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Psychiatric Diagnosis Needs Rethinking

Psychiatric Diagnosis Needs Rethinking: Psychologist Richard Bentall’s Alternative Paradigm

Psychiatric DiagnosisFor many years, British psychologist Richard Bentall has promoted rethinking about the way psychiatric diagnosis has been conceptualized. When I first read his book, Madness Explained (Bentall, 2006), I was immediately impressed by his carefully researched and referenced arguments that challenged many mainstream views on mental illness. For example, he challenged the prevailing assertion that genetic research has demonstrated conclusive evidence that schizophrenia and bipolar illness are genetically determined and are fundamentally medical diseases. His work is careful not to rehash outdated arguments of nature versus nurture or mind/body dichotomies, but rather to put into proper focus the evidence and limitations of such research.

Bentall’s justification for abandoning the Kraepelinian model for mental illness is built upon Kraepelin’s presupposition that mental disorders are discreet entities, like diseases. The medical model of madness insists that mental disorders exhibit the same characteristics as physical processes and have etiologies rooted in identifiable alterations of the organism’s structure. To that end, neurotransmitters, brain regions, and genetic associations have been researched and are promoted as causal.

However, biochemistry, structure, and ancestry do not directly predict any mental disorder and are, rather, descriptions of how the human organism functions—not why. Whereas some neurotransmitters are clearly related to certain psychological phenomena, such as pleasure, excitement, or comfort, none are pathognomonic to any specific conditions. In fact, no specific genetic findings for specific mental illnesses have been established. Instead, research is favoring multiple etiological factors as both biological and experiential.

Given the complexity of contributing factors, Bentall also notes that some psychiatric categories are outdated artifacts of ancient traditions and concepts. Schizophrenia is not a “split mind,” nor is hysteria a “wandering womb.”  Instead, Bentall proposes a psychiatric diagnosis based on the patient’s presenting complaints, with careful consideration being given to hearing the patient’s life story. The need for an encompassing category (i.e., a psychiatric diagnosis) is both unnecessary and potentially misleading. He advocates for the individuality of the patient, rather than the fitting of the patient into preconceived categories.

Given the constantly expanding number of mental disorders being developed by the DSM system (American Psychiatric Association, 2013), it is clear that no category completely captures the significance of each patient’s needs. When used as a glossary of technical terms, the DSM is clearly useful for operational definitions; where it fails to be useful is in capturing the humanity of the patients under examination. Perhaps the consideration in the DSM-5 for dimensional diagnoses, as seen in the section on personality disorders, may extend across all of the conditions.

Perhaps too, we will stop talking about conditions or disorders, and consider people. Ironically, at the same time that progressive societies espouse the importance of difference and tolerance, we are also pathologizing and labelling each other with great confidence. 

For more on diagnosis, see DSM-5 Diagnoses and Defenses.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bentall, R. (2006). Madness explained: Why we must reject the Kraepelinian paradigm and replace it with a “complaint-oriented” approach to understanding mental illness. Medical Hypotheses, 66, 220-233.

DSM-5 Diagnoses and Defense Mechanisms

DSM-5 Diagnoses and Defense Mechanisms

Most clinicians in the United States make psychiatric diagnoses with the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders).  While “DSM-5 diagnoses” and “defense mechanisms” are rarely terms seen together, the diagnostic process is benefitted by a deep understanding of the person.

The DSM-5

Checklist for DSM-5 DiagnosesFirst published by the American Psychiatric Association in 1952, the DSM began as a brief manual listing 106 diagnoses; now, in its fifth edition it consists of a weighty book outlining nearly 300 diagnoses. 

The DSM is controversial.  Each diagnosis is presented as a series of largely behavioral criteria that must be met or ruled out, with checklists and decision trees.  Its reliability and validity have been challenged by many sources.  Some find it to be too superficial, while others too subjective.  Nevertheless, it is a central focus of most diagnostic training courses in psychology and psychiatry.

DSM-5 Diagnoses

Unfortunately, the DSM-5 itself is often misunderstood and misused.  The manual does in fact begin with a discussion of the importance of clinical judgment in diagnosis.  Many clinicians, however, view the criteria as factual checklists to be memorized and applied in a concrete manner.  As a member of the task force involved in the creation of the DSM-5, I can attest to the importance of applying the diagnoses cautiously, with an understanding of the person you are trying to describe.

People are not diagnoses; people are unique.  At the point that they struggle in ways that significantly interfere with their functioning or that cause significant distress, they may be described with a diagnosis.  But a diagnosis is also not a tangible tumor-like entity to be extracted; a person’s struggles cannot be summarized well by a mere listing of behaviors.  

Understanding defense mechanisms can help deepen and guide the clinician’s judgment in making helpful psychiatric diagnoses, especially for Personality Disorders.

Defense Mechanisms

Simply defined, defense mechanisms are the unconscious or automatic mental activities a person engages in to balance subjectivity and reality.  In psychoanalytic theory, they refer to a constellation of mental processes developed to protect the integrity of the ego system (mind).  As such, defenses protect against threatening impulses and desires (internally generated) as well as against potential threats from the external environment.

Examples of Defense Mechanisms at Work

A person might “forget” to sign an alimony check or gasp “no!” when hearing of the death of a valued friend.  Both acts can be understood as the product of denial.  A politician who says “I’ll tell you the truth” has already admitted to a tendency toward deception.  Likewise, Shakespeare’s “me thinks the lady doth protest too much” demonstrates reaction formation as a defense used to disguise a truth with an exaggerated opposite presentation.

Defense Mechanisms in Personality Disorders

Personality Disorders (character pathology) are largely evidenced through their consistent use of a rigid set of defensive patterns.  

The Paranoid Personality projects aggressive thoughts onto others, creating a view of the environment as dangerous and untrustworthy.  The Obsessive Compulsive Personality works diligently to pre-empt chaos and disorder by being overly conscientious, detailed, and meticulous.  The Histrionic Personality fears rejection and being unloved, leading to flirtatious, seductive, and approval-seeking interactions.  In each of these examples, the blueprint for the structure of the person’s lifestyle is characterized by the repeated set of ego defenses used for preserving sanity.

The online course, Personality Disorders from a Psychoanalytic Perspective, provides an in-depth discussion of the ego defenses that underlie each personality disorder and how they are manifested.

DSM-5 Diagnoses and Defense Mechanisms

Having a clear understanding of defense mechanisms and how they manifest can help the clinician better understand the complexity of human experience.  Some theoretical orientations, such as Cognitive Behavior Therapy, focus on easily accessible world views, cognitive “errors,” “maladaptive thoughts,” “irrational thoughts,” etc.  Others, such as behaviorism, focus solely on observable behaviors.  Regardless of clinical orientation, however, the DSM-5 is used by psychologists and other health care professionals in the US as the authoritative guide to diagnosis, and it describes Personality Disorders in terms of rigid and pervasive ways of relating to the world. 

Whatever one’s theoretical perspective, knowledge of various motivating factors enriches the clinician’s toolbox and promotes an empathic appreciation for psychological suffering.

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