Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
One characteristic of the DSM approach to diagnosis is that the professional first attends to an individual’s complaints and subsequently translates them into standard psychiatric language. This is illustrated in the Structured Clinical Interview for DSM Disorders (SCID). In the SCID interview, the diagnostician doesn’t permit the interviewee to express his problems in the idiom he would normally make use of, but reviews all DSM criteria to ascertain whether they apply to what the patient presents. The SCID interview, like the DSM, is carefully designed to avoid the (messy) idiosyncratic representations and ideas that characterize an individual’s experience of psychopathology. For example, in the context of making a diagnosis of premenstrual dysphoric disorder it is asked whether in the week before onset of the menses a woman experiences
“marked irritability or anger or increased interpersonal conflicts,” and whether these “symptoms” improve within few days after onset (DSM-5, p. 172). In making a DSM diagnosis one examines whether such a criterion applies to an individual.
In doing so, it is assumed that laypersons and trained professionals can sufficiently agree on how they define “irritability,” “anger,” and “interpersonal conflict.” Likewise it is taken for granted that they use corresponding standards for assessing what can be defined as “marked” irritability, and that they use comparable thresholds in determining whether the psychological state one experiences as “marked” is actually abnormal or pathological. What is not explored is the question as to how and under what circumstances this would be the case. Variation in terms of contextual psychosocial factors and in how an individual lives through her complaint is left completely out of consideration. Moreover, no attention is paid to the manner in which the individual interprets or weaves meaning around her experience.
Following the semiotic theorist and novelist Umberto Eco (1976), such an approach bears witness to a neopositivist approach to psychical distress. In such an approach it is assumed that specific symptoms are relatively stable and unambiguous indicators of an underlying condition. Considered from the perspective of medical semiotics, the DSM assumes that symptoms are signifiers that can be linked to a fixed referent. In semiotic theory, the signifier refers to the physical carrier of information (Eco 1976). Examples of signifiers are multiple, ranging from written letters and spoken sound to icons on doors or red lights on the corner of a street. Likewise, behavioral, verbal, and bodily expressions can be understood as signifiers of distress. The referent, in its turn, is the physical object, event, action, or illness to which a signifier refers (Eco 1976). For example, the material object I press my fingers on as I type is the referent of the signifier “keyboard.” In the DSM, the disorders that the system discerns are the referents to which the inclusion and exclusion criteria qua signifier refer. Each of the 347 referents in the system is accompanied by unique but overlapping sets of signifiers that should give rise to unambiguous diagnoses.
More specifically, the DSM seems to start from the belief that symptoms are so-called indexical signifiers, or signs. This means that, following the logic of the DSM, the relationship between signifier and referent is not only fixed, but also causal in nature: the disorder as referent causes the manifestation of the symptom qua signifier. This is what I conclude from the suggestion that the criterion sets “point to an underlying disorder” (DSM-5, p. 19, my italics). Within the DSM a potential patient is seen as the sender of signifiers of illness, which the diagnostician qua receiver must decode. For this decoding process to be successful it is crucial that the receiver possess the code whereby the signifiers can be linked to the correct referent. In psychiatric diagnostics, as performed within the DSM, the handbook with its list of disorders and their criteria makes up such code (Vanheule 2012).
As indicated, the note on clinical case formulation in the DSM-5 suggests that a “summary of the social, psychological, and biological factors” might be relevant in diagnosis since it allows the practitioner to grasp “the relative severity and valence” of the checklist criteria (DSM-5, p. 19). In semiotic terms, this seems to imply that such factors are significant in terms of how they alter or moderate signal strength. The DSM-5 doesn’t actually specify this, but if we follow this line of reasoning one might, for example, expect that personality characteristics influence the way in which symptoms are expressed. A particularly extrovert person might communicate complaints differently than an extremely introverted person, and be more dramatic and expressive. The person’s overall style thus moderates the way the symptom is expressed, but doesn’t alter the nature of the symptom itself. A similar line of reasoning could be applied to how innate temperamental characteristics or social class influence symptom expression: such factors modify the form of the symptom but don’t affect its inherent qualities. Within this line of reasoning, symptoms resemble natural objects like vegetables: depending on the circumstances in which lettuce is grown (in a garden or in a greenhouse; near the equator or near the polar circle) its shape, color, and taste might differ, but it is still just lettuce. Similarly, context variables might shape the form of symptoms, but the moderating effect these variables have is inconsequential for the nature of the symptom itself. Indeed, social, psychological, and biological factors might add noise to the disorder signs the sender is transmitting, but these factors do not change the indexical relation between the symptom qua signifier and the disorder qua referent.
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