Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
Following the French physiologist Rene Leriche, Canguilhem (1966, p. 91) conceptualizes health as “life lived in the silence of the organs,” and disease as “what irritates men in the normal course of their lives and work, and above all, what makes them suffer.” In this line of reasoning the idea of “the normal course” does not suggest that normative standards derived from the group should be applied to the individual, but to a relatively homeostatic balance in the functioning of the individual, which might be destabilized or not. In his view symptoms express global disturbance, meaning that disease requires a holistic approach that takes into account the connection between diverse aspects of an individual’s functioning. Hence his idea that “the norm in pathology is above all an individual norm” (Canguilhem 1966, p. 119).
Concordant with Canguilhem’s theory, mental health might be described as a state of functioning in which thoughts, feelings, and behaviors are self-evident to an individual, and don’t make themselves heard in a self-reflective loop. Psychopathology, by contrast, is a mode of functioning in which thoughts, feelings, and behaviors start functioning as symptoms that actively disturb the way one wants to live, to the extent that intense suffering is produced. In line with our triangular model of symptom formation (see Chap. 3), symptoms are indicators of imbalance and conflict that take shape at the crossroad between contextual influences (individual, familial, social, and (sub-)cultural factors), physiological processes, and the act of speaking. Although language-based configuration processes determine symptoms and suffering, these, from a Lacanian point of view, also always imply a real component. This means that they reflect elements of inconsistency and impasse, and express an extimate experience of jouissance, which challenges the experience of identity and produces pathos.
Within this view, diagnosis does not come down to “syndrome labeling,” but to constructing a thoughtful formulation pertaining to the conditions, constellations, and dynamics in an individual’s life that make up the systemic context within which symptoms and suffering take shape. In building such case construction, clinical knowledge and theoretical models about syndromes might be helpful, but the main focus is on the abductive formulation of a framework that tentatively explains the logic within which symptoms and suffering are most plausibly embedded. Indeed, case formulation is a matter of abductive reasoning, starting from a specific symptom within a singular case, characteristic features of functioning are evaluated, and through addressing the question as to what might have caused the problem the most likely explanation is retained. While in psychiatric reflection, abductive reasoning often focuses on syndrome detection (Rejon Altable 2012), it might more broadly be applied to contextualizing case formulation approaches as well (Vertue and Haig 2008). What is important to such a case-construction-oriented approach to diagnosis is that while starting from what goes wrong in an individual, specific attention should also be paid to disabling factors in the relationship with the other, as well as to strengths and stability-creating factors that counter the experience of psychopathology.
Classificatory approaches to mental health problems often mainly build on a normative judgment of abnormality in terms of the statistical or societal standards the diagnostician adheres to. Along this way, the experience of psychopathology, as defined in the previous sections, is often neglected. While case formulation can just as well be used in an approach that prioritizes the diagnostician’s standards, it is especially suited for taking into account a patient-based value judgment of specific thoughts, feelings, and behaviors. Case formulation might be used to articulate an ethical position that highlights the patient’s position. Indeed, since diagnosis invariably implies the establishment of power regimes, great care should be taken that the patient does not receive the message that she should adapt to external norms. What should come first is the question as to how the elements of disorder the patient is living through are organized, and how these problems might be addressed in a sustainable way, such that idiosyncrasies in the patient’s functioning are voiced and valued.
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