On DSM-V and the Diagnosis of Mental Illness

Allen Frances in “Diagnosing the D.S.M.,” The New York Times

…the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts… Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.

Vaughan Bell in “news from the borders of mental illness,” The Observer

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the book that lists psychiatric diagnoses, is due out in May. The latest revision has emerged after a decade of unfriendly debates over what should be included and where the boundaries should lie…. It is… no accident that critics of psychiatry have always had a particular dislike for the use of diagnosis. There are those on the outer fringes who still argue that classifying anything as a “mental illness” is fundamentally flawed, but most of the debate centres on the possibility of distinguishing different forms of psychological disability. One of the key issues is whether different diagnoses such as schizophrenia, bipolar or depression represent distinct disorders that have specific causes or whether these are just convenient and perhaps improvised ways of dividing up human distress for the purposes of treatment…

The hardline biological psychiatrists have had diagnoses undermined by exactly the techniques they use to support them and the social constructionists may have to accept that the best evidence for their “humane” conclusions are biological studies which they reject as supposedly “alienating”…

The mistake made by both sides was to consider biology and lived experience as somehow in opposition when really they are all part of our common humanity.

Liah Greenfeld in the Introduction to Mind, Modernity, Madness

If we are able to explain mental disease as a function of the mind, consciousness, affected by the open modern culture, then we have the green light for the scientific study of the non-material reality of the mind, in general (making it as proper a subject for such study as gravity or evolution), and, with it, finally, for a real, cumulative, science of humanity…

The view that the mind is a cultural phenomenon and that madness (schizophrenia, mania, depression) is a disease of the mind, rather than the brain, permits the advancement of a comprehensive interpretation of the underlying psychological structure of the disease(s) in question — at present lacking in the field — which leaves out and contradicts nothing of what is known about the phenomenon.

The argument… is that the psychotic disease of this kind is fundamentally a malfunction of the “acting self“ (the functional system or “structure” of will). It is experienced as a loss of the familiar self and as a loss of control over one’s physical and mental activity. The three varieties of madness distinguished today (unipolar depression, bipolar depression — that is depression with mania, and schizophrenia) may, to begin with, be placed on a continuum of the complexity of the will-impairment experienced, from the loss of positive (motivating) control in action and content of thought in depression, through the loss of positive and negative (restraining) control in action and content of thought in manic-depression, to the complete alienation of the acting self, i.e., complete loss of cultural individualization and loss of positive and negative control in action and both content and structure of thought in schizophrenia. More complex forms of the disorder should not be equated with more severe ones: clearly, in terms of danger to life that it poses, depression must be considered the most severe of the functional psychoses. What further contributes to the complexity of such disorders and, in particular, is responsible for rendering the most complex of them, schizophrenia, so bizarre is the involvement of the third, autonomous mental structure, the thinking self. As long as only the content of thought escapes the control of the will, the thinking self remains to a certain extent integrated with the rest of the individual’s mental process, i.e., it does the mind’s thinking. The liberation of the thought structure from the control of the will indicates complete disintegration of the individual’s mind and, leaving the thinking self (which serves the function of the culture process in general and not of the individual) on its own, changes its function. It becomes the observing self, the I of (unbidden) self-consciousness. In observing the dissolution of the self as agency, and observing itself observing it, it uses the resources of culture in general, of culture not individualized for the purposes of the individual’s adaptation. This explains not only the nature of schizophrenic delusions, but the strange hyper-reflexivity of schizophrenics, their intellectual hyperactivity and cerebral, detached approach to reality, incongruously combined with what appears as a loss of “higher intellectual functions” and of “ego-boundaries,” for which current interpretations cannot account. It also explains the extraordinary linguistic creativity of many patients, their sensitivity to the semantic multivalence of words and propensity to neologisms, as well as their tendency to switch between contextual logics, which may appear and is often interpreted as the loss of ability to think logically. Having vast cultural resources as if free ranging in their brains and no mechanisms to rein them in and channel them into personally relevant directions, schizophrenics, in a way, have culture, always multiperspectival, think for them and language, always multivalent, speak for them. Thus it is possible to have full-blown schizophrenia without displaying any of the neurobiological abnormalities expected and in many (though never all) cases present with the disease…

The theory I offer to your consideration, therefore, combines philosophical, psychological, historical, and sociological arguments. The problem before us does not belong to any particular discipline and the project is, therefore, necessarily transdisciplinary.

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