Liah Greenfeld's Blog - Posts Tagged "dsm-5"
The Real Trouble With DSM-5
Let us take a little break from the discussion of the historical development of modern emotions and modern mental disease—that is, of the modern mind-—pursued in the previous posts of this blog, and instead focus on the present. May 22 is the official publication date of the much-talked-about DSM-5, a significant day for all who are in any way concerned with mental health, patients as well as professionals who are trying to help them, and therefore for many in the Psychology Today community. The manual has been subject to severe criticism for months preceding its publication; it appears that hardly anyone has a good word to say about it, the time and effort spent in its preparation seems to have been largely wasted. The poor baby is likely to be dead on arrival, stillborn, its own family having turned away, unwilling to embrace it. Just a week ago the mighty NIMH all but completely renounced it.
But why is it such a disappointment? And who or what is to blame for the problems with DSM-5? The answer to the first question, I would say, lies not in anything DSM-5 contributes to the previous versions of the manual (whether in terms of additions or subtractions), but in what it does not change in them at all. The answer lies in that it does not solve the fundamental problem of psychiatry and psychology, i.e., does not provide them with the understanding of the human mental process—tthe mind—healthy or ill. This is, obviously, not a problem which the DSM-5 creates, or which was created by any of the preceding versions of this document. It is the problem at the core of the psychiatric/psychological/mental health establishment in its entirety-—both its research and its clinical branches, and including in the first place its central, most powerful, and richest institution, NIMH.
According to the prepublication materials, the essence of the new DSM consists in the modifications it introduces in the extensive psychiatric nosology, specifically adding diagnostic categories to diseases of unknown biological origin and uncertain etiology. But the real problem lies much deeper—in the understanding of such diseases itself; it is the problem with the old, fundamental, and universally accepted diagnostic categories of thought disorder vs. affective disorders, or schizophrenia vs. manic and unipolar depression, on which all the other diagnostic categories of mental illness of unknown etiology, new and not so new, are based. DSM’s approach is similar to attempting to salvage a house, falling apart because built on an unsound foundation, by adding to it a fresh coat of paint and new shutters. What is needed, in contrast, is to dismantle the structure, establish a sound foundation, and then rebuild the house on top of it.
DSM-5, and DSM in general, is just an expression of the increasing confusion in the mental health community (including both researchers and clinicians, and both psychiatry and psychology with their neuroscience contingents) in regard to the nature of the human mental processes—or the mind-—altogether. Before this confusion is cleared, none of the problems with the DSM and the resulting mental health practice can be resolved. And the criticism of the DSM should in all fairness apply also to its critics and judges, such as the NIMH.
Despite its nearly exclusive biological focus and the equation of the mind and the brain, the source of the mental health professions’ misunderstanding of the mind lies in their deviation from the norm in biology. Psychiatry and psychology consider the human individual as their subject. Biology, in distinction, studies the organic world. The most important causal factor in biology is the environment in which organisms find themselves (think of natural selection) and no specialization in this mighty science, among the sub-disciplines of which neuropsychiatry and neuropsychology, at least, would like to range themselves, would limit itself to the study of a form of life in isolation from the environment. Consider, for example, medical (i.e., applied biological) specializations such as gastroenterology or pulmonology: is it possible to imagine a physician who would be unaware that the process of digestion is necessarily affected by the nature and quantity of food the stomach digests, or the process of breathing by the nature and quantity of the air inhaled? No, because this is what our organs do: they process intakes from the environment, and these intakes have at least as much to do with our health and illness as the structure and physiology of the organs which process them. Yet, we forget this when it comes to the brain and mental processing—the mind.
The environment of the human brain is far more complex than that of the stomach and lungs, or than the environment of the brains of other animals. Most of its intakes come not from the organic and physical world, but, instead, from the world of meanings and symbolic systems which convey them, that is, culture. If digestion can be defined as what happens to food in, and what food does to, the stomach, the mind, by analogy, can be conceptualized as what happens to culture in, and what culture does to, the (human) brain. It is very likely that most mental diseases (just like most gastrointestinal or pulmonary ones) come from the intake of the processing organ, rather than from the organ itself, i.e., it is likely that they are caused by culture. Mental health professions pay no attention to it, and no revision of the DSM will make them improve their ability to help the mentally ill.
To solve the problem of the psychiatric/psychological/mental health establishment, which the DSM has failed to do (thereby disappointing its closest associates), one has to start by questioning and analyzing the fundamental diagnostic categories used by this establishment, consider them against the existing clinical, neurobiological, genetic, and epidemiological evidence, and-—most important—bring into the mix the never-before-considered cultural data. It is likely that on this basis one would reach the conclusion I have arrived at, that the two (schizophrenia and manic-depressive illness) or even three (schizophrenia, manic depression, and unipolar depression) discreet diseases are better conceptualized—and therefore treated—as the same disease, with one (and cultural) cause, which expresses itself differently depending on the circumstances in which this cause becomes operative. Psychiatric epidemiologists, at least, have long suspected that “the black box of culture” is an important contributing factor in these diseases. However, as the phrase indicates, they lack the means to understand or even examine its contribution. Let us unpack the “black box” and add a missing yet essential dimension to the diagnostic tool-kit, which the new DSM, like the old ones, disregards.
[Originally published on Psychology today]
Mind, Modernity, Madness: The Impact of Culture on Human Experience
But why is it such a disappointment? And who or what is to blame for the problems with DSM-5? The answer to the first question, I would say, lies not in anything DSM-5 contributes to the previous versions of the manual (whether in terms of additions or subtractions), but in what it does not change in them at all. The answer lies in that it does not solve the fundamental problem of psychiatry and psychology, i.e., does not provide them with the understanding of the human mental process—tthe mind—healthy or ill. This is, obviously, not a problem which the DSM-5 creates, or which was created by any of the preceding versions of this document. It is the problem at the core of the psychiatric/psychological/mental health establishment in its entirety-—both its research and its clinical branches, and including in the first place its central, most powerful, and richest institution, NIMH.
According to the prepublication materials, the essence of the new DSM consists in the modifications it introduces in the extensive psychiatric nosology, specifically adding diagnostic categories to diseases of unknown biological origin and uncertain etiology. But the real problem lies much deeper—in the understanding of such diseases itself; it is the problem with the old, fundamental, and universally accepted diagnostic categories of thought disorder vs. affective disorders, or schizophrenia vs. manic and unipolar depression, on which all the other diagnostic categories of mental illness of unknown etiology, new and not so new, are based. DSM’s approach is similar to attempting to salvage a house, falling apart because built on an unsound foundation, by adding to it a fresh coat of paint and new shutters. What is needed, in contrast, is to dismantle the structure, establish a sound foundation, and then rebuild the house on top of it.
DSM-5, and DSM in general, is just an expression of the increasing confusion in the mental health community (including both researchers and clinicians, and both psychiatry and psychology with their neuroscience contingents) in regard to the nature of the human mental processes—or the mind-—altogether. Before this confusion is cleared, none of the problems with the DSM and the resulting mental health practice can be resolved. And the criticism of the DSM should in all fairness apply also to its critics and judges, such as the NIMH.
Despite its nearly exclusive biological focus and the equation of the mind and the brain, the source of the mental health professions’ misunderstanding of the mind lies in their deviation from the norm in biology. Psychiatry and psychology consider the human individual as their subject. Biology, in distinction, studies the organic world. The most important causal factor in biology is the environment in which organisms find themselves (think of natural selection) and no specialization in this mighty science, among the sub-disciplines of which neuropsychiatry and neuropsychology, at least, would like to range themselves, would limit itself to the study of a form of life in isolation from the environment. Consider, for example, medical (i.e., applied biological) specializations such as gastroenterology or pulmonology: is it possible to imagine a physician who would be unaware that the process of digestion is necessarily affected by the nature and quantity of food the stomach digests, or the process of breathing by the nature and quantity of the air inhaled? No, because this is what our organs do: they process intakes from the environment, and these intakes have at least as much to do with our health and illness as the structure and physiology of the organs which process them. Yet, we forget this when it comes to the brain and mental processing—the mind.
The environment of the human brain is far more complex than that of the stomach and lungs, or than the environment of the brains of other animals. Most of its intakes come not from the organic and physical world, but, instead, from the world of meanings and symbolic systems which convey them, that is, culture. If digestion can be defined as what happens to food in, and what food does to, the stomach, the mind, by analogy, can be conceptualized as what happens to culture in, and what culture does to, the (human) brain. It is very likely that most mental diseases (just like most gastrointestinal or pulmonary ones) come from the intake of the processing organ, rather than from the organ itself, i.e., it is likely that they are caused by culture. Mental health professions pay no attention to it, and no revision of the DSM will make them improve their ability to help the mentally ill.
To solve the problem of the psychiatric/psychological/mental health establishment, which the DSM has failed to do (thereby disappointing its closest associates), one has to start by questioning and analyzing the fundamental diagnostic categories used by this establishment, consider them against the existing clinical, neurobiological, genetic, and epidemiological evidence, and-—most important—bring into the mix the never-before-considered cultural data. It is likely that on this basis one would reach the conclusion I have arrived at, that the two (schizophrenia and manic-depressive illness) or even three (schizophrenia, manic depression, and unipolar depression) discreet diseases are better conceptualized—and therefore treated—as the same disease, with one (and cultural) cause, which expresses itself differently depending on the circumstances in which this cause becomes operative. Psychiatric epidemiologists, at least, have long suspected that “the black box of culture” is an important contributing factor in these diseases. However, as the phrase indicates, they lack the means to understand or even examine its contribution. Let us unpack the “black box” and add a missing yet essential dimension to the diagnostic tool-kit, which the new DSM, like the old ones, disregards.
[Originally published on Psychology today]
Mind, Modernity, Madness: The Impact of Culture on Human Experience
Is Depression A Real Disease?
The May 2013 issue of The British Journal of General Practice contains an editorial “Depression as a culture-bound syndrome: implications for primary care” by Dr. Christopher Dowrick, Professor of Primary Medical Care at the Institute of Psychology, Health, and Society of the University of Liverpool. Dr. Dowrick claims that depression “fulfills the criteria for a culture-bound syndrome,” i.e. , one of the “’illnesses’, limited to specific societies or culture areas, composed of localized diagnostic categories,” like, for instance ataque de nervios in Latin America. In the case of depression the culture area affected is “westernized societies.” Putting the word “illness,” when applied to culture-bound syndromes into quotation marks indicates that Dr. Dowrick does not consider such syndromes real illnesses; it follows that depression--a culture-bound syndrome of westernized societies--is also not a real illness. Dr. Dowrick further argues that depression as a diagnostic category cannot be seen as “a universal, transcultural concept,” because it has no validity and utility, and it does not have validity and utility, because “there is no sound evidence for a discrete pathophysiological basis” for depression. I find myself in absolute agreement with Dr. Dowrick’s two specific statements above (that depression is a culture-bound syndrome of westernized societies, and that there is no discrete pathophysiological basis for this diagnostic category), and yet completely disagree with the implication that depression is not a real disease.
It is important to remember what a disease, or illness, in general, is. Both terms clearly focus on the personal, subjective experience of suffering: dis-ease as opposed to ease, illness as opposed to wellness. So does the word “pathology,” which derives from the Greek for “suffering” (pathos) and Greek for “knowledge” or “understanding” (logos). Thus pathology = understanding of suffering. Even health professionals, whose task is to alleviate suffering, first of all, often forget this, and think that “pathology” refers not to the understanding of the patient’s suffering, but to an objective morbid condition underlying it, and also equate “disease” and “illness” with such objective morbid condition. Moreover, they also believe that such objective morbid condition is necessarily material, i.e., biological. As a result, the absence of “a discrete pathophysiological basis” for depression can lead Dr. Dowrick to the conclusion that depression is not a real illness, but a category, invented for commercial and professional reasons of pharmaceutical companies and medical practitioners who want to get paid for services rendered, which was developed on the basis of “an ethic of happiness, within which aberrations from the norm are assumed to indicate illness.” But, as my previous post [The Real Trouble With DSM-5] argued, mental diseases are likely to be caused by culture, rather than biology, because the mind, or the mental process, while occurring in the brain, is mostly processing intakes from the cultural, symbolic environment, in which it is unlike digestion or breathing, which process intakes from the material, physical and organic, environment. There is an objective underlying condition for the disease (i.e., the suffering) of depression, but this condition is cultural: it is the cultural condition of anomie, caused by the openness of modern Western societies and the bewildering multiplicity of choices for possible self-definition they offer their members [see The Modern Mental Disease]. Depression is, indeed, a culture-bound syndrome and at the same time it is a terrible disease, which cannot and should not be equated with low or bad mood, sadness, or any other “aberration from the norm of happiness”: it differs from these normal mental states symptomatically in the intensity of suffering experienced, in its character (such as resistance to distraction and other symptoms of the paralysis of the will, expressed among other things in the characteristic lack of motivation), and in its functional effects. An occasionally sad person is not dysfunctional, a depressed one is--depression destroys relationships and renders one incapable of performing one’s duties, it is as real and serious a handicap as any physical one. Neither should depression be seen as an exaggeration of normal mental states, differing from them only quantitatively, or equated with normal reactions to particularly traumatic life events, such as bereavement. (Indeed, Dr. Dowrick, like many other critics, justly castigates DSM-5 for including in the depressive diagnosis grief lasting more than two weeks--as if it were normal, in either statistical or medical sense of the word, to fully adjust to the loss of a close family member in two weeks!) One of the central characteristics of depression--and an exacerbating factor of the suffering it causes--is precisely its lack of connection to specific life events. As anyone who has experienced depression or observed closely persons suffering from depression knows, this absence of an external cause often leads the suffering individual to suspect oneself of madness. The most characteristic feature of severe depression, expressive of the intensity of suffering associated with it, is suicidal thinking. Twenty percent of people suffering from depression eventually commit suicide, which makes it one of the deadliest diseases today. It would be quite irresponsible of a health professional to let the lack of a “discrete pathophysiological basis” obscure this.
Because depression is a real disease, severe and often lethal, it requires the attention of a health professional. Because the causes of depression are cultural, it stands to reason that methods used for the treatment of physical diseases won’t be successful in its treatment. This does not mean that medications won’t have any effect. Pharmaceutical substances are powerful agents, just like alcohol or recreational drugs, and will influence the chemical balance in the brain, sometimes wreaking havoc in it and sometimes alleviating some of the symptoms. But even when the effects of medications are positive, they won’t address the cause of the disease. That’s why, so far, depression has no cure. It is a recurrent, or chronic, illness. Dr. Dowrick suggests that the primary physician serve as a spiritual advisor of sorts to the patient who comes to the clinic with such a mental complaint, talk to such a patient about life problems, ask about the patient’s “physical, psychological, and social circumstances…propose ideas for change… offer hope of an alternative.” But this, while a reflection of kindness and sympathy, is similar to treating cancer with cold compresses, the medication being physical like the disease, unlikely to cause any damage, but also totally irrelevant. Depression has an objective cause; to cure the disease, the therapy, just like in cancer, must focus on this objective cause and neutralize it. In depression, unlike in cancer, this objective cause is cultural. In the case of cancer, a responsible primary physician will refer the patient to an oncologist. In the case of depression, the physician must refer the patient to a specialist who understands the cultural causes of this awful disease and can treat it. There are no such specialists today. Psychiatry must recognize the cultural causes of depression and make cultural expertise an essential element of its therapeutic arsenal. Depression is a culture-bound syndrome. It is also a terrible real disease. It can be cured. But we must at last open our eyes to its cultural causation.
[Originally published on Psychology Today]
Mind, Modernity, Madness: The Impact of Culture on Human Experience
It is important to remember what a disease, or illness, in general, is. Both terms clearly focus on the personal, subjective experience of suffering: dis-ease as opposed to ease, illness as opposed to wellness. So does the word “pathology,” which derives from the Greek for “suffering” (pathos) and Greek for “knowledge” or “understanding” (logos). Thus pathology = understanding of suffering. Even health professionals, whose task is to alleviate suffering, first of all, often forget this, and think that “pathology” refers not to the understanding of the patient’s suffering, but to an objective morbid condition underlying it, and also equate “disease” and “illness” with such objective morbid condition. Moreover, they also believe that such objective morbid condition is necessarily material, i.e., biological. As a result, the absence of “a discrete pathophysiological basis” for depression can lead Dr. Dowrick to the conclusion that depression is not a real illness, but a category, invented for commercial and professional reasons of pharmaceutical companies and medical practitioners who want to get paid for services rendered, which was developed on the basis of “an ethic of happiness, within which aberrations from the norm are assumed to indicate illness.” But, as my previous post [The Real Trouble With DSM-5] argued, mental diseases are likely to be caused by culture, rather than biology, because the mind, or the mental process, while occurring in the brain, is mostly processing intakes from the cultural, symbolic environment, in which it is unlike digestion or breathing, which process intakes from the material, physical and organic, environment. There is an objective underlying condition for the disease (i.e., the suffering) of depression, but this condition is cultural: it is the cultural condition of anomie, caused by the openness of modern Western societies and the bewildering multiplicity of choices for possible self-definition they offer their members [see The Modern Mental Disease]. Depression is, indeed, a culture-bound syndrome and at the same time it is a terrible disease, which cannot and should not be equated with low or bad mood, sadness, or any other “aberration from the norm of happiness”: it differs from these normal mental states symptomatically in the intensity of suffering experienced, in its character (such as resistance to distraction and other symptoms of the paralysis of the will, expressed among other things in the characteristic lack of motivation), and in its functional effects. An occasionally sad person is not dysfunctional, a depressed one is--depression destroys relationships and renders one incapable of performing one’s duties, it is as real and serious a handicap as any physical one. Neither should depression be seen as an exaggeration of normal mental states, differing from them only quantitatively, or equated with normal reactions to particularly traumatic life events, such as bereavement. (Indeed, Dr. Dowrick, like many other critics, justly castigates DSM-5 for including in the depressive diagnosis grief lasting more than two weeks--as if it were normal, in either statistical or medical sense of the word, to fully adjust to the loss of a close family member in two weeks!) One of the central characteristics of depression--and an exacerbating factor of the suffering it causes--is precisely its lack of connection to specific life events. As anyone who has experienced depression or observed closely persons suffering from depression knows, this absence of an external cause often leads the suffering individual to suspect oneself of madness. The most characteristic feature of severe depression, expressive of the intensity of suffering associated with it, is suicidal thinking. Twenty percent of people suffering from depression eventually commit suicide, which makes it one of the deadliest diseases today. It would be quite irresponsible of a health professional to let the lack of a “discrete pathophysiological basis” obscure this.
Because depression is a real disease, severe and often lethal, it requires the attention of a health professional. Because the causes of depression are cultural, it stands to reason that methods used for the treatment of physical diseases won’t be successful in its treatment. This does not mean that medications won’t have any effect. Pharmaceutical substances are powerful agents, just like alcohol or recreational drugs, and will influence the chemical balance in the brain, sometimes wreaking havoc in it and sometimes alleviating some of the symptoms. But even when the effects of medications are positive, they won’t address the cause of the disease. That’s why, so far, depression has no cure. It is a recurrent, or chronic, illness. Dr. Dowrick suggests that the primary physician serve as a spiritual advisor of sorts to the patient who comes to the clinic with such a mental complaint, talk to such a patient about life problems, ask about the patient’s “physical, psychological, and social circumstances…propose ideas for change… offer hope of an alternative.” But this, while a reflection of kindness and sympathy, is similar to treating cancer with cold compresses, the medication being physical like the disease, unlikely to cause any damage, but also totally irrelevant. Depression has an objective cause; to cure the disease, the therapy, just like in cancer, must focus on this objective cause and neutralize it. In depression, unlike in cancer, this objective cause is cultural. In the case of cancer, a responsible primary physician will refer the patient to an oncologist. In the case of depression, the physician must refer the patient to a specialist who understands the cultural causes of this awful disease and can treat it. There are no such specialists today. Psychiatry must recognize the cultural causes of depression and make cultural expertise an essential element of its therapeutic arsenal. Depression is a culture-bound syndrome. It is also a terrible real disease. It can be cured. But we must at last open our eyes to its cultural causation.
[Originally published on Psychology Today]
Mind, Modernity, Madness: The Impact of Culture on Human Experience
