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Journal of Evaluation in Clinical Practice ISSN 1365-2753
Mental suffering and the DSM-5: a critical review Stijn Vanheule PhD1 and Ignaas Devisch PhD2 1 2
Professor, Department of Psychoanalysis and Clinical Consulting, Ghent University, Gent, Belgium Professor, Department of Medical Sciences, Ghent University, Gent, Belgium
Keywords diagnosis, distress, pathos, psychopathology, measurement, case formulation, Ricoeur Correspondence Prof. Dr. Stijn Vanheule Department of Psychoanalysis and Clinical Consulting Ghent University H. Dunantlaan 2 B-9000 Gent Belgium E-mail: [email protected] Accepted for publication: 2 April 2014 doi:10.1111/jep.12163
Abstract The definition of mental disorder included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), indicates that mental disorders are usually associated with significant distress. However, the handbook is vague with respect to whether distress is crucial to the diagnosis of mental disorders, and a conceptual framework on the precise nature of distress is lacking. As a result, it remains vague how the term ‘distress’ is to be taken into account in actual diagnostic situations: the DSM-5 provides no operational framework for diagnosing distress. The authors argue that the work of Georges Canguilhem, who focuses on the topic of abnormality and pathology, and Paul Ricoeur’s philosophical reflections on the theme of mental suffering may provide a structure for conceptualizing and evaluating distress. Ricoeur’s phenomenological model of mental suffering is discussed. Here, mental suffering can be thought of in terms of the relationship between self and other, and also in terms of the continuum made up by, what he terms, languishing and acting. Ricoeur suggests that distress is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Consequently, diagnosticians should describe and document how individuals experience subjective distress. On a practical level, this means that clinicians’ ideas about patients’ distress should be embedded in case formulations. A detailed evaluation of an individual’s pathos-experience should be made before conclusions are drawn with regard to diagnosis.
Introduction In May 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1]. The manual was announced [2,3] and introduced [4,5] as a step forward in the scientific innovation of contemporary psychiatry, and is now being used in research projects, health care administrations and clinical practice. However, the DSM-5 has also been criticized for a number of reasons. For example, Allen Frances, the president of the DSM-IV task force, suggested that because of its use of vague diagnostic criteria, the DSM-5 will most probably give rise to false positive epidemics for several disorders, like attention-deficit/hyperactivity disorder (ADHD) [6,7]. In addition, serious doubts have been raised about the frequently overestimated reliability and validity of the manual [8,9], as well as the financial conflicts of interest that might have distorted decision-making processes in the DSM-5 panels [10,11]. In this paper, we focus on a fundamental issue about the DSM-5; namely, that while it notes that the experience of distress
is important in relation to mental disorders, the handbook is vague with respect to whether distress is crucial for diagnosis. Moreover, the manual lacks a conceptual framework concerning what distress precisely is. As a result, it remains vague as to how distress is to be taken into account in actual diagnostic situations. Indeed, it is often believed that the DSM-5 provides an operational framework for diagnosing psychopathology [12]. Yet, with respect to distress, this is far from the case. Given the centrality of distress in the DSM-5 definition of mental disorder, this is clearly problematic: in making diagnostic psychiatric evaluations with the manual, diagnosticians must rely on their own intuitive appraisal of manifestations in the patient’s functioning that could be indicative of severe mental distress. Such mere use of intuition might give rise to logical fallacies that discredit diagnostic decision making [13]. We argue that by starting from the work of Georges Canguilhem on the topic of abnormality and pathology [14], and the philosophical reflections of Paul Ricoeur on the theme of mental suffering [15], the quality of psychiatric diagnosis could be greatly
Journal of Evaluation in Clinical Practice 20 (2014) 975–980 © 2014 John Wiley & Sons, Ltd.
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improved and could give rise to more subtle diagnostic decision making.
Mental disorders and distress: are they necessarily linked? In the introductory pages of the DSM-5, a definition of mental disorder can be found. Here it specifies that: ‘Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities’ ([1], p. 20). However, next to this brief note, the manual contains no further discussion on the nature of distress or disability. Historically speaking, the specification of distress in mental disorders first appeared in the DSM-III [16]. The two previous versions of the manual did not contain such a specification, and left the concept of mental disorder largely undefined. Indeed, the first versions of the manual specifically concentrated on formulating brief descriptions of disorders and providing templates for statistical and administrative purposes [9]. A more robust section on how mental disorders could be defined was added following heated discussions in the 1970s concerning homosexuality [17,18]. Whereas in the DSM-II, homosexuality was included as a mental disorder, Robert Spitzer, the president of the DSM-III task force, came to the conclusion that many homosexuals did not suffer from their sexual preference, but from society’s reactions to it. Fellow psychiatrists who were homosexual, as well as gay activists, convinced Spitzer that they had no mental illness. In order to avoid misdiagnosis, the category of homosexuality was replaced by ‘ego-dystonic homosexuality’ in the DSM-III. The main difference between non-problematic, ego-syntonic homosexuality and the ego-dystonic variant is that the latter provokes distress, while the former does not. In general, Spitzer concluded that the experience of distress is central to the diagnosis of mental disorders, hence its inclusion in the overall definition of mental disorder [17,18]. Since that time, philosophers of psychiatry have emphasized the role of distress in the definition of mental disorders [19,20]. For example, in her discussion of the DSM, Rachel Cooper indicates: ‘The schizophrenic for whom it is a good thing to be schizophrenic is not diseased, while another for whom it is a bad thing is. Here I am suggesting that we should think about diseases in a way analogous to the way in which we think about weeds. Thus a daisy can be a weed in one garden but a flower in another, depending on whether or not it is a good thing in a particular garden’ ([19], p. 26). However, the definition of mental disorders included in the DSM-5 is ambiguous with respect to the status of mental suffering. It says that ‘Mental disorders are usually associated with significant distress or disability’ ([1], p. 20, our italics), which implies that it remains possible that psychiatric diagnoses are given to individuals that do not subjectively suffer from aspects of their own mental functioning. Guided by the work of the French philosopher and physician Georges Canguilhem [14] we suggest that the DSM-5 definition of mental disorder is confusing and mixes up pathology and abnormality.
Pathology and abnormality In his writings on the topic of diagnosis, Canguilhem [14] makes a crucial distinction between pathology and abnormality, thus 976
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paving the way for the studies of his student Michel Foucault on the topics of psychiatric power and biopolitics. In Canguilhem’s view, decision making about normality and abnormality is generally based on two factors. One starts from the observation that there is variability in the ways human beings function: individuals present with a variety of behaviours just as their mental life is characterized by a variety of beliefs and experiences, of which some are more prevalent than others. Then, a judgment is made about (ab-)normality; this tends to be based on a norm or standard against which all behaviours are evaluated and considered as deviant or not. At this level, two possibilities open: a judgement is made based on either psychosocial criteria or statistical norms. If the judgement is based on psychosocial criteria, it is the extent to which the individual’s functioning fits his environment that is assessed. Following this logic, behaviours are ‘normal’ if no one is particularly concerned about it or if they do not cause the others inconvenience. This line of reasoning might seem plausible, but it is based on the idea that individuals must adapt to their context: ‘To define abnormality in terms of social maladaptation is more or less to accept the idea that the individual must subscribe to the fact of such a society, hence must accommodate himself to it as to a reality which is at the same time a good’ ([14], p. 283). As social conventions change across time, identical modes of human functioning will be judged differently. The case of homosexuality illustrates this well; in the early 20th century, it was mainly seen as a moral aberration; and in the works of early sexologists, homosexuality was classified as a perversion. This gave rise to the medicalized idea of homosexuality as a mental disorder. However, following much protest in the 1970s, homosexuality was gradually accepted as a sexual preference, alongside heterosexuality. Applied to the DSM-5, it can be concluded that some disorders, particularly those diagnosed in children, remain strongly based on judgement in lieu of norms that are imposed onto the individual. For example, the criteria for diagnosing ADHD exclusively build on third-party opinions about the individual and use common sense ideas about desired behaviours in specific contexts (e.g. school) as the standard against which behaviours are evaluated. Indeed, diagnostic criteria for ADHD include characteristics like ‘Often does not seem to listen when spoken to directly (e.g. mind seems elsewhere, even in the absence of any obvious distraction)’, ‘Is often forgetful in daily activities (e.g. doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments)’ and ‘Often has difficulty waiting his or her turn (e.g. while waiting in line)’ ([1], pp. 59–60). In the DSM-5, and other relevant literature, these diagnostic criteria are rarely discussed, leaving all interpretation as to (i) what is meant by the term ‘often’ and (ii) why specific behaviours are deemed problematic, down to the judging diagnostician. Thus, it is the professional’s personal opinion that functions as the norm against which an individual is evaluated. In other words, because strict scientific standards for making such evaluations do not exist, it is the belief system of the diagnostician that determines the standard. This can provoke over-diagnosis [6], especially if particular professionals are inclined to problematize particular behaviours. The other option for evaluating the (ab-)normality of human mental functioning is to refer to statistical norms. Canguilhem
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indicates that this kind of judgement is rooted in the work of the Belgian mathematician Adolphe Quetelet (1796–1874), who aimed to study human functioning through a new discipline he coined ‘social physics’. His underlying thesis was that social scientists should study the variability of human characteristics, ranging from physical qualities to aspects of psychological and behavioural functioning. Quetelet aimed to map how people generally function, thus giving rise to a mode of thinking ‘in which normality’ is considered in terms of the statistical normal distribution. In this line of reasoning, normality implies a mode of functioning that closely adheres to the mean or median in statistical distribution. Abnormality, in its turn, implies a mode of functioning that strongly deviates from the average: individuals with an extreme score in terms of the normal distribution are abnormal. From a Foucauldian point of view, this statistically based evaluation of human behaviour engenders a bio-political approach to human functioning [21,22]: based on a marked deviance from the average, individuals are subjected to disciplinary practices that aim to engender (self-)control. Nowadays, certain psychological testing practices function according to the same logic: an individual’s score is compared with cut-off values that are listed in so-called norm tables. Such tables are composed of scores obtained by administering the same test in large populations (clinical and/or non-clinical). To evaluate the individual’s test score, professionals often only compare it with the distribution of scores in the general population, and thus determine whether it deviates from the norm or not. According to Nikolas Rose ([23], p. 7) psychological tests provide ‘a mechanism for rendering subjectivity into thought as a calculable force’. In his view, psychological assessment and evaluation practices provide a technology, starting from which contemporary man inspects and perfects himself, and likewise scrutinizes and manages others. Through the lens of psychological testing, we began to think of ourselves as manageable machinery. Assessment instruments map individual differences, appraise them in terms of statistical or other social norms and engender ‘techniques for the disciplining of human difference’ ([24], p. 19). Canguilhem argues that in the diagnosis of pathology, by contrast, the subjective experience of human suffering is the hallmark. Indeed, for diagnosing pathology, one cannot start from societal or statistical norms. ‘Pathological implies pathos, the direct and concrete feeling of suffering and impotence, the feeling of life gone wrong’ ([14], p. 137). Such a diagnosis of pathology does not build on the opinions of experts, but on patients’ appraisal of their own distress. Moreover, it does not neglect the heteronomy in the patient’s functioning [22], but examines how heteronomy is experienced. By referring to the experience of distress in the definition of mental disorders, the DSM-5 takes into account pathology. Yet as one examines specific DSM-5 disorder criteria, one sees that for certain conditions the subjective experience of distress is not necessarily crucial. For example, none of the diagnostic criteria for ADHD refers to the experience of distress by the child or adult for whom the diagnosis is considered ([1], pp. 59–65). In the diagnosis of other conditions, like major depressive disorder ([1], pp. 160–161), the subjective experience of distress is taken into account more strongly. In our view, the quality of psychiatric diagnosis would be greatly enhanced if pathos, as mentioned by Canguilhem, were mandatory to all diagnostic decision making.
© 2014 John Wiley & Sons, Ltd.
Mental suffering and the DSM-5: a critical review
What is pathos? One weakness of Canguilhem’s work is that while he stresses the importance of pathos in clinical diagnosis, he never fully operationalizes this concept. In order to make pathos operational, the work of French philosopher Paul Ricoeur, who combined phenomenology and hermeneutics, is most inspiring. In 1992, Ricoeur presented a paper entitled La souffrance n’est pas la douleur – Suffering is not the same as pain [15], which provides a framework on how suffering and distress are expressed. While Ricoeur explicitly indicates that his analysis is not based on clinical practice, in our view, his reflections may well be applied to psychiatric problems. The first distinction Ricoeur makes in this context concerns the difference between pain and suffering. What both have in common is that they are affective experiences. Yet whereas pain manifests as an effect on the body, suffering is a mental experience that is related to the language-based reflections we make about ourselves and about others. This means that, above all, suffering is a distressing emotional event that we will all live through at one time or another, for example, when a loved one dies. In such a context, Freud [25] argues that mourning consumes the one who is left behind and is faced with the work of revising their representations of reality, a process that is without a doubt consumed with sorrow. If applied to psychiatric diagnosis, it could be argued that in a number of psychiatric conditions like panic disorder or somatic symptom disorder, pain and mental suffering are not clearly separated. In both disorders, pain and suffering are presented as enmeshed phenomena. This is true, yet what Ricoeur’s analysis suggests is that logically speaking, they can also be quite clearly discerned. One characteristic of suffering qua mental experience is that it cannot be objectified. Whereas a thermometer can assist us in discerning fever in the body and medical imaging can allow us to observe brain damage, pathos cannot be measured via technical devices. Ricoeur indicates that we must ‘read’ people’s distress by paying attention to ‘the signs of suffering’. Suffering is neither self-evident nor open to empirical observation: It can only be discerned when people express what they live through, whether through words, somatic phenomena or behaviour, indicating a certain despair that overwhelms them. Moreover, Ricoeur discerns two orthogonal axes on which he situates mental suffering, which we represent in Fig. 1. In Fig. 1 we see that pathos can be thought of in terms of the relationship
Self
Languishing
Acting
Other Figure 1 Two orthogonal axes on which Ricoeur situates mental suffering.
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between self and other, and in terms of a continuum, between languishing (‘pâtir’) and acting (‘agir’). In terms of the self–other relationship, Ricoeur indicates that suffering consists of withdrawing from the bond with the other. Those who suffer frequently feel isolated and overwhelmed by the misery they endure. Such isolation renders the individual ensnared by an intolerable experience; life is indeed a living hell: ‘the world no longer comes across as liveable, but as emptied’ ([14], p. 17). In clinical contexts, certain patients will still address others in an attempt to articulate their struggle to cope, yet often trust in the support of others is minimal. Other patients, by contrast (such as those in acute psychosis with delusions of reference or in cases of chronic abuse), disconnect from others in more radical ways; they simply do not believe that the other could possibly understand what they are living through. Indeed, sometimes the other is seen as the aggressor from which nothing positive can come, which only heightens the experience of psychological isolation and, thus, intensifies psychological suffering. In terms of the dimension between languishing and acting, Ricoeur indicates that pathos implies an impossibility at the level of performing an act that could transform one’s self-experience. He situates this impossibility in four levels. First, suffering is often characterized by a certain impossibility at the level of speech. This is characterized by something of a fissure between two tendencies: while the patient would like to speak about what he lives through, he cannot find the right words. When speech radically fails, mental suffering finds expression in more crude and rudimentary (non-verbal) ways: inconsolable weeping, restlessness, agonized crying or self-harm. Here the individual is overwhelmed by an experience he cannot articulate. If speech is possible, distress can prompt a minimal appeal for ‘help’ or can be expressed in verbal complaints (‘I can’t live like this anymore’). Such expressions open up the possibility of an elementary dialogue, and can be the impetus for integrating the painful experience into a broader narrative. Second, Ricoeur situates the impossibility of acting at the level of general passivity and a basic inability of taking action. Often, he who suffers would like to do something, but believes that nothing can be done, thus giving rise to a position in which one has to endure one’s state of agony. Indeed, often, patients in distress have the feeling that they are caught in a vicious cycle, where nothing can alleviate their experience. This often drives the individual to despair. When an individual has the impression that he can link concrete actions as potential solutions to his experiences, a shift along this dimension (i.e. towards taking action) occurs. For example, a man who indicates that dark thoughts disappear for a while when playing the piano, or a mother who indicates that her baby stops crying when she lets him rest on her body, bear witness to basic steps towards overcoming the position passivity with respect to an otherwise overwhelming psychological experience. The third point in which Ricoeur situates the impossibility of performing an act is at the level of narration. In line with many other scholars [26,27], Ricoeur believes that the way in which we experience ourselves and the world is largely based on narrative based: ‘a life is nothing but the story of this life, and a quest of narration. Understanding oneself comes down to being capable of telling stories about oneself that are both intelligible and acceptable’ ([15], p. 21). The underlying idea is that our experiences are not inherently organized; such organization is inaugurated pre978
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cisely by telling our stories. In the experience of pathos, such organization is missing: ‘suffering is expressed as a rupture in the narrative thread’ ([15], p. 22). Indeed, often, patients are seriously distressed by experiences they can hardly speak about. Speaking might be too threatening, too painful or experienced as an impossible endeavour. Moreover, if this narrative thread is broken, the experience of time becomes seriously altered: the future and the past lose sense, and what one is left with is the burden of the actual moment. The fourth, and final point Ricoeur refers to is the impossibility of valuing oneself. People only make the step towards performing an act if they think of themselves as agents that are capable of making accurate judgements. In Ricoeur’s view, suffering individuals break down at this level. They no longer know what they do or do not appreciate; they are unsure about what they want and what they do not want. Uncertain as they are, suffering individuals no longer trust their own judgment. At the level of self-experience, this might lead to the conclusion of being stuck in a dead-end situation (‘I’m incapable of overcoming this’), followed by inevitable feelings of guilt concerning their sense of impotence in overcoming their misery. In some patients, this self-appraisal can obtain an interpersonal quality, giving rise to the sense that others cannot be trusted: others cannot possibly comprehend what they are living through, they are malevolent creatures in relation to whom one is nothing but an object. Finally, Ricoeur indicates that pathos not only comes down to an experience of impossibility, but also coheres with a sense of being overwhelmed by excess. He who suffers is devastated by a surplus of affective stimuli that cannot be contained by means of words and actions. Likewise, suffering usually gives rise to a plethora of questions that simply cannot be answered in straightforward ways; answers are incessantly sought nevertheless: ‘Indeed, questioning is related to plaints: Until when? Why me? Why my child?’ ([15], p. 30). Suffering often has a stupefying effect, yet it provokes a perpetual search for sense and reason concerning the why and wherefore of one’s experience.
A plea for studying the quality of mental suffering What is interesting about Ricoeur’s analysis is that it urges us to question the quality of mental suffering; not only should we ask whether prospective patients are actually ‘in distress’, but above all, we should examine precisely how they express what they live through. As indicated earlier, Ricoeur does not buy in to the idea that distress should be considered as a quantity that can be measured. In other words, Pathos cannot be grasped on a measurement scale, but only by studying how people make sense of themselves, and act in relation to others. In its most extreme form, pathos is expressed via withdrawal from the other, accompanied by non-verbal expressions of discontent, which is by no means immediately related to speech. Catatonic schizophrenia, where the patient remains immobile, apathetic and barely able to communicate is illustrative of this. However, following Ricoeur’s two axes, pathos could be thought of as an expressive phenomenon that must be read. No doubt, such a reading of pathos should be considered a personoriented endeavour. Indeed, at a clinical level, pathos should be carefully studied in each individual case concerning what the
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patient lives through and how they express distress. For instance, for an inconsolable 6-month-old baby pathos is expressed differently than it is for the toddler who simply cannot sit still. Similarly, in an adult who repeatedly and anxiously consults his physician, pathos is expressed in a manner that is quite distinct from the recluse who believes that others are perpetually mocking him. As a consequence, diagnosticians must above all describe and document as specifically as possible how an individual expresses the particularity of what the DSM-5 has rather vacantly termed ‘distress’. Professionals should have an eye, and an ear, for how the patient’s symptoms generate isolation from others. Likewise, it should be taken into account that suffering is often expressed through impasses: the inability to speak, take action, narrate and value oneself. In terms of practical clinical reality, this viewpoint implies that mapping suffering and distress entails a lot more than administering redundant self-report questionnaires. Such instruments aim to measure psychological experience. Yet following Ricoeur’s analysis, mental suffering cannot be quantified. Crucial qualities with respect to the experience of distress cannot be grasped in numbers. In our view, this does not imply that all standardized measurement scales have little use. Frequently administered questionnaires, like the Hopkins Symptom Checklist or the Symptom Checklist-90 Revised [28,29], which aimed to measure mental distress, may occupy a meaningful role in diagnostic practice. However, when interpreting questionnaire scores professionals should not neglect the broader ways in which the individual experiences subjective distress. Questionnaire scores might provide useful indications that can alert clinicians to the presence of mental suffering in an individual, yet an appraisal of the person’s experience of pathos requires a narrative-based qualitative approach. Practically, this implies that clinicians’ ideas about patients’ distress should be embedded in case formulations. Case formulations are narratives in which clinicians single out essential information about a case and integrate their findings in a tentative explanatory structure [30]. For the first time in the history of the manual, the DSM-5 ([1], p. 19) devotes two paragraphs to the idea that diagnostic conclusions should indeed be embedded in clinical case formulations. Yet the handbook does not provide details on the characteristics of a good clinical case formulation, and adheres to a narrow idea about the value of information included in such formulations [9]. For example, the DSM-5 does not specify that clinicians should describe and discuss how mental distress is expressed in a given case. Based on Ricoeur’s model on the phenomenology of mental suffering, we believe that any evaluation of mental disorders should start from a detailed qualitative study of mental distress. Before making diagnostic conclusions about how an individual fits a disorder category, a detailed evaluation of his or her pathos-experience must be made.
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3. Regier, D. A., Narrow, W. E., Kuhl, E. A. & Kupfer, D. J. (2009) The conceptual development of DSM-5. The American Journal of Psychiatry, 166, 645–650. 4. Bernstein, C. A. (2011) Meta-structure in DSM-5 process. Psychiatric News, 46 (5), 7–29. 5. Freedman, R., Lewis, D. A., Michels, R., et al. (2013) The initial field trials of DSM-5: new blooms and old thorns. The American Journal of Psychiatry, 170, 1–5. 6. Frances, A. (2013) Saving Normal – An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. New York: William Morrow & Harper Collins Publishers. 7. Batstra, L. & Thoutenhoofd, E. D. (2012) The risk that DSM-5 will further inflate the diagnostic bubble. Current Psychiatry Reviews, 8, 260–263. 8. Vanheule, S., Desmet, M., Meganck, R., et al. (2014) Reliability in psychiatric diagnosis with the DSM: old wine in new barrels. Psychotherapy and Psychosomatics. 9. Vanheule, S. (2014) Diagnosis and the DSM: A Critical Review. London & New York: Palgrave Macmillan. 10. Cosgrove, L. & Krimsky, S. (2012) A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: a pernicious problem persists. PLoS Medicine, 9, e1001190. 11. Cosgrove, L., Krimsky, S., Wheeler, E. E., et al. (2014) Tripartite conflicts of interest and high stakes patent extensions in the DSM-5. Psychotherapy and Psychosomatics, 83, 106–113. 12. Maj, M. (2011) Psychiatric diagnosis: pros and cons of prototypes vs. operational criteria. World Psychiatry, 10 (2), 81–82. 13. Gurova, L. (2013) Understanding it makes it normal’: is it a reasoning fallacy or not? Journal of Evaluation in Clinical Practice, 19 (3), 524–527. 14. Canguilhem, G. (1991/1966) The Normal and the Pathological. New York: Zone Books. 15. Ricoeur, P. (1992) La souffrance n’est pas la douleur [suffering is not the same as pain]. In Souffrance et Douleur (eds C. Marin & N. Zaccaï-Reyners), pp. 13–33. Paris: Presses Universitaires de France. 2013. 16. American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders, Third Edition – DSM-III. Washington, DC: American Psychiatric Association. 17. Decker, H. (2013) The Making of DSM-III. New York: Oxford University Press. 18. Kutchins, H. & Kirk, S. A. (1997) Making US Crazy: DSM – The Psychiatric Bible and The Creation of Mental Disorders. New York: The Free Press. 19. Cooper, R. (2005) Classifying Madness – A Philosophical Examination of the Diagnostic and Statistical Manual of Mental Disorders. Dordrecht: Springer. 20. Cooper, R. (2007) Psychiatry and Philosophy of Science. Stocksfield: Acumen 21. Foucault, M. (2004) Naissance de la biopolitique. Cours au Collège de France. 1978–1979. Paris: Gallimard/Seuil. 22. Devisch, I. & Vanheule, S. (2014) Singularity and medicine: is there a place for heteronomy in medical ethics? The Journal of Evaluation of Clinical Practice. 20 (6), 965–969. 23. Rose, N. (1999) Governing the Soul – The Shaping of the Private Self – Second Edition. London & New York: Free Association Books. 24. Rose, N. (1996) Inventing our Selves – Psychology, Power and Personhood. Cambridge: Cambridge University Press. 25. Freud, S. (1917) Mourning and Melancholia. The Standard Edition of the Complete Psychological Works for Sigmund Freud, Vol. 14, pp. 243–258. London: Hogarth. 26. Bruner, J. (1990) Acts of Meaning. Cambridge: Harvard University Press.
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27. Damasio, A. (2010) Self Comes to Mind: Constructing the Conscious Brain. New York: Vintage. 28. Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H. & Covi, L. (1974) The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behavioral Science, 19, 1–15.
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29. Derogatis, L. R. & Unger, R. (2010) Corsini Encyclopedia of Psychology, 1–2. Hoboken, NJ: John Wiley & Sons. 30. Sturmey, P. (2009) Case Formulation: A Review and Overview of this Volume, in Clinical Case Formulation: Varieties of Approaches (ed. P. Sturmey). Oxford, UK: Wiley-Blackwell.
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Journal of Evaluation in Clinical Practice ISSN 1365-2753
Mental suffering and the DSM-5: a critical review Stijn Vanheule PhD1 and Ignaas Devisch PhD2 1 2
Professor, Department of Psychoanalysis and Clinical Consulting, Ghent University, Gent, Belgium Professor, Department of Medical Sciences, Ghent University, Gent, Belgium
Keywords diagnosis, distress, pathos, psychopathology, measurement, case formulation, Ricoeur Correspondence Prof. Dr. Stijn Vanheule Department of Psychoanalysis and Clinical Consulting Ghent University H. Dunantlaan 2 B-9000 Gent Belgium E-mail: [email protected] Accepted for publication: 2 April 2014 doi:10.1111/jep.12163
Abstract The definition of mental disorder included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), indicates that mental disorders are usually associated with significant distress. However, the handbook is vague with respect to whether distress is crucial to the diagnosis of mental disorders, and a conceptual framework on the precise nature of distress is lacking. As a result, it remains vague how the term ‘distress’ is to be taken into account in actual diagnostic situations: the DSM-5 provides no operational framework for diagnosing distress. The authors argue that the work of Georges Canguilhem, who focuses on the topic of abnormality and pathology, and Paul Ricoeur’s philosophical reflections on the theme of mental suffering may provide a structure for conceptualizing and evaluating distress. Ricoeur’s phenomenological model of mental suffering is discussed. Here, mental suffering can be thought of in terms of the relationship between self and other, and also in terms of the continuum made up by, what he terms, languishing and acting. Ricoeur suggests that distress is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Consequently, diagnosticians should describe and document how individuals experience subjective distress. On a practical level, this means that clinicians’ ideas about patients’ distress should be embedded in case formulations. A detailed evaluation of an individual’s pathos-experience should be made before conclusions are drawn with regard to diagnosis.
Introduction In May 2013, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1]. The manual was announced [2,3] and introduced [4,5] as a step forward in the scientific innovation of contemporary psychiatry, and is now being used in research projects, health care administrations and clinical practice. However, the DSM-5 has also been criticized for a number of reasons. For example, Allen Frances, the president of the DSM-IV task force, suggested that because of its use of vague diagnostic criteria, the DSM-5 will most probably give rise to false positive epidemics for several disorders, like attention-deficit/hyperactivity disorder (ADHD) [6,7]. In addition, serious doubts have been raised about the frequently overestimated reliability and validity of the manual [8,9], as well as the financial conflicts of interest that might have distorted decision-making processes in the DSM-5 panels [10,11]. In this paper, we focus on a fundamental issue about the DSM-5; namely, that while it notes that the experience of distress
is important in relation to mental disorders, the handbook is vague with respect to whether distress is crucial for diagnosis. Moreover, the manual lacks a conceptual framework concerning what distress precisely is. As a result, it remains vague as to how distress is to be taken into account in actual diagnostic situations. Indeed, it is often believed that the DSM-5 provides an operational framework for diagnosing psychopathology [12]. Yet, with respect to distress, this is far from the case. Given the centrality of distress in the DSM-5 definition of mental disorder, this is clearly problematic: in making diagnostic psychiatric evaluations with the manual, diagnosticians must rely on their own intuitive appraisal of manifestations in the patient’s functioning that could be indicative of severe mental distress. Such mere use of intuition might give rise to logical fallacies that discredit diagnostic decision making [13]. We argue that by starting from the work of Georges Canguilhem on the topic of abnormality and pathology [14], and the philosophical reflections of Paul Ricoeur on the theme of mental suffering [15], the quality of psychiatric diagnosis could be greatly
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improved and could give rise to more subtle diagnostic decision making.
Mental disorders and distress: are they necessarily linked? In the introductory pages of the DSM-5, a definition of mental disorder can be found. Here it specifies that: ‘Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities’ ([1], p. 20). However, next to this brief note, the manual contains no further discussion on the nature of distress or disability. Historically speaking, the specification of distress in mental disorders first appeared in the DSM-III [16]. The two previous versions of the manual did not contain such a specification, and left the concept of mental disorder largely undefined. Indeed, the first versions of the manual specifically concentrated on formulating brief descriptions of disorders and providing templates for statistical and administrative purposes [9]. A more robust section on how mental disorders could be defined was added following heated discussions in the 1970s concerning homosexuality [17,18]. Whereas in the DSM-II, homosexuality was included as a mental disorder, Robert Spitzer, the president of the DSM-III task force, came to the conclusion that many homosexuals did not suffer from their sexual preference, but from society’s reactions to it. Fellow psychiatrists who were homosexual, as well as gay activists, convinced Spitzer that they had no mental illness. In order to avoid misdiagnosis, the category of homosexuality was replaced by ‘ego-dystonic homosexuality’ in the DSM-III. The main difference between non-problematic, ego-syntonic homosexuality and the ego-dystonic variant is that the latter provokes distress, while the former does not. In general, Spitzer concluded that the experience of distress is central to the diagnosis of mental disorders, hence its inclusion in the overall definition of mental disorder [17,18]. Since that time, philosophers of psychiatry have emphasized the role of distress in the definition of mental disorders [19,20]. For example, in her discussion of the DSM, Rachel Cooper indicates: ‘The schizophrenic for whom it is a good thing to be schizophrenic is not diseased, while another for whom it is a bad thing is. Here I am suggesting that we should think about diseases in a way analogous to the way in which we think about weeds. Thus a daisy can be a weed in one garden but a flower in another, depending on whether or not it is a good thing in a particular garden’ ([19], p. 26). However, the definition of mental disorders included in the DSM-5 is ambiguous with respect to the status of mental suffering. It says that ‘Mental disorders are usually associated with significant distress or disability’ ([1], p. 20, our italics), which implies that it remains possible that psychiatric diagnoses are given to individuals that do not subjectively suffer from aspects of their own mental functioning. Guided by the work of the French philosopher and physician Georges Canguilhem [14] we suggest that the DSM-5 definition of mental disorder is confusing and mixes up pathology and abnormality.
Pathology and abnormality In his writings on the topic of diagnosis, Canguilhem [14] makes a crucial distinction between pathology and abnormality, thus 976
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paving the way for the studies of his student Michel Foucault on the topics of psychiatric power and biopolitics. In Canguilhem’s view, decision making about normality and abnormality is generally based on two factors. One starts from the observation that there is variability in the ways human beings function: individuals present with a variety of behaviours just as their mental life is characterized by a variety of beliefs and experiences, of which some are more prevalent than others. Then, a judgment is made about (ab-)normality; this tends to be based on a norm or standard against which all behaviours are evaluated and considered as deviant or not. At this level, two possibilities open: a judgement is made based on either psychosocial criteria or statistical norms. If the judgement is based on psychosocial criteria, it is the extent to which the individual’s functioning fits his environment that is assessed. Following this logic, behaviours are ‘normal’ if no one is particularly concerned about it or if they do not cause the others inconvenience. This line of reasoning might seem plausible, but it is based on the idea that individuals must adapt to their context: ‘To define abnormality in terms of social maladaptation is more or less to accept the idea that the individual must subscribe to the fact of such a society, hence must accommodate himself to it as to a reality which is at the same time a good’ ([14], p. 283). As social conventions change across time, identical modes of human functioning will be judged differently. The case of homosexuality illustrates this well; in the early 20th century, it was mainly seen as a moral aberration; and in the works of early sexologists, homosexuality was classified as a perversion. This gave rise to the medicalized idea of homosexuality as a mental disorder. However, following much protest in the 1970s, homosexuality was gradually accepted as a sexual preference, alongside heterosexuality. Applied to the DSM-5, it can be concluded that some disorders, particularly those diagnosed in children, remain strongly based on judgement in lieu of norms that are imposed onto the individual. For example, the criteria for diagnosing ADHD exclusively build on third-party opinions about the individual and use common sense ideas about desired behaviours in specific contexts (e.g. school) as the standard against which behaviours are evaluated. Indeed, diagnostic criteria for ADHD include characteristics like ‘Often does not seem to listen when spoken to directly (e.g. mind seems elsewhere, even in the absence of any obvious distraction)’, ‘Is often forgetful in daily activities (e.g. doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments)’ and ‘Often has difficulty waiting his or her turn (e.g. while waiting in line)’ ([1], pp. 59–60). In the DSM-5, and other relevant literature, these diagnostic criteria are rarely discussed, leaving all interpretation as to (i) what is meant by the term ‘often’ and (ii) why specific behaviours are deemed problematic, down to the judging diagnostician. Thus, it is the professional’s personal opinion that functions as the norm against which an individual is evaluated. In other words, because strict scientific standards for making such evaluations do not exist, it is the belief system of the diagnostician that determines the standard. This can provoke over-diagnosis [6], especially if particular professionals are inclined to problematize particular behaviours. The other option for evaluating the (ab-)normality of human mental functioning is to refer to statistical norms. Canguilhem
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indicates that this kind of judgement is rooted in the work of the Belgian mathematician Adolphe Quetelet (1796–1874), who aimed to study human functioning through a new discipline he coined ‘social physics’. His underlying thesis was that social scientists should study the variability of human characteristics, ranging from physical qualities to aspects of psychological and behavioural functioning. Quetelet aimed to map how people generally function, thus giving rise to a mode of thinking ‘in which normality’ is considered in terms of the statistical normal distribution. In this line of reasoning, normality implies a mode of functioning that closely adheres to the mean or median in statistical distribution. Abnormality, in its turn, implies a mode of functioning that strongly deviates from the average: individuals with an extreme score in terms of the normal distribution are abnormal. From a Foucauldian point of view, this statistically based evaluation of human behaviour engenders a bio-political approach to human functioning [21,22]: based on a marked deviance from the average, individuals are subjected to disciplinary practices that aim to engender (self-)control. Nowadays, certain psychological testing practices function according to the same logic: an individual’s score is compared with cut-off values that are listed in so-called norm tables. Such tables are composed of scores obtained by administering the same test in large populations (clinical and/or non-clinical). To evaluate the individual’s test score, professionals often only compare it with the distribution of scores in the general population, and thus determine whether it deviates from the norm or not. According to Nikolas Rose ([23], p. 7) psychological tests provide ‘a mechanism for rendering subjectivity into thought as a calculable force’. In his view, psychological assessment and evaluation practices provide a technology, starting from which contemporary man inspects and perfects himself, and likewise scrutinizes and manages others. Through the lens of psychological testing, we began to think of ourselves as manageable machinery. Assessment instruments map individual differences, appraise them in terms of statistical or other social norms and engender ‘techniques for the disciplining of human difference’ ([24], p. 19). Canguilhem argues that in the diagnosis of pathology, by contrast, the subjective experience of human suffering is the hallmark. Indeed, for diagnosing pathology, one cannot start from societal or statistical norms. ‘Pathological implies pathos, the direct and concrete feeling of suffering and impotence, the feeling of life gone wrong’ ([14], p. 137). Such a diagnosis of pathology does not build on the opinions of experts, but on patients’ appraisal of their own distress. Moreover, it does not neglect the heteronomy in the patient’s functioning [22], but examines how heteronomy is experienced. By referring to the experience of distress in the definition of mental disorders, the DSM-5 takes into account pathology. Yet as one examines specific DSM-5 disorder criteria, one sees that for certain conditions the subjective experience of distress is not necessarily crucial. For example, none of the diagnostic criteria for ADHD refers to the experience of distress by the child or adult for whom the diagnosis is considered ([1], pp. 59–65). In the diagnosis of other conditions, like major depressive disorder ([1], pp. 160–161), the subjective experience of distress is taken into account more strongly. In our view, the quality of psychiatric diagnosis would be greatly enhanced if pathos, as mentioned by Canguilhem, were mandatory to all diagnostic decision making.
© 2014 John Wiley & Sons, Ltd.
Mental suffering and the DSM-5: a critical review
What is pathos? One weakness of Canguilhem’s work is that while he stresses the importance of pathos in clinical diagnosis, he never fully operationalizes this concept. In order to make pathos operational, the work of French philosopher Paul Ricoeur, who combined phenomenology and hermeneutics, is most inspiring. In 1992, Ricoeur presented a paper entitled La souffrance n’est pas la douleur – Suffering is not the same as pain [15], which provides a framework on how suffering and distress are expressed. While Ricoeur explicitly indicates that his analysis is not based on clinical practice, in our view, his reflections may well be applied to psychiatric problems. The first distinction Ricoeur makes in this context concerns the difference between pain and suffering. What both have in common is that they are affective experiences. Yet whereas pain manifests as an effect on the body, suffering is a mental experience that is related to the language-based reflections we make about ourselves and about others. This means that, above all, suffering is a distressing emotional event that we will all live through at one time or another, for example, when a loved one dies. In such a context, Freud [25] argues that mourning consumes the one who is left behind and is faced with the work of revising their representations of reality, a process that is without a doubt consumed with sorrow. If applied to psychiatric diagnosis, it could be argued that in a number of psychiatric conditions like panic disorder or somatic symptom disorder, pain and mental suffering are not clearly separated. In both disorders, pain and suffering are presented as enmeshed phenomena. This is true, yet what Ricoeur’s analysis suggests is that logically speaking, they can also be quite clearly discerned. One characteristic of suffering qua mental experience is that it cannot be objectified. Whereas a thermometer can assist us in discerning fever in the body and medical imaging can allow us to observe brain damage, pathos cannot be measured via technical devices. Ricoeur indicates that we must ‘read’ people’s distress by paying attention to ‘the signs of suffering’. Suffering is neither self-evident nor open to empirical observation: It can only be discerned when people express what they live through, whether through words, somatic phenomena or behaviour, indicating a certain despair that overwhelms them. Moreover, Ricoeur discerns two orthogonal axes on which he situates mental suffering, which we represent in Fig. 1. In Fig. 1 we see that pathos can be thought of in terms of the relationship
Self
Languishing
Acting
Other Figure 1 Two orthogonal axes on which Ricoeur situates mental suffering.
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between self and other, and in terms of a continuum, between languishing (‘pâtir’) and acting (‘agir’). In terms of the self–other relationship, Ricoeur indicates that suffering consists of withdrawing from the bond with the other. Those who suffer frequently feel isolated and overwhelmed by the misery they endure. Such isolation renders the individual ensnared by an intolerable experience; life is indeed a living hell: ‘the world no longer comes across as liveable, but as emptied’ ([14], p. 17). In clinical contexts, certain patients will still address others in an attempt to articulate their struggle to cope, yet often trust in the support of others is minimal. Other patients, by contrast (such as those in acute psychosis with delusions of reference or in cases of chronic abuse), disconnect from others in more radical ways; they simply do not believe that the other could possibly understand what they are living through. Indeed, sometimes the other is seen as the aggressor from which nothing positive can come, which only heightens the experience of psychological isolation and, thus, intensifies psychological suffering. In terms of the dimension between languishing and acting, Ricoeur indicates that pathos implies an impossibility at the level of performing an act that could transform one’s self-experience. He situates this impossibility in four levels. First, suffering is often characterized by a certain impossibility at the level of speech. This is characterized by something of a fissure between two tendencies: while the patient would like to speak about what he lives through, he cannot find the right words. When speech radically fails, mental suffering finds expression in more crude and rudimentary (non-verbal) ways: inconsolable weeping, restlessness, agonized crying or self-harm. Here the individual is overwhelmed by an experience he cannot articulate. If speech is possible, distress can prompt a minimal appeal for ‘help’ or can be expressed in verbal complaints (‘I can’t live like this anymore’). Such expressions open up the possibility of an elementary dialogue, and can be the impetus for integrating the painful experience into a broader narrative. Second, Ricoeur situates the impossibility of acting at the level of general passivity and a basic inability of taking action. Often, he who suffers would like to do something, but believes that nothing can be done, thus giving rise to a position in which one has to endure one’s state of agony. Indeed, often, patients in distress have the feeling that they are caught in a vicious cycle, where nothing can alleviate their experience. This often drives the individual to despair. When an individual has the impression that he can link concrete actions as potential solutions to his experiences, a shift along this dimension (i.e. towards taking action) occurs. For example, a man who indicates that dark thoughts disappear for a while when playing the piano, or a mother who indicates that her baby stops crying when she lets him rest on her body, bear witness to basic steps towards overcoming the position passivity with respect to an otherwise overwhelming psychological experience. The third point in which Ricoeur situates the impossibility of performing an act is at the level of narration. In line with many other scholars [26,27], Ricoeur believes that the way in which we experience ourselves and the world is largely based on narrative based: ‘a life is nothing but the story of this life, and a quest of narration. Understanding oneself comes down to being capable of telling stories about oneself that are both intelligible and acceptable’ ([15], p. 21). The underlying idea is that our experiences are not inherently organized; such organization is inaugurated pre978
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cisely by telling our stories. In the experience of pathos, such organization is missing: ‘suffering is expressed as a rupture in the narrative thread’ ([15], p. 22). Indeed, often, patients are seriously distressed by experiences they can hardly speak about. Speaking might be too threatening, too painful or experienced as an impossible endeavour. Moreover, if this narrative thread is broken, the experience of time becomes seriously altered: the future and the past lose sense, and what one is left with is the burden of the actual moment. The fourth, and final point Ricoeur refers to is the impossibility of valuing oneself. People only make the step towards performing an act if they think of themselves as agents that are capable of making accurate judgements. In Ricoeur’s view, suffering individuals break down at this level. They no longer know what they do or do not appreciate; they are unsure about what they want and what they do not want. Uncertain as they are, suffering individuals no longer trust their own judgment. At the level of self-experience, this might lead to the conclusion of being stuck in a dead-end situation (‘I’m incapable of overcoming this’), followed by inevitable feelings of guilt concerning their sense of impotence in overcoming their misery. In some patients, this self-appraisal can obtain an interpersonal quality, giving rise to the sense that others cannot be trusted: others cannot possibly comprehend what they are living through, they are malevolent creatures in relation to whom one is nothing but an object. Finally, Ricoeur indicates that pathos not only comes down to an experience of impossibility, but also coheres with a sense of being overwhelmed by excess. He who suffers is devastated by a surplus of affective stimuli that cannot be contained by means of words and actions. Likewise, suffering usually gives rise to a plethora of questions that simply cannot be answered in straightforward ways; answers are incessantly sought nevertheless: ‘Indeed, questioning is related to plaints: Until when? Why me? Why my child?’ ([15], p. 30). Suffering often has a stupefying effect, yet it provokes a perpetual search for sense and reason concerning the why and wherefore of one’s experience.
A plea for studying the quality of mental suffering What is interesting about Ricoeur’s analysis is that it urges us to question the quality of mental suffering; not only should we ask whether prospective patients are actually ‘in distress’, but above all, we should examine precisely how they express what they live through. As indicated earlier, Ricoeur does not buy in to the idea that distress should be considered as a quantity that can be measured. In other words, Pathos cannot be grasped on a measurement scale, but only by studying how people make sense of themselves, and act in relation to others. In its most extreme form, pathos is expressed via withdrawal from the other, accompanied by non-verbal expressions of discontent, which is by no means immediately related to speech. Catatonic schizophrenia, where the patient remains immobile, apathetic and barely able to communicate is illustrative of this. However, following Ricoeur’s two axes, pathos could be thought of as an expressive phenomenon that must be read. No doubt, such a reading of pathos should be considered a personoriented endeavour. Indeed, at a clinical level, pathos should be carefully studied in each individual case concerning what the
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patient lives through and how they express distress. For instance, for an inconsolable 6-month-old baby pathos is expressed differently than it is for the toddler who simply cannot sit still. Similarly, in an adult who repeatedly and anxiously consults his physician, pathos is expressed in a manner that is quite distinct from the recluse who believes that others are perpetually mocking him. As a consequence, diagnosticians must above all describe and document as specifically as possible how an individual expresses the particularity of what the DSM-5 has rather vacantly termed ‘distress’. Professionals should have an eye, and an ear, for how the patient’s symptoms generate isolation from others. Likewise, it should be taken into account that suffering is often expressed through impasses: the inability to speak, take action, narrate and value oneself. In terms of practical clinical reality, this viewpoint implies that mapping suffering and distress entails a lot more than administering redundant self-report questionnaires. Such instruments aim to measure psychological experience. Yet following Ricoeur’s analysis, mental suffering cannot be quantified. Crucial qualities with respect to the experience of distress cannot be grasped in numbers. In our view, this does not imply that all standardized measurement scales have little use. Frequently administered questionnaires, like the Hopkins Symptom Checklist or the Symptom Checklist-90 Revised [28,29], which aimed to measure mental distress, may occupy a meaningful role in diagnostic practice. However, when interpreting questionnaire scores professionals should not neglect the broader ways in which the individual experiences subjective distress. Questionnaire scores might provide useful indications that can alert clinicians to the presence of mental suffering in an individual, yet an appraisal of the person’s experience of pathos requires a narrative-based qualitative approach. Practically, this implies that clinicians’ ideas about patients’ distress should be embedded in case formulations. Case formulations are narratives in which clinicians single out essential information about a case and integrate their findings in a tentative explanatory structure [30]. For the first time in the history of the manual, the DSM-5 ([1], p. 19) devotes two paragraphs to the idea that diagnostic conclusions should indeed be embedded in clinical case formulations. Yet the handbook does not provide details on the characteristics of a good clinical case formulation, and adheres to a narrow idea about the value of information included in such formulations [9]. For example, the DSM-5 does not specify that clinicians should describe and discuss how mental distress is expressed in a given case. Based on Ricoeur’s model on the phenomenology of mental suffering, we believe that any evaluation of mental disorders should start from a detailed qualitative study of mental distress. Before making diagnostic conclusions about how an individual fits a disorder category, a detailed evaluation of his or her pathos-experience must be made.
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