Academic journal article Ethical Human Psychology and Psychiatry

Is a Correct Psychiatric Diagnosis Possible? Major Depressive Disorder as a Case in Point

Academic journal article Ethical Human Psychology and Psychiatry

Is a Correct Psychiatric Diagnosis Possible? Major Depressive Disorder as a Case in Point

Article excerpt

The desire on the part of American psychiatry in the 1970s to "rejoin medicine" resulted in DSM-III and subsequent editions. The form of medical conditions is imitated as closely as possible by listing criteria symptom sets for supposedly discrete, autonomous clinical entities, although relevant biological phenomena remain conspicuously lacking. As in somatic medicine, symptoms are unconnected to social background, history, context, and so on. But the necessity to interpret what people say and to depict behavior as the basis for diagnosis inevitably leads to intractable problems of meaning and evidence, as illustrated by a close examination of Major Depressive Episode. Plausible description and understanding of personal problems requires patient-supplied depiction of the nature and scope of the problem, history, and context, and when these are fleshed-out clinical entities and the usefulness of mental disorder disappear.

Keywords: psychiatric diagnosis; mental disorder; anti-psychiatry; meaning; context; story

I wish to draw attention to the striking difference between the criteria sets for primary mental disorders and the textual discussions that precede the criteria sets in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The criteria sets, examined in isolation, suggest that a DSM diagnosis is a straightforward matter involving little, if any, interpretive skill or latitude on the part of the diagnostician. The DSM-IV-TR criteria set for major depressive episode (MDE; American Psychiatric Association [APA], 2000, p. 356) can serve as an example, especially since it is now widely accepted that MDE is the scourge of life in contemporary America. By contrast, the textual discussions preceding the criteria sets cannot help but draw attention to what I will characterize as intractable conceptual, linguistic, and evidentiary problems that emerge in the course of forcing personal difficulties into the mold of specific medical diseases (specific clinical entities). The textual discussion preceding the criteria set for MDE can serve as an example (APA, 2000, pp. 349-356). I emphasize that intractable problems spring from the effort to depict how people think, feel, and act within a framework that is suitable for depicting biological phenomena. No future research findings can dissolve this problem. I hope to dispel the illusion that depictions of human behavior can be disciplined to approximate depictions of impersonal biological phenomena, and likewise the illusion that disagreement about how to depict human behavior is a problem that can and should be solved. The present point, namely that language and dialogue are not barriers to detecting the clinical entity that is there because no clinical entity is there, is meant to add to the force of prior arguments against the claim that psychiatry is really medicine or medical (e.g., Cohen, 1990, 1994; Goffman, 1961; Laing & Esterson, 1970; Scheff, 1966; Szasz, 1961).

It is fundamental that the point of a DSM diagnosis of major depressive disorder (MDD; major depressive disorder will stand for any and all DSM primary mental disorders) is not to note that the patient feels depressed or the patient's mood is depressed but rather that the patient is suffering from a distinct clinical entity-a mental disorder-that exists whether the patient realizes it or not (like diabetes). It is up to the diagnostician to recognize the presence of a clinical entity that is there via a "semiotic act" (Kleinman, 1988). In more familiar language the diagnostician recognizes the presence of a something that is there by connecting signs and symptoms such that a coherent whole, a known clinical entity, emerges from the overall noise of the totality of all the patient has said and how he or she has conducted himself or herself in the clinical interview. But the distinction between noise and signal presupposes the actuality of a psychiatric clinical entity, so to speak, lurking in the totality of all the patient says and does in the assessment interview. …

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