that function as the norm against which an individual is evaluated. In other words, because stringent scientific standards for making such evaluations simply do not exist, the belief system of the diagnostician and his colleagues determine the standard. This can provoke overdiagnosis (Frances 2013), especially if particular professionals are inclined to problematize particular behaviors, like the teacher in my previous example. Conversely, it might equally give rise to underdiagnosis: a most tolerant diagnostician, who embraces the ideal human diversity, or who believes that nowadays far too many people are diagnosed, might qualify many behaviors and complaints as “normal,” thus rendering these as not amenable for diagnosis. In both cases it is the diagnostician’s opinion and not the diagnosed’s distress that makes up the point of departure.
Within this view, normality comes down to an individual’s adherence to normative standards of functioning, which are time- and (sub-) culture-dependent. Paul Verhaeghe (2004) notes that already in the earliest Western essays on psychology, such normative reasoning can be found. The 1590 essay by philosopher Rudolph Goclenius entitled “Psychologia: hoc est, De hominis perfectione, animo et in primis ortu hujus, com- mentationes ac disputationes quorundam theologorum & philosopho- rum nostrae aetatis” illustrates this: psychology is concerned with the perfecting of human functioning. Such a perfecting attitude seems to pervade contemporary psychological evaluation of human functioning as well. Westerners see themselves as the managers of their own life and of the life of others, and the main project they are concerned with is the manufacturing of life in terms of criteria that make one socially successful (Verhaeghe 2014). The aspiration of social success implies that norms and values held by the group dictate to the individual how he should behave. Hence Canguilhem’s focus on social adaptation as one angle through which abnormality is defined.
The other option Canguilhem (1966) refers to for evaluating the normality or abnormality of human mental functioning are statistical norms.
Canguilhem indicates that such a statistically based judgment is rooted in the work of the Belgian mathematician Adolphe Quetelet (1796-1874), who aimed to study human functioning through a new discipline he coined “social physics.” His underlying proposition was that social scientists should investigate and map the variability of human characteristics, ranging from physical qualities to aspects of psychological and behavioral functioning. Quetelet focused on recording how people generally function, thus giving rise to a mode of thinking in which normality is considered in terms of the statistical normal distribution, that is, in terms of the bell curve. In this line of reasoning normality implies a mode of functioning that closely adheres to the mean or median in statistical distribution. Abnormality, in its turn, implies a mode of functioning that strongly deviates from the average: individuals with an extreme score in terms of the normal distribution are rare or abnormal cases. Usually, the 2-10% of people deviating most strongly from the statistical norm are seen as abnormal.
Remarkably, common interpretation of statistical normal distribution frequently obtains a moral quality, meaning that significant deviation from the statistical norm is seen as indicative of deviation from normality in the moral sense of the word: significant deviation from the mean or median is evaluated as “bad” in nature. At this point moral and statistical evaluation merge: instead of using plain categorical moral criteria (e.g., “restlessness and agitation are problematic/bad”), an individual’s functioning is evaluated more subtly from a dimensional perspective. This implies that traits and characteristics are still treated as morally sensitive in nature (e.g., “restlessness and agitation could be problematic/ bad”), but only get sanctioned if endorsed by significant deviance from the statistical norm (e.g., “restlessness and agitation in an individual are problematic/bad if these traits are most pronounced compared to others from the same population”). Yet, statistical deviance does not imply that the extreme characteristics an individual might have are also problematic. Statistical distribution might just bear witness to variety in groups, and to variability between individuals. Variety and variability are not intrinsically good or bad, although in specific contexts extreme manifestations of certain traits might pose difficulties in interactions with others. For example, restlessness might be problematic in the kind of school environment that stresses ex cathedra instruction by the teacher, which forces the student into a receptive passive position that some have difficulty with. Thus considered, if restlessness poses problems it tells us just as much about the individual student’s habits and inclinations as it does about the school context that frowns upon such behavior.
Psychological testing practices might play an important role in such a statistically based evaluation of abnormality. Often, test responses are not seen as codified responses to standardized triggers, which might further be explored through interview and observation, but are merely quantified with the aim of making comparisons with reference groups: an individual’s score is compared to cut-off values that are listed in norm tables. Such tables are composed of scores obtained by administering the same test in large populations (clinical and/or non-clinical). To evaluate the individual’s test score, professionals often only compare it to the distribution of scores in the general population, and along this way determine whether it deviates from the norm or not. According to Nikolas Rose (1999, p. 7) psychological tests thus provide “a mechanism for rendering subjectivity into thought as a calculable force.” In his view psychological assessment and evaluation practices provide a technology, through which contemporary man inspects and perfects himself, and likewise scrutinizes and manages others. Through the lens of psychological testing, we began to think of ourselves as manageable machinery. Assessment instruments map individual differences, appraise them in terms of statistical or other social norms, and engender “techniques for the disciplining of human difference” (Rose 1999, p. 19). As the latter step is made, the group with its particular statistical distribution of scores tends to function as the moral norm against which the individual is evaluated.
As he shifts the focus from abnormality, which is appraised based on either psychosocial criteria or statistical norms, Canguilhem (1966) argues that in the diagnosis of pathology, the subjective experience of human suffering is the hallmark. Indeed, for diagnosing pathology, one cannot start from societal or statistical norms. “Pathological implies pathos, the direct and concrete feeling of suffering and impotence, the feeling of life gone wrong” (Canguilhem 1966, p. 137). Such a diagnosis does not build on the opinions of experts, but on patients’ appraisal of their own distress, which tallies with Cooper’s (2005) second criterion for the diagnosis of disease, which says that a condition can only be diagnosed if an individual is agonized and unhappy because of her own mental state.
Following Cooper (2005) it could be argued that in addition to the presence of pathos, which Canguilhem (1966) also stresses, psychopathology involves moral evaluation: pathology implies that an individual experiences aspects of her own functioning as bad. Indeed, qualifying certain experiences as good or bad implies a moral evaluation. After all, it is always in reference to standards and values that such judgments take place. Yet, while in the appraisal of normality and abnormality the opinions of others, or general tendencies in groups stand to the fore, psychopathology implies that an individual determines and evaluates her own functioning in terms of the standards and values she adheres to. Indeed, psychopathology entails an experience of falling short, which coheres with the occurrence of disruption and disturbance in the intimacy of one’s own mental functioning and/or in the heart of one’s relationships with others: thoughts, feelings, impulses, and actions overwhelm the individual, such that she not only feels out of control, but also believes that important norms and standards of human functioning are violated. To use a Freudian metaphor: what determines psychopathology is the acute and repetitive experience of not being the master in one’s own house. For example, if an individual observes restlessness in her own functioning, which, in her opinion, undermines relational and professional functioning, restlessness makes up a relevant characteristic in terms of a diagnosis of psychopathology. This time restlessness is not problematic because others find it inappropriate, or for its exceptional intensity. What counts is the “dis-ease” it provokes in terms of how an individual fails to master what she is living through.
Obviously, psychopathology does not always involve an inward focus, with an attribution of the origin of the problem experienced to the self. For example, an individual might suffer from being persecuted by black birds that announce the arrival of Doomsday. As we focus on psychopathology, such an experience is not evaluated in terms of the incorrectness of the conviction, or in terms of the extraordinary nature of what the person is living through. What is taken into consideration is whether and how the experience baffles the individual, disrupts the ideas and norms she holds about herself and about others, and interferes with her daily functioning. In this case, an individual might feel like a defenseless victim at the mercy of a cruel other, or be perplexed with fear that she is actually going insane. What stands to the fore in both cases is the appraisal of private functioning, and the evaluation of experiences as bad/problematic in terms of her own norms and values.
However, the standards that an individual uses to evaluate her own functioning always also reflect the context the she lives in, meaning that along this way normative opinions of others have a determining effect on the appraising individual. The main difference with evaluations of normality and abnormality resides in the compulsory quality of norms and values. An individual’s appraisal of psychopathology reflects her attachment to standards of functioning, but also always entails a certain amount of choice and freedom. This means that across time similar characteristics might be evaluated differently, depending on changes in the context (e.g., from unemployment to employment) and/or in her own mindset (e.g., a strong concern vs. relaxed attitude about the opinions of her parents).
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