Abstract
In this chapter Stijn Vanheule discusses how the DSM-5 takes context into account and clarifies the “kind of entity” the manual considers mental disorders to be. In the DSM-5 the context of the individual (i.e., the personal life history, social circumstances, and cultural background) is thought to play a minor moderating role in relation to symptom formation and expression. Moreover, as the manual follows a sign-based logic, it coheres with the assumption that biological irregularities lie at the basis of mental distress. The author argues that, by doing this, the DSM cultivates a naïve essentialistic view of mental disorders, which is not supported by relevant evidence. Starting from phenomenological psychiatry and Lacanian psychoanalysis, Vanheule proposes an alternative model of symptom formation. Within this model, the symptom is a multidimensional product with certain speech-act specific qualities, biological characteristics, and contextual configuration features covering characteristics that are specific of an individual, family, social context, and (sub-)culture.
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Notes
- 1.
- 2.
Thusly so, Westen’s (2012) plea for a return to explicit prototype-based diagnosis as an alternative should be taken seriously.
- 3.
Sometimes the DSM’s focus on description is characterized as “phenomenological” (e.g., Decker 2013). This is confusing since the phenomenological approach to psychopathology, as illustrated by the quote of Parnas, largely exceeds the DSM-like focus on description.
- 4.
It is important to note that within various philosophical traditions the concepts of subjectivity and subject obtain different interpretations. For example, in phenomenological approaches, subjectivity is identified with conscious experience as the fundamental ground of our understanding of both the world and ourselves. This dimension of conscious experience is considered to be accessible through self-reflection, based on which a person can construct a narrative about what he lives through. In this view subjectivity is knowable and, eventually, amenable to a normative evaluation (is this person’s self-experience adequate or not?). From a Lacanian psychoanalytic point of view, by contrast, the subject qua product of self-reflexivity is not a discernible entity but a self-relating “emptity.” Self-related thoughts and speech connote who we are and what we live through, but never denote the subject. Within this view the notion of the subject refers to the multitude of signifiers, based on which self-experience is constituted and across which self-experience is fundamentally scattered; hence the idea that the subject is “divided.” Lacan does not think of the subject as a psychological or teleological instance that makes use of signifiers, but as the connotative effect of using signifiers. The subject doesn’t produce speech; speech produces the subject. Thus considered, self-reflexivity does not imply self-transparency. On the contrary, from a Lacanian point of view self-reflexivity is marked by an impossibility, which makes up the unconscious. Nevertheless, what both philosophical traditions have in common is the explicit valorization of subjectivity.
- 5.
Interesting psychometric challenges for the DSM approach to mental symptoms can be found in the work of Denny Borsboom and colleagues (e.g., Borsboom and Cramer 2013).
- 6.
The terms particularities and singularities are often used synonymously. I suggest distinguishing them: “particular” refers to characteristics that hold true for subgroups; “singular” refers to characteristics and events that cannot be generalized.
- 7.
Lacanian psychoanalysis does not reject the idea that psychopathology is governed by laws that can be described in scientific terms, but maintains that the reflexive relation an individual has to his own condition cannot be reduced to these laws. This theoretical position does not give rise to an idealist theory of the mind in which non-material mental forces are presumed to be active, but to a so-called decentered materialism. Crucial to this Lacanian materialism is the divided subject’s relation to the Real (De Vos 2014). In this context, Lacan made a relevant distinction between nature and physics. Nature is that which determines us in how we act and through our self-reflexive attitude we can relate to it. Physics, like all other sciences, is a discourse based on which we study and intervene upon the world. Science constitutes just one way of relating to nature. It transforms our way of relating to nature, but never eliminates what is Real to a subject.
- 8.
In Chap. 2 I discuss the fact that this hard work to improve the reliability of psychiatric classification was not particularly successful.
- 9.
Obviously, these reflections gave rise to the appendix on cultural formulation in the DSM-5.
- 10.
In a 19-page document entitled Highlights of Changes from DSM-IV-TR to DSM-5 (http://www.dsm5.org/documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf) all changes are reviewed. Nevertheless, several authors, like Allen Frances (2013), correctly suggest that for several disorders inclusion and exclusion criteria were subtly relaxed, thus predicting waves of inflating diagnosis. For example, whereas DSM-IV-TR indicates that a diagnosis of ADHD can be made only if symptoms are present before the age of seven, the DSM-5 indicates that the diagnosis can be made if symptoms are present before the age of 12. This “small” criterion change actually implies that the population eligible for the diagnosis actually doubled.
- 11.
In the process of researching this book I contacted the DSM-5 task force chair and vice-chair, David Kupfer and Darrel Regier, asking both of them whether the scientific studies on the basis of which decisions were made about disorder criteria could be provided. Neither of them responded.
- 12.
- 13.
In psychology, different emotions, like happiness, sadness, anger and anxiety, are sometimes considered as natural kinds. However, whether this is justified or not remains an object of continuous debate (Lindquist et al. 2013).
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Vanheule, S. (2017). Symptom and Context: The Issue of Validity in Diagnosis. In: Psychiatric Diagnosis Revisited. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-44669-1_3
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