Articles by David H Jacobs Ph.D

What’s the matter? (Diagnosis)

Based on persistent distress and so on, people ask about themselves or others ‘What’s the matter?’

Over the past 31 years (that is, since the 1980 publication of the American Psychiatric Association’s third edition of its Diagnostic and Statistical Manual, the DSM for short), American psychiatry has trained not only the mental health industry but also the public at large to think and speak in the language of DSM disorder categories. This is an important topic because thinking and speaking about personal problems in the terms laid out in the DSM leads away from understanding what actually is the matter. I am tempted to remark that like the comic strip character Mandrake the Magician (I’m dating myself), the DSM and the ‘educational’ efforts of the American Psychiatric Association ‘have the power to cloud men’s minds’ (and women’s, too).

Stated as succinctly as I can, the purpose of DSM-III (published in 1980) and subsequent editions was/is to assert that distressing or impairing features of a person’s mental life are really only symptoms of an underlying although unfortunately for the moment unknown biological pathology. The unfortunately unknown causes of mental disorders would soon enough, it was claimed, yield to sustained biological research. The more immediate good news, it was claimed, was that more or less serendipitously (I am recalling the view from the 1970s) a variety of drugs had already been discovered that significantly reduced the suffering and impairment associated with a variety of psychiatric conditions. The future would bring more and better drugs as well as major discoveries concerning the underlying biological causes of mental disorders.

There is no doubt that the American Psychiatric Association has been massively successful in training the public at large to think of personal difficulties as genuine medical illnesses that can be treated effectively and safely with drugs. Just about every client I meet in my office is taking several psychiatric drugs and has been for some time (with indifferent results, to point out the obvious). From 1980 to the present ordinary psychiatric practice has shifted from primarily doing psychotherapy to primarily prescribing drugs. The result, as I have already suggested, does not look anything like what is seen when effective drugs are employed in conventional medical practice (for example, contrast antibiotics to antidepressants). The causal biological discoveries concerning mental disorder that were confidently expected in the 1970s have not materialized. There is a lot of confusing hype about this matter, but the truth is easy to see: as has been the case since DSM-III was published in 1980, DSM-V (to be published in 2012 or 2013) is expected to continue the unbroken tradition of making psychiatric disorder diagnoses exclusively on behavioral grounds, in other words no biological information of any sort will enter into psychiatric diagnosis (no biological information of any sort can be used to ‘confirm’ a psychiatric diagnosis; contrast this to medical practice). Needless to say, the complete absence of biological information of any kind that is needed or relevant in any way for the purpose of making a psychiatric diagnosis is hard to reconcile with the claim that psychiatry is a medical specialty, or that psychiatric disorders are actually medical disorders.

In 1994 DSM-IV went so far as to completely rule out the existence of ‘functional’ disorders, meaning it denied that what it referred to as mental disorders (e.g., being in a depressed mood) could be brought into being on the basis of what had occurred or was occurring in a person’s life (relationships, occupation, and so on). This was based purely on ideology, since DSM-IV, as usual, based diagnosis exclusively on patient complaints and observed behavior – no relevant biological discoveries had been made that would support the claim that what the DSM called mental disorders were caused by biological pathology. As mentioned above, this state of affairs has not changed from 1994 to the present, and DSM-V when it is published in 2012 or 2013 will draw upon no relevant biological discoveries regarding mental disorder (because there are no relevant biological discoveries).

The pronouncement that ‘functional’ disorders do not exist, in other words the denial that ‘clinically significant’ distress or suffering could be brought about by the vicissitudes of life, means that no matter how clear a person is about the adversity he/she endured in the past or is facing in the present, the official view of American psychiatry is that the person is suffering from a cause unknown medical illness. This why psychiatrists focus on eliciting ‘symptoms’ and are basically uninterested in the nature and quality of the personal environment in which the individual lived in the past and in which the individual is living in the present. The ‘symptoms of a specific illness’ perspective has no more use for getting to know and understand the individual’s personal lived environment than in medicine in general. For example, you have an eye infection. Diagnosing it and treating it is completely independent of what is happening between you and your wife, or your boss, or what life was like for you growing up in your family. American psychiatry has decided that your depression, anxiety, or as whatever likewise has nothing to do with the personal environment in which you live. Your depression (your ‘clinical’ depression) and so forth is simply a disorder of unknown cause that you have, to be treated practically speaking by trying out one combination of drugs after another.

The ‘symptoms’ perspective, as I suggested above, leads away from a serious and realistic inquiry of ‘What is the matter?’ Noting, for example, that you are in a depressed mood does not by itself reveal and make explicit why your mood is depressed. Perhaps your mood is depressed because you feel very threatened, or because you are bitterly disappointed about something, or your dignity has been assaulted by some development, and so on. If depressed mood is the outcome, understanding and assisting you to feel better realistically requires clarifying what has brought the outcome about. This cannot be accomplished by focusing on the outcome itself. Actually diagnosis in psychiatry is a distortion of diagnosis in medicine. A physician does not treat your eye with antibiotics unless there is physical evidence indicating that you have a bacterial infection in your eye. It is pointless, perhaps harmful, and improper to expose you to a medication in the absence of physical evidence concerning what has caused your symptoms. By contrast in psychiatry the ‘symptoms’ themselves are the basis for prescribing drugs, since it is widely acknowledged that conceived as a medical disorder the cause of your disorder is unknown (there is, for example, no evidence that a person diagnosed with what the DSM calls a mental disorder is suffering from a ‘chemical imbalance’ of any kind, and indeed there is a good deal of evidence indicating that this is not in fact the case). Is there solid evidence that psychiatric medications, despite being prescribed for ’cause unknown’ conditions, actually are effective and safe? The public (meaning people who are not scholars in this area) is largely unaware of how contentious this issue is in the scientific literature considered as a whole (I am one of many who has written critically on this matter; please see the publications section of my website. As I suggested above, it is commonplace to meet clients who have gone from one drug regimen to another and are still seeking help).

For the purpose of making the point that treatment must inquire into what has brought about the clinical outcome of interest, I probably gave a misleading impression about how straightforward this is (e.g., depression caused by a disappointment). It is in fact rarely the case that the clinical outcome of interest can be succinctly described (I could call this the DSM-created myth of clear-cut, easy to describe, specific, and autonomous disorders) and straightforwardly attributed to one equally clear-cut, discrete, time-limited event or incident in a person’s life. Persistent, long-standing distress and/or impairment implicate a long and complex history and course of development. This can only be made explicit on the basis of protracted discussion between client and therapist. It is usually the case that a client does not realize how much he/she knows about the origins and reasons for his/her troubles until a suitable speaking and discussion (back and forth) situation is provided (i.e., the therapy relationship). Both the question what is the matter and why what is the matter has been brought about can be answered if a suitable dialogue situation is provided. In therapy both questions are integrated with the issue of positive progress.

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