Diagnosis in the field of psychotherapy: A plea for an alternative to the DSM-5.x (original) (raw)
Related papers
2004
1 The question of nosological classifications The question of diagnosis is not for the practising psychoanalyst a purely theoretical or academic one. It is of clinical and ethical importance, and it has more to do with decisions, that is, acts that we produce and which affect our patients directly, than with conceptual debates as to whether a certain patient fits in a certain category or whether a particular phenomenon should be regarded as a true symptom. The expression ‘differential diagnosis’ is somehow redundant, as all diagnosis is differential, in the sense of involving the discrimination, on the basis of established knowledge, between mutually exclusive categories. To diagnose means to identify positively on the basis of typical or ‘pathognomonic’ (to use the medical term) traits, signs and symptoms, and it has never been good practice to diagnose only by exclusion (‘It must be a psychosis because we have not found any traces of neurosis or perversion’). It has always been an...
Diagnosis: Psychiatric and psychoanalytic perspectives
The American Journal of Psychoanalysis, 1983
Psychiatry is the branch of medicine that deals with the treatment of mental illness. The word psychiatry is derived from psyche, meaning "mind," and iatreia, meaning "medical treatment." Medical treatment has traditionally attempted to rest upon sound diagnosis; thus, it is not surprising to find much of the work of general psychiatrists centering around the activity of diagnostic assessment. In what follows, I discuss diagnosis in the field of both psychiatry and psychoanalysis. PSYCHIATRIC PERSPECTIVES The word diagnosis is derived from dia, which means "through" or "throughout," and gnosis, which means "knowledge." Diagnosis implies knowing throughout. In medical tradition, the object of diagnosing has been to distinguish one disease from another based on observable signs or subjectively reported symptoms. Although there has been much study concerning psychiatric diagnosis from many diverse fields, including biochemistry, physiology, and the neurosciences, the same basic division of patients has endured. As Havens has recently stated: "For all the emphasis on sectarianism and subjectivism.., two elements of diagnosis have remained the same: first, the structure of diagnosis has remained the same and second, there have been very few losses of patients from psychiatry to internal medicine or neurology as occurred with syphilitic insanity, the vitamin psychoses, and epilepsy. "1 By structure of diagnosis, Havens meant the distribution of patients "among the organic states, psychoses, neuroses, and the personality or character disorders. "1 This structure was laid down by Kraepelin at the end of the nineteenth century. Although there are This paper was presented as a scientific meeting presentation of the Association for the Advancement of Psychoanalysis in January 1982.
Libr. Trends, 1998
PSYCHIATRIC activity that CLASSIFICATION IS A PROFOUNDLY IMPORTANT directs subsequent treatment decisions, assumptions about etiology, and prognostic considerations. While the ideal classification scheme would be clear, concise, comprehensively inclusive of, and hospitable to, the entities under consideration, in practice, all classification systems reflect tradeoffs and embody flawed structures. Accordingly, it is essential to be fully cognizant of the shortcomings, biases, and tacit assumptions of extant systems so that classifications can be improved and so that misrepresentations will not be blindly repeated or reproduced. Modern psychiatric classification and diagnosis are almost exclusively defined within the context of the nomenclature and diagnostic categories of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). This article adapts Giddens’s (1984) theory of “structuration” to explain how at least some of the consequences of ...
… , and Humanities in …, 2012
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM -whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.
Four Core Concepts in Psychiatric Diagnosis
Psychopathology, 2021
In the present article, we aimed at describing the diagnostic process in Psychiatry through a phenomenological perspective. We have identified 4 core concepts which may represent the joints of a phenomenologically oriented diagnosis. The “tightrope walking” attitude refers to the psychiatrist’s ability to swing between 2 different and sometimes contrasting tendencies (e.g., engagement and disengagement). The “holistic experience” includes all those intuitive, nonverbal, and pre-thematic elements that emerge in the early stages of the clinical encounter as an emanation of the atmospheric quality of the intersubjective space. The “co-construction of symptoms” regards the hermeneutic process behind psychiatric symptoms, involving both the patient as a self-interpreting agent and the clinician as a translator of his/her experience. Finally, by the “evolving typification” we mean that the closer the relationship becomes with the patient, the more specific and nuanced becomes the typification behind psychiatric diagnosis. Each of these concepts will be accompanied by an extract from a clinical case deriving from one of the authors’ most recent clinical experiences.
Hermeneutics, Understanding, and Interpretation in Psychiatry
The Philosophy of Psychiatry: A Companion. Edited by Jennifer Radden. Oxford University Press, 2004, pps. 351-363., 2004
Psychopathology and Psychotherapy in Present-Day Psychiatry: Psychiatry is moving through a period in which its basic subject matter, namely, the experiential world of its patients, seems inaccessible and unknowable. Contemporary psychiatry does claim that there are certain aspects of mental disorders that we can know. Indeed, psychiatry is experiencing a time of steady growth of knowledge in particular areas. Neurobiology and psychopharmacology seem to be based on firm scientific foundations, and these important fields constitute a considerable part of the picture of psychiatric understanding and treatment. Moreover, psychiatry has developed manuals of diagnostic categories, the Diagnostic and Statistical Manual of Mental Disorders and ICD-10, which are highly regarded for the rigorous procedures by which they have been constructed and revised. It is inevitable, then, that traditional psychiatric concerns like psychopathology and psychotherapy would fall within the shadow cast by these steadily advancing fields. What is not inevitable, we think, is that in comparison with these other fields psychopathology and psychotherapy would fall into the disrepute into which they have in fact fallen. This disrepute is not due to the intrinsic merits of psychopathology and psychotherapy. We believe that, for a large part, it is due to political and economic forces that today powerfully shape the reality of psychiatry. Economic forces impose limitations on the time psychiatrists can spend with patients, and political pressures enforce these limitations by dictating treatments that take no longer than the little time allowed (Schwartz et al, 2002). Aiding the economic and political forces, however, is a particular view of psychiatric " science. " It is assumed in many quarters – even in those quarters unhappy with the assumption – that the methodology used in drug trials on large populations of subjects along with the methodology employed in neurobiology are the sole scientific methodologies. Or, if the field of scientific proof is admitted to reach further, the natural sciences – sometimes called " the hard sciences " – still define the paradigm. Since it is impossible to adapt these methodologies so that they can be applied in psychopathology and psychotherapy, the latter two fields are assumed to be doomed to unscientific stagnation. Much is lost, however, with the withering away of psychopathology and psychotherapy: namely, a large part of the understanding of mental disorders is forfeited. Moreover, with the loss of this understanding comes a fragmentation and incoherence in psychiatric conceptualization and treatment. Psychiatrists sometimes deal with this incoherence and fragmentation by claiming that they are " pragmatists " : they do " whatever works. " This, of course, is only a direct admission that they have little understanding of what they are doing. Before, however, we entirely despair of the possibility of placing psychopathology and psychotherapy on respectable foundations, we think it wise to reexamine the subject matters of these areas in order to try to determine how an understanding of them might be attainable.
Should psychological formulation replace diagnosis for psychiatrists
Psychological formulation has been promoted as a replacement for diagnosis in mental health. This does not take into account the time pressures facing psychiatrists and their needs in clinical practice. Using an example of a published psychological formulation for psychosis it can be demonstrated that psychological formulation is inferior to psychiatric diagnosis for clinical functions (prognosis and choosing treatments). It is also inferior for research (classifying participants) and social roles (including access to welfare and administrative integration with the rest of healthcare). For psychiatrists, diagnosis is still superior but should be supplemented by diagnostic formulation which can incorporate psychological mechanisms.
Conceptual analysis of psychiatric approaches: phenomenology, psychopathology, and classification
Current Opinion in Psychiatry
Philosophic approaches to psychopathology and nosology show diversity but also a need for a conceptual framework. Anglo-American and Continental phenomenological approaches contribute diversely to a common framework without definitive results. The dilemmas of c lassification and diagnosis may, in part, be overcome if we adopt an approach that goes beyond the common-sense assumptions.