Anthropological Perspectives in Psychiatric Nosology
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DSM, etiology, Aristotelian causes, social dramas
Psychiatry and clinical psychology, as we learn in this paper, are disciplines in need of an ontological perspective. Very few branches of contemporary learning share this characteristic. Probably only theoretical physic and theology—as the rest have long ago given up trying to define and understand the essence of their object, for example, life in the case of biology or mind in psychology. Consequently, the paper by Pérez-Álvarez, Sass and García-Montes, “The Ontology of Mental Disorders in Constructivist Perspective,” (2008) should be welcomed and indeed included in the reading lists for trainees in psychiatry and clinical psychology.
The authors propose an approach to the understanding of mental disorders that is extremely attractive and well articulated, and which also has practical implications for clinicians. It is not just another “philosophical divertimento” devoid of scientific and practical importance. Let us analyze the article in an orderly way.
Less Dsm
The authors of the target paper disapprove of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III/IV approach to defining illnesses by starting from the symptoms that are present—on the grounds that this may lead clinicians to assume that their sole role is to identify, fight, and suppress the symptoms by whichever procedure. They propose an alternative that is dear to myself because it follows the path of the so-called “anthropological” psychiatry of Binswanger, von Gebsattel, Erwin Strauss, Zutt, López-Ibor, Sr., and others. In essence, this is a phenomenological approach to the meaning of mental diseases, one that emphasizes how the illness is revealed to the patient him- or herself.
The target article’s criticism of DSM should be considered in the context of the abuses committed on its behalf. The DSM is not a textbook of psychiatric disorders, nor does it contain a definition of the diseases. The DSM does not tell what a disease is (Klerman et al. 1984)—something that is impossible with a classification system based on the manifestations of the diseases, the signs and symptoms. The DSM, as its title states, is just a diagnostic and statistical manual, which does not contain anything about the origin of [End Page 259] any disease nor an explanation of why it exists or what it means. The DSM is, in fact, just a tool to determine whether a disease is present, and therefore to facilitate communication between professionals and with other individuals, without saying anything about the disease’s aitia—a key term (associated with notions of essence as well as cause) to be discussed below. In theory, most clinicians should understand these limitations; it may be, however, that this is not really the case for many who read or use the DSM. In the world there are around 200,000 psychiatrists; since 1980 the number of DSM copies sold is in the order of several hundred thousand.
The misuse of a classification system is even more noticeable in the International Classification of Diseases (ICD)-10 Research Version. The instructions for the use of this version recommend that the first step is to make an inventory of all the symptoms present, and then to construct a diagnosis based on them. This how all computer-assisted systems work. This procedure can, however, only be valid if the clinician has already reached a diagnostic conclusion by other means—a diagnosis then to be confirmed for research purposes. It may be that this is one of the reasons why the ICD-10 Research Version has almost never actually been used for research.
Furthermore, the concept of symptoms in psychiatry applies only to organic mental disorders (Schneider 1959), conditions in which the patient’s attitude and way of experiencing the symptoms do not play the kind of role that they play in schizophrenia and other mental disorders. The quotation from the important paper by Sass and Parnas in this context is most appropriate. It is indeed that case that “subjective experience can play an important causal role in the progressive experiential transformations of a developing schizophrenic illness...
